Uploaded byDr.Mahmoud Abbas
Ventilatory Modes.
This document discusses different modes of mechanical ventilation and their use over time. It provides data from several international studies on the types of ventilation modes used for different patient populations and conditions. Some key findings include: - In the 1950s, the mortality rate from respiratory paralysis was around 87% but decreased significantly with the introduction of invasive mechanical ventilation. - By the 1980s, the most commonly used ventilation modes were CMV/ACV (55%) and IMV/SIMV (26%). - More recent international studies show A/C is still the most commonly used mode but SIMV-PSV is becoming more frequent, especially in certain regions like Latin America. - A prospective randomized trial of 79 ARDS
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Ventilatory Modes.
- 1. Andrés Esteban Modes ofMechanical Ventilation: Is There Anyone Better? Hospital Universitario de Getafe
- 2. 1952: Copenhagen polio epidemic Firstmonth 31 patients with respiratory paralysis 27 patients died (87%)
- 3. 0 10 20 30 40 50 60 70 80 90 100 1 2 34 5 6 7 8 Mortality July 1952 March 1953 Months
- 4. QUESTIONAIRE MAILED …………3982 QUESTIONAIRE RETURNED ……. 1272 (32%) IMV IS USED AS PRIMARY MODE OF VENT…….... 71.6 % B. Venus et al 1987 Crit Care Med 15:530
- 5. Ventilatory Modes CMV /ACV ………….... 55 % IMV / SIMV ……………. 26 % SIMV + PSV …………… 8 % PSV ……………………. 8 % PCV ……………………. 1 % A. Esteban, I. Alía et al. Chest 1994;106:1188
- 6. USA CAN SPA ARGBRA CHI POR URU TOTAL A / C 34 62 68 40 75 44 25 47 SIMV 6 7 9 4 5 -- 20 6 P S 18 11 10 10 5 34 2 15 SIMV / PS 34 13 7 31 17 13 52 25 OTHERS 7 6 6 15 2 9 -- 7 A. Esteban, A. Anzueto, I. Alía et al Am J Respir Crit Care Med 2000;161:1450 Modes of ventilation (%)
- 7.
- 8. 0 1000 2000 3000 4000 5000 1 4 710 13 16 19 22 25 28 0 10 20 30 40 50 60 70 80 90 100 Patients A/C PCV PS SIMV SIMV+PS VNI Others Numbersofpatientsmechanicallyventilated Days from the start of mechanical ventilation Percentageofpatientsventilatedwith eachventilatorymode A.Esteban, A. Anzueto, F. Frutos, I. Alía et al. JAMA 2002;287:345-355
- 9. A. Esteban, A.Anzueto, F. Frutos, et al. JAMA 2002;287:345-355 International study of 5183 patients 449 patients (8.6%) meet the ARDS criteria Mode of ventilation Volume controlled: 69% Pressure controlled: 24%
- 10. USA CANADA AC SIMV SIMV-PSV PSV PCV 46 % 6 % 15% 2 % 20 % AC SIMV SIMV-PSV PSV PCV 52% 4 % 10 % 4 % 22 % AC SIMV SIMV-PSV PSV PCV 39 % 3 % 21 % 6 % 24 % LATIN AMERICA AC SIMV SIMV-PSV PSV PCV 85 % 3 % 6 % 2 % 2 % AC SIMV SIMV-PSV PSV PCV 74 % 5 % 9 % 2 % 7 % AC ----- SIMV-PSV ----- PCV 71 % 14 % 7% EUROPE AC SIMV SIMV-PSV PSV PCV 62 % 3 % 9 % 1 % 15 % AC SIMV SIMV-PSV PSV PCV 57 % 2 % 6 % 2 % 23 % AC ---- SIMV-PSV PSV PCV 57 % 5 % 4 % 23 % DAY 1 DAY 4 DAY 7 MODES OF VENTILATION
