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Department of Surgical Sciences and
Integrated Diagnostics (DISC)
University of Genoa, Italy
Lung Recruitment in
ALI/ARDS
JRUR, Marseille, France, 2012
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AGENDA
• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
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Superimposed Pressure
Opening Pressure
Normal 0
Alveolar Collapse (Reabsorption) 20-30 cmH2O
Small Airway Collapse
10-20 cmH2O
Consolidation
The ARDS Lung
Rouby Intensive Care Med 2000
Gattinoni JAMA 1993, Pelosi AJRCCM 1994, Gattinoni AJRCCM 2002, Gattinoni ICM 2005
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x g x h
P = 5 cmH2O P = 10 cmH2O
LESS EDEMA-ATELECTASIS
LOWER PEEP – LOWER MORTALITY
HIGHER EDEMA-ATELECTASIS
HIGHER PEEP – HIGHER MORTALITY
EDEMA – ATELECTASIS IN ALI/ARDS
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Mild Moderate Severe
TimingAcute onset within 1 week of a known clinical insult or new/worsening
respiratory symptoms
Hypoxemia PaO2/FiO2 201-300with PEEP/CPAP 5
PaO2/FiO2 200 withPEEP 5
PaO2/FiO2 100 withPEEP 10
Origin of EdemaRespiratory failure not fully explained by cardiac failure or fluid
overload**
RadiologicalAbnormalities
Bilateral opacities* Bilateral opacities*Opacities involving at
least 3 quadrants*
AdditionalPhysiologicalDerangement
N/A N/AVE Corr > 10 L/min
orCRS<40 ml/cmH2O
*Not fully explained by effusions, nodules, masses, or lobar/lung collapse; use training set of CXRs
**Need objective assessment if no risk factor present (See table)VE Corr = VE x PaCO2/40
ARDS
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300 250 200 150 100 50
Low Tidal Volume Ventilation
Higher PEEP
HFO
Prone Positioning
ECMO
Low – Moderate PEEP
NeuromuscularBlockade
PaO2 /FiO2
Increasing Severity of Lung Injury
Mild ARDS Moderate ARDS Severe ARDS
I n c r e a s i n g
I n
t e n s i t y
o f I n t e r v e n t i o n
NIV
ECCO2-R
iNO
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Mechanical Ventilation of Sepsis-Induced AcuteRespiratory Distress Syndrome (ARDS)
We suggest recruitment maneuvers inpatients with severe refractory
hypoxemia (Grade 2C).
SURVIVING SEPSIS CAMPAIGN GUIDELINES
2012
R. Phillip Dellinger and Rui MorenoOn behalf of the SSC Committee (SCCM-ESICM)
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AGENDA
• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
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The concept of PEEP and Recruitment
optimal-PEEP
recruited vol.
Pelosi P, De Abreu G, Rocco PR Crit Care. 2010 Mar 9;14(2):210.
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Recruitment in ALI/ARDS ?
WHY NOT ?
• Improves oxygenation• Improves respiratory mechanics
• Increases lung volume/reduces atelectasis• Not associated with major adverse effects
• Before PEEP setting
•After dysconnection from MV or suctioning
• Rescue maneuvre
WHEN ?
Pelosi P, De Abreu G, Rocco PR Crit Care. 2010 Mar 9;14(2):210.
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ICM 2003,29:218
CCM 2001, 1255: 1260
45%
23%
20%
Fan E et al. Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008
Recruitment Maneuvers for Acute Lung Injury:
A Systematic Review
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AGENDA
• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
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Santiago VR et al Crit Care Med. 2010 Nov;38(11):2207-14.
Recruitment maneuver in experimental acute lung
injury: the role of alveolar collapse and edema
ALI-M with the same alveolar collapse
but less edema compared to ALI-S
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Silva PL et al. Critical Care 2010, 14:R114
Hypervolemia induces and potentiates lung damage
after RM in a model of sepsis-induced ALI
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Effects of pressure profile and duration of RM on lung morpho-
functional and biological impact in experimental lung injury
Silva Pl et al Crit Care Med. 2011 May;39(5):1074-81.