- 11. Esteban A etal. Chest 2000; 117:1690-1696 ARDS N = 79 PCV vs. CMV Mortality Hospital Relative risk 0.65 (0.46 - 0.96) Derdak S et al. Am J Respir Crit Care Med 2002; 166:801-808 ARDS N = 148 HFOV vs. PCV 30 day Survival Relative risk 1.14 (0.73 - 1.80)
- 12. 79 patients withcriteria of ARDS Randomization PCV (n = 42) VCV (n =37) Main outcome Hospital Mortality Esteban A, Alía I, Gordo F, et al. Prospective randomized trial comparing pressure-controlled ventilation and volume-controlled ventilation in ARDS Chest 2000; 117:1690-1696
- 13. Ventilator Modes Esteban etal Chest 2000; 117:1690
- 14. UNIVARIATE ANALYSIS O RCI 95 % AGE ≥ 65 a. 1’57 1’13 – 2’17 SAPS II ≥ 40 1’63 1’15 – 2’32 ≥ 2 ORGAN FAILURE 2’31 1’38 – 3’85 RENAL FAILURE 1’76 0’98 – 3’17 COAGULOPATHY 1’36 0’99 – 3’86 V C V 1’53 1’08 – 2’17 A, Esteban, I. Alía, et al. Chest 2000;117:1690-1696
- 15. Odds ratio (CI95 %) p SAPS II, per point 1.03 (1.00 – 1.05) 0.03 Cardiovascular failure 4.00 (1.87 – 8.86) < 0.001 Hepatic Failure 3.99 (1.35 – 11.81) 0.01 Variables associated to mortality Multivariate analysis
- 16. 39 2 12 1212 6 9 6 2 60 6 12 6 7 4 3 0 10 20 30 40 50 60 C MV S IMV S IMV- PS V PS V PC V PR VC B IPAP NIV Other Overall population 1998 2004
- 17. CMV, AMV, SIMV,HFV PS, PRV, PCV, VCV ACPRV, FLOW BY, CPAP
- 18. VENTILATORY MODE SIMV STARTTO BE USED ............................. 1970 FIRST PUBLICATION Intermittent mandatory ventilation A new approach to weaning patients from mechanical ventilation J. B. Downs, EF Klem et al Chest 64:331.................................... 1973
- 19. PRESSURE SUPPORT VENTILATION STARTTO BE USED ................................. 1980 FIRST PUBLICATIONS M.J. Banner, R.R. Kirby Crit Care Med 13;997-998 ................... 1985 O. Prakash, S. Meij Chest 88;403-408 ................................. 1985
- 20. Topics to solve… There is some mode of ventilation superior or better than other? What is the optimal tidal volume? What is the “best” PEEP? How we can optimize patient–ventilator interaction? When to think that the NIV has failed? When it is necessary to use adjunctive therapies (eg. prone position) in the ARDS?
- 21. Topics to solve… There is some mode of ventilation superior or better than other? What is the optimal tidal volume? What is the “best” PEEP? How we can optimize patient–ventilator interaction? When to think that the NIV has failed? When it is necessary to use adjunctive therapies (eg. prone position) in the ARDS?
- 22. New Modes VolumeAssured Pressure Support Pressure Regulated Volume Control/ Volume Support Proportional Assist Ventilation Automatic Tube Compensation Adaptive Support Ventilation Airway Pressure Release Ventilation/ Bi-level Pressure Ventilation
- 24. N = 4968 22% Excluded patients because they were ventilated with other modes that A/C or SIMV N = 1681 N = 3287 N = 1969 37 % 21 % 42 % Patients ventilated only with SIMV-PSV N = 350 Patients initially ventilated with SIMV-PSV and switched to A/C N = 54 Patients ventilated only with A/C N = 1228 Patients initially ventilated with A/C and switched to SIMV-PSV N = 54 Crude (non-adjusted) Intensive Care Unit Mortality Excluded patients because they were ventilated with a combination of more than 2 modes including A/C and SIMV N = 1318
- 25. Patients ventilated withSIMV - PS 367 Patients ventilated with A/C 1.228 PRIMARY OUTCOME was in hospital mortality After adjustment for propensity score, the overall effect of SIMV - PS was not significant. Odds ratio 1.04;95% CI 0.77-1.42 p= .78 G. Ortiz, F. Frutos-vivar et al. Chest 2010 (in press)
- 26. Factors Associated withVentilation Using SIMV-PS: Univariate and Multivariate Logistic-Regression Analysis Univariate Analysis Multivariate analysis Odds Ratio (95% CI) P value Odds Ratio (95% CI) P value Geographic area • Latin America • Europe • United States and Canada • Other (Saudi Arabia, Tunisia, Turkey) 1 1.76 (1.32 - 2,53) 4.25 (3.07 - 5.88) 8.13 (4.77 - 13.87) <.001 1 1.64 (1.12 - 2.40) 3.41 (2.40 - 4.83) 8.58 (4.77 - 15.44) <.001 Simplified acute physiology score II, per point 0.98 (0-97 - 0-99) <.001 0.99 (0-98 - 0.99) .02 Main reason for mechanical ventilation • COPD • Asthma • Coma • Acute respiratory failire Postopoerative Sepsis Pneumonia Congestive heart failure Trauma 0.59 (0.31 - 1.13) 0.20 (0.03 - 1.38) 0.48 (0.36 - 0.63) 2.46 (2.06 - 2.93) 0.69 (0.48 - 1.01) 0.66 (0.44 - 1.00) 0.62 (0.36 - 1.09) 2.51 (1.98 - 3.19) .09 .06 <.001 .001 .05 .04 .08 <.001 --- 0.12 (0.02 - 0.94) 0.56 ( 80.38 - 0.82) 2.58 (1.85 - 3.60) -- -- -- 3.59 (2.09 - 6.18) -- .04 .003 <.001 -- -- -- <.001
- 27. Factors Associated withVentilation Using SIMV-PS: Univariate and Multivariate Logistic-Regression Analysis Univariate Analysis Multivariate analysis Odds Ratio (95% CI) P value Odds Ratio (95% CI) P value Complications during the mechanical ventilation • ARDS • Sepsis • Ventilator associated pneumonia • Cardiovascular failure • Respiratory failure • Hematologic failure 0.21 (0.07 - 0.63) 0.21 (0.09 - 0.49) 0.40 (0.18 - 0.86) 0.49 (0.38 - 0.65) 0.57 (0.45 - 0.72) 0.46 (0.26 - 0.81) .001 <.001 .009 <.001 <.001 .003 --- 0.28 (0.11 - 0.73) --- 0.66 (0.46 - 0.94) --- --- -- .009 -- .02 -- --
- 28. Cases N = 234 Controls N= 234 P value Days of mechanical ventilation, median (interquartile range) 3 (2, 5) 3 (2,6) 0,61 Days of weaning, median (interquartile range) 1 (1, 2) 1 (1,2) 0.28 Reintubation, n (%) 100/140 (7) 101/139 (7) 0.99 Tracheostomy, n (%) 46 (20) 25 (11) 0.007 Lengh of stay in the intensive care unit, median (interquartile range) 6 (3, 14) 6 (3, 12) 0.11 Mortality in the intensive care unit, n (%) 65 (28) 78 (33) 0.19 Lengh of stay in the hospital, median (interquartile range) 18 (11, 38) 17 (8, 31) 0.05 Mortality in the hospital, n (%) 81 (35) 90 (38) 0.50 Outcomes of patients included in the matched-case study
- 30. Preservation ofspontaneous breathing It may have important effects on VILI (not proven) Better cardiac output and oxygen delivery Improvements in gas exchange Reduction in overall sedation requirements APRV - Advantages
- 31. Putensen, AJRCCM 2001;164:43 APRV -What is The Evidence Six studies (740 patients) and 2 RCT Most of the studies are small case series or cross-over studies with surrogates of outcome or physiologic endpoints such as oxygenation. One RCT enrolled 30 trauma patients with ARDS, APRV with SB vs PC time cycled ventilation with sedation and paralysis for 72 hours. Weaning in both group was performed on APRV.