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AGENDA
• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
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“New” recruitment Maneuvres:
Assisted VentilationSigh
Variable Ventilation
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Ventilator Induced Lung Injury Spieth P et al. Crit Care Med. 2011 Apr;39(4):746-55
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Effects of frequency and inspiratory plateau
pressure during recruitment manoeuvres
on lung and distal organs in acute lung injurySteimback PW et al Intensive Care Med 35:1120-1128, 2009
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16 ml/kgVolutrauma
1,6 ml/kgAtelectrauma
S
h e a r s t r e s s
B i o t r a u m a
Variable VTs improve different lung protective ventilation
strategies in experimental ALISpieth PM et al Am J Respir Crit Care Med 2009 15;179(8):684-93
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Variable VTs improve different lung protective ventilation
strategies in experimental ALISpieth PM et al Am J Respir Crit Care Med 2009 15;179(8):684-93
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AGENDA
• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
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Recruitment Maneuvers for Acute Lung Injury:
A Systematic ReviewFan E et al. Am J Respir Crit Care Med Vol 178. pp 1156–1163, 2008
Hypotension
Desaturation
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Respiratory and hemodynamic changes during
decremental open lung PEEP titration in ARDSGernoth W et al Critical Care 2009, 13:R59; Epub 2009 Apr 17
Right ventricular Tei index [%]
39±1142±10
36±11
BeforeDuring RM
After
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Non recruiter
0
2
4
6
8
10
12
14
Weight (grams)
Peep 5 cmH2O
Paw 45cmH2O
Peep 5 cmH2O
Paw 45cmH2O Gattinoni et al NEJM 2006, 354(17):1775-86
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Paw 45cmH2O
Recruiter
Peep 5 cmH2O
Weight (grams)
0
10
20
30
40
50
60
Peep 5 cmH2O
Paw 45cmH2O
Gattinoni et al NEJM 2006, 354(17):1775-86
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potential for lung recruitment [% total lung weight]
F r e q u e n c y
[ n o . o
f p a t i e n t s ]
0
2
4
6
8
10
1214
16
18
20
22
24
ALI patients
ARDS patients
higher
21 ± 10%
(374 ± 236 grams)
lower
5 ± 4%
(59 ± 51 grams)
Potential for lung recruitment
Gattinoni et al NEJM 2006, 354(17):1775-86
R it t i f ti f l i ht
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Recruitment is a function of lung weight
Potential for recruitment [% total lung weight] -10 0 10 20 30 40 50 60 70
[ % t o
t a l l u n g w e i g h t ]
-5 0 5
10 15 20 25 30 35
Gattinoni et al NEJM 2006, 354(17):1775-86
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Mortality at ICU-discharge
mortality
[%]
quartiles of potential for lung recruitment 1st 0
10 20 30 40 50 60
lower-
potential
2nd 3rd 4th 17
n =
17
17
17
higher-
potential
P=0.006
Gattinoni et al NEJM 2006, 354(17):1775-86
H l i th l it bilit i l ARDS
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How large is the lung recruitability in early ARDS: a
prospective case series of patients monitored by CT
De Matos GFJ et al Critical Care 2012, 16:R4
- Less than 72 hours onset
- PaO2/FIO2 < 200, with PEEP 10 cmH2O, FIO2 of 1.0 and pressure-controlled
ventilation with driving pressure set at 15 cmH2O
Ho large is the l ng recr itabilit in earl ARDS a
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How large is the lung recruitability in early ARDS: a
prospective case series of patients monitored by CT
De Matos GFJ et al Critical Care 2012, 16:R4
How large is the lung recruitability in early ARDS: a
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How large is the lung recruitability in early ARDS: a
prospective case series of patients monitored by CT
De Matos GFJ et al Critical Care 2012, 16:R4
How large is the lung recruitability in early ARDS: a
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How large is the lung recruitability in early ARDS: a
prospective case series of patients monitored by CT
De Matos GFJ et al Critical Care 2012, 16:R4
How large is the lung recruitability in early ARDS: a
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How large is the lung recruitability in early ARDS: a
prospective case series of patients monitored by CT
De Matos GFJ et al Critical Care 2012, 16:R4
How large is the lung recruitability in early ARDS: a
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How large is the lung recruitability in early ARDS: a
prospective case series of patients monitored by CT
De Matos GFJ et al Critical Care 2012, 16:R4
Optimal duration of a sustained inflation recruitment
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Arnal JM et al Intensive Care Med (2011) 37:1588–1594
Optimal duration of a sustained inflation recruitment
maneuver in ARDS patients
Optimal duration of a sustained inflation recruitment
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Arnal JM et al Intensive Care Med (2011) 37:1588–1594
Optimal duration of a sustained inflation recruitment
maneuver in ARDS patients
A 10-s sustained inflation RM maybe recommended to achieve a plateau in the volume
recruited and to prevent hemodynamic compromise
Prolonged moderate pressure recruitment manoeuvre
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Prolonged moderate pressure recruitment manoeuvre
results in lower optimal PEEP and plateau pressure
Lowhagen K et al Acta Anaesthesiol Scand 2011; 55: 175–184
Prolonged moderate pressure recruitment manoeuvre
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Prolonged moderate pressure recruitment manoeuvre
results in lower optimal PEEP and plateau pressure
Lowhagen K et al Acta Anaesthesiol Scand 2011; 55: 175–184
Randomised controlled trial of an open lung strategy with
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p g gy
staircase recruitment, titrated PEEP and targeted low airway
pressures in patients with ARDSHodgson et al. Critical Care 2011, 15:R133
Randomised controlled trial of an open lung strategy with
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p g gy
staircase recruitment, titrated PEEP and targeted low airway
pressures in patients with ARDSHodgson et al. Critical Care 2011, 15:R133
Randomised controlled trial of an open lung strategy with
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p g gy
staircase recruitment, titrated PEEP and targeted low airway
pressures in patients with ARDSHodgson et al. Critical Care 2011, 15:R133
Randomised controlled trial of an open lung strategy with
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p g gy
staircase recruitment, titrated PEEP and targeted low airway
pressures in patients with ARDSHodgson et al. Critical Care 2011, 15:R133
Clinical efficacy and safety of recruitment maneuver in patients
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with acute respiratory distress syndrome using low tidal volume
ventilation: a multicenter randomized controlled clinical trial
Xiu-Mimg XI et al Chin Med J 2010;123(21):3100-3105
Clinical efficacy and safety of recruitment maneuver in patients
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with acute respiratory distress syndrome using low tidal volume
ventilation: a multicenter randomized controlled clinical trial
Xiu-Mimg XI et al Chin Med J 2010;123(21):3100-3105
AND Less organ failure at day 28th
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AGENDA
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AGENDA
• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
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Focal loss of areation Diffuse loss of areation
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SUPINE AFTER 12H PRONE
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Lung
recruitment:
No more non
aerated zones
Lung
recruitment:
More normally
aerated zones
Non
AeratedNon
Aerated
Aerated
Hyperinflation Hyperinflation
Nougaret et al, in progress
Sigh in supine and prone during ARDS
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g p p gPelosi P et al Am J Respir Crit Care Med 2003; 167: 521-527
Prone position and recruitment manoeuvre: the
bi d ff t i ti
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combined effect improves oxygenationRival G et al. Critical Care 2011, 15:R125
Prone position and recruitment manoeuvre: the
bi d ff t i ti
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combined effect improves oxygenationRival G et al. Critical Care 2011, 15:R125
Prone position and recruitment manoeuvre: the
combined effect improves oxygenation
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combined effect improves oxygenationRival G et al. Critical Care 2011, 15:R125
Prone position: CO2 and Survival
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Gattinoni et al Crit Care Med 2003;31:2727
AGENDA
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• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position
• How to set PEEP after Recruitment
• Conclusions
Oxygenation and collapsed tissue
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Borges et al Am J Respir Crit Care Med 174; 268-278, 2006
PaO2 / FiO2 < 150
at PEEP 5 cmH2O
Assessment of Pulmonary Morphology in ALI
Absence of Lower Inflection Point in the P-V Curve
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Vieira et al. Am J Resp Crit Care Med 1999; 159:1612-1623.