- 32. 4968 Patients 563 (11.3%) patients were ventilated at least one day with APRV/BIPAP 1228 (24.7 %) were ventilated with AC all the time 234 patients were ventilated all the time with APRV/BIPAP 234 were ventilated with AC Study Patients Controls
- 33. APRV - Discussion APRV/BIPAP were in a minority of patients (5.2 %). The major outcomes in a heterogeneous population of mechanicaly ventilated patients were similar when they are ventilated with APRV/BIPAP or with AC. The upper airway pressure was lower than peak airway pressure and the low pressure was higher than PEEP. There was a lack of improvement in gas exchange (may be to different population). The proportion of patients the received sedatives were similar between the group.
- 34. Outcomes There wereno differences in the proportion of patients that received sedatives (73% in the APRV/BIPAP vs. 79 % in the AC group, p=0.08) or neuromuscular blocking (11 % vs 9%; p=0.47) We excluded the 29 patients who received a neuromuscular blocking agent irrespective of the number of doses and did not change the results of the outcome
- 35. Outcomes Cases N = 263 Controls N= 263 P value Reintubation, n (%) 10/147 (6.5 %) 7/142 (5%) 0.50 Tracheostomy, n (%) 54 (21 %) 29 (11 %) 0.003 Lenght of stay in the hospital, median (interquartile range) 19 (11, 38) 17 (8, 33) 0.06 Mortality in the hospital, n (%) 92 (35 %) 105 (40 %) 0.23
- 36. • Non InvasiveMechanical Ventilation
- 37. A. Esteban, A.Anzueto, I. Alía et al JAMA 2002;287:345-355 ARF INVASIVE VENTILATION.......... 31 % (p=0.01) Mortality COPD-NIV-SUCCESSFUL................... 9.5 % COPD-NIVINTUBATED...................... 27.3 % COPD INVASIVE VENTILATION....... 23.8 % (p=0.91) ARF-NIV-SUCCESSFUL...................... 16.8 % ARF-NIV-INTUBATED......................... 48.1 %
- 38. Ram FS etal. (COPD and Mortality) Cochrane Database Syst Rev. 2004;(3):CD004104. Bott 1993 0.33 (0.10 – 1.11) Servillo 1994 1.00 (0.08 – 11.93) Brochard 1995 0.33 (0.11 – 0.93) Celikel 1998 0.33 (0.01 – 7.56) Avdeev 1998 0.33 (0.10 – 1.11) Plant 2000 0.50 (0.26 – 0.95) Conti 2002 1.36 (0.48 – 3.86) Dikensoy 2002 0.50 (0.05 – 5.01) Khihari 2002 1.50 (0.28 – 8.04) POOLED RESULTS 0.52 (0.35 – 0.76) Relative Risk 1 5 10.1 .2 Favors NIV Favors Conventional
- 39. Keenan SP etal. (ARF and Mortality) Crit Care Med 2004; 32:2516-2523 Confalonieri 1999 Antonelli 2000 Hilbert 2001 Auriant 2001 Keenan 2002 POOLED RESULTS -1.0 -0.5 0 0.5 1.0 Absolute Risk Reduction Favors NIV Favors Control
- 40. 16,5 4 7 44 10 27 0 10 20 30 40 50 60 COPD ARF CHF 1998 2004 Useof non-invasive ventilation (ICU Participant in both studies)