Overdistension
Assessment of Pulmonary Morphology in ALI
Significance of Lower Inflection Point in the P-V Curve
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gVieira et al. Am J Resp Crit Care Med 1999; 159:1612-1623.
Overdistension
Elastance to titrate PEEP in ALI/ARDS C lh AR P l i P l I i C M d 2008 D 34(12) 2291 9
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Carvalho AR, Pelosi P et al. Intensive Care Med. 2008 Dec;34(12):2291-9
The stress index: is it useful to set TV ?Fanelli V et al Crit Care Med 2009 Mar;37(3):1046-53
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Fanelli V et al Crit Care Med. 2009 Mar;37(3):1046-53.
Grasso S et al Crit Care Med. 2004 Apr;32(4):1018-27Ranieri VM et al. Am J Respir Crit Care Med. 1994 Jan;149(1):19-27
PEEP-induced changes in lung volume in ARDS.
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Two methods to estimate alveolar recruitmentDellamonica J et al Intensive Care Med (2011) 37:1595–1604
Probes
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Réanimation Polyvalente, Hôpital Pitié-Salpêtrière, Université Paris 6
Probe 5-10 MHz Lung
periphery
Probe 4-5 MHz
Deep Lung
Curvilinear
probe
15 11 2008
Phased array probe 3 MHz
Hemodynamic monitoring
Convex probe 3.5 MHz
Lung and hemodynamicapplications
Linear probe 7.5 MHz
vascular application
Image quality
1 to 17 cm
Lung imaging for titration of mechanical ventilation
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The role of lung ultrasoundLuecke T, Corradi F, Pelosi P Curr Opinion in Anaesthesiology, 2011 ( Ahead of Print)
Lung imaging for titration of mechanical ventilation
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The role of lung ultrasoundLuecke T, Corradi F, Pelosi P Curr Opinion in Anaesthesiology, 2011 ( Ahead of Print)
Peep 5 cmH2O Peep 5 cmH2O
Bedside Ultrasound Assessment of
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PEEP–induced Lung RecruitmentBouhemad B et al. Am J Respir Crit Care Med 183: 341–347, 2011
LUNG ULTRASOUND PROTOCOL
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Pelosi P, Corradi F Anesthesiology 2012 ( Ahead of Print)
How to perform a PEEP trial
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Time
5
10
15
20
25
30
35
40
P r e s s u r e ( c m H 2 O )
5 min 1-2 min 5-10 min per step
in most severe ARDS patients ?
PEEP to achieve
the “ best” Cst,rsVT 6 ml/Kg IBW
Pelosi P, Abreu GM, Rocco PR Crit Care 2010; 14(2):210.
How to perform a PEEP trial
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in most severe ARDS patients ?
Maximal PEEP to achieveVT 6 ml/Kg IBW,
with Pplat,rs = 30-27 cmH2O
Time
5
10
15
20
25
30
35
40
P r e s s u r e ( c m H 2 O )
5 min 1-2 min 5-10 min per step
Pelosi P, Abreu GM, Rocco PR Crit Care 2010; 14(2):210.
AGENDA
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• ARDS: principles of treatment
• Recruitment in ARDS:
- The rationale
- Experimental data
- “New” recruitment maneuvres
• Clinical data
• Recruitment and prone position• How to set PEEP after Recruitment
•
Conclusions
Use of computed tomography scanning to guide lung
recruitment and adjust PEEP in ALI/ARDS
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Pelosi P. et al. Curr Opin Crit Care. 2011 Jun;17(3):268-74
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Thanks
Royal Library, British Museum, London, UK