- 41. All – NIVRepeat ICUs 1998 n=256 2004 n=479 1998 n=61 2004 n=186 p value Arterial Blood Cases Prior to NIV • pH, mean (SD) 7.31 (0.09) 7.32 (0.1) 7.31 (0.09) 7.32 (0.1) 0.73 • PaCO2, mean (SD) 56 (21) 52 (21) 58 (23) 53 (22) 0.23 PaO2/FiO2, mean (SD) 162 (73) 171 (94) 172 (33) 175 (90) 0.8 Day 1 after NIV • pH, mean (SD) 7.37 (0.08) 7.34 (0.09) 7.35 (0.09) 7.34 (0.1) 0.49 • PaCO2, mean (SD) 50 (18) 50 (19) 53 (21) 51 (21) 0.57 PaO2/FiO2, mean (SD) 200 (76) 191 (95) 194 (92) 211 (77) 0.20
- 42. All – NIVRepeat ICUs 1998 n=256 2004 n=479 1998 n=161 2004 n=186 p value Arterial Blood Cases Prior to NIV • pH, mean (SD) 7.31 (0.09) 7.32 (0.1) 7.31 (0.09) 7.32 (0.1) 0.73 • PaCO2, mean (SD) 56 (21) 52 (21) 58 (23) 53 (22) 0.23 PaO2/FiO2, mean (SD) 162 (73) 171 (94) 172 (33) 175 (90) 0.8 Day 1 after NIV • pH, mean (SD) 7.37 (0.08) 7.34 (0.09) 7.35 (0.09) 7.34 (0.1) 0.49 • PaCO2, mean (SD) 50 (18) 50 (19) 53 (21) 51 (21) 0.57 PaO2/FiO2, mean (SD) 200 (76) 191 (95) 194 (92) 211 (77) 0.20
- 43. N I Vutilization 1998 N = 161 2004 N = 186 p value Chronic obstructive pulmonary disease 22 / 133(16.5%) 40 / 113 (35 %) <0.001 Asthma 1 / 13 (8 %) 7 / 28 (25 %) 0.38 Congestive heart failure 10 / 152 (7 %) 18 / 105 (17 %) <0.001 Acute respiratory failure 21 / 373 (6 %) 44 / 446 (10 %) 0.03 ● Acute respiratory distress syndrome 4 / 67 (6 %) 8 / 65 (12 %) 0.19 ● Pneumonia 16 / 183 (9 %) 20 / 2006 (15 %) 0.08 ● Sepsis 1 / 123 (1 %) 6 / 175 (3 %) 0.25
- 44. Invasive ventilation n=162 Successful NIV n=78 Failure NIV n=27 p Hours NIV median(IQR) 48 (21, 98) 16 (6, 30) < 0.001 Days of MV median (IQR) 4 (2, 9) 3 (2, 5) 5 (3, 15)* 0.01 Tracheostomy, % 15% -- 11% 0.002 Length of stay ICU median (IQR) 9 (5, 15) 5 (3, 8) 11 (5, 21) <0.001 Length of stay hospital median (IQR) 15 (10, 27) 17 (9, 22) 20 (11, 32) 0.25 ICU Mortality, % 23% 9% 41% 0.001 Hospital Mortality, % 32% 17% 54% 0.001
- 45. All – NIVRepeat ICUs 1998 n=256 2004 n=479 1998 n=161 2004 n=186 p value Need for intubation (failure NIV) 32 % 40 % 31 % 35 % 0.59 Mortality (failed NIV) 42 % 47 % 47 % 47 % 0.98 COPD 27 % 41 % 50 % 47 % 0.73 ARF 48 % 50 % 46 % 54 % 0.63 Mortality (successful NIV) 14 % 14 % 21 % 10 % 0.08 COPD 9 % 9 % 12.5 % 3 % 0.24 ARF 17 % 15 % 27 % 15 % 0.21
- 46. All – NIVRepeat ICUs 1998 n=256 2004 n=479 1998 n=161 2004 n=186 p value Need for intubation (failure NIV) 32 % 40 % 31 % 35 % 0.59 Mortality (failed NIV) 42 % 47 % 47 % 47 % 0.98 COPD 27 % 41 % 50 % 47 % 0.73 ARF 48 % 50 % 46 % 54 % 0.63 Mortality (successful NIV) 14 % 14 % 21 % 10 % 0.08 COPD 9 % 9 % 12.5 % 3 % 0.24 ARF 17 % 15 % 27 % 15 % 0.21
- 47. Conclusions The useof NIV in the ICU has doubled from 1998 to 2004 for all causes of acute respiratory failure. The strong concordance of predicted and observed practice changes suggest that clinical trials have influenced usual care over time.
- 48. Mechanical ventilation isuseful to “buy” time…. Meanwhile: To avoid to injury the lung (barotrauma, volutrauma, atelectrauma..) To avoid the organ dysfunction To avoid the muscular atrophy To avoid the nosocomial infections