1、PV tool and lung recruitmentChengdu mechanical ventilation training.Sept.2011Dr Jean-Michel ArnalIntensive Care Unit.Hpital Font PrToulon Francejean-michelarnal.orgAtelectrauma resulting from repeated alveolar recruitment/derecruitmentBarotrauma and/or volutrauma resulting from lung overdistension M
2、echanisms of Ventilator Induced Lung InjuriesMechanical InjuryBiotrauma:alveolar inflammation Inflammatory InjuryPrevention of VILIReduced tidal volume and airway pressure limitation strategyRecruitment strategy:recruitment maneuver +PEEP to avoid derecruitmentWhat do we know about ARDS?Lower tidal
3、volume and airway pressure limitation decreases mortality No effect of PEEP on mortalityARDS network.N Engl J Med 2000ALVEOLI.Brower.N Engl J Med 2004EXPRESS.Mercat JAMA 2008LOVS.Meade.JAMA 2008Effect of PEEP on mortality in ARDSALVEOLI.Brower.N Engl J Med 2000PEEP=8,3 3,2 cmH2O13,2 3,5 cmH2On=549Ef
4、fect of PEEP on mortality in ARDSBriel.JAMA 2010What do we know about PEEP?PEEP does not recruit or just a little Collapse/re-expansion occurs during tidal volume Recruitment of previously collapsed lung with a recruitment maneuver PEEP may avoid collapse and derecruitment in a lung previously expan
5、ded/recruitedDont set PEEP without recruiting the lung!RecruitmentCollapsed compliant airways/alveoliFluid occlusion of non collapsed airwaysAm J Respir Crit Care Med 200624 sur 26 patientsAm J Respir Crit Care Med 2006n=68 Recruitability depends on Type of ARDS Time from the beginning of the diseas
6、e Pressure Chest wall complianceType of ARDS Mechanism:extra pulmonary pulmonary Localization:diffuse lobar Etiology:aspiration pneumonia CAPRiva.Crit Care Med 2008Puybasset.Intensive Care Med 2000Time from the beginning of the diseaseEarly phaseProtein rich edema fluids and polyneutrophilsLate phas
7、eFibrosing alveolitis24 on 26 patientsPressureBorges.Am J Resp Crit Care Med 2006Chest wall complianceChest wall complianceAirway pressure is a rough estimate of transpulmonary pressureTalmor.Crit Care Med 2006Assessment of recruitability Early in the management of ARDS When hemodynamic condition is
8、 controlledLow flow inflation and deflation PV curve from 0 to 40 cmH2OAssessment of recruitabilityAssessment of recruitabilityShape of the curveGrasso.AJRCCM 2005Assessment of recruitabilityLinear complianceMaggiore.AJRCCM 2001CLIN=37 mL/cmH2OCLIN=83 mL/cmH2OAssessment of recruitabilityLinear compl
9、ianceAssessment of recruitabilityHysteresisDemory.Intensive Care Med 20086 798 cmH2O.ml25 115 cmH2O.mlDemory.Intensive Care Med 2008Assessment of recruitabilityHysteresisAssessment of recruitabilityHysteresis and volume difference at 20 cmH2ODemory.Intensive Care Med 2008r2=0.97Assessment of recruit
10、ability300200100Assessment of recruitabilityCLIN=20 cmH2O/mLCLIN=60 cmH2O/mLHMAX=50 mLHMAX=200 mLClinical caseClinical caseMr.Be M,63 years old Leukemia treated by steroids Acute respiratory failure Community acquired pneumoniaMrs.Le D,72 years old Lymphoma treated by chemotherapy Acute respiratory
11、failure Community acquired pneumoniaClinical caseMr.Be M,63 years oldMrs.Le D,72 years oldDecision at the bedsideLow potential of recruitabilityHigh potential of recruitabilityLower inflection pointNonePresentLinear complianceLowHighHysteresisLowHighDecision at the bedsideLow potential of recruitabi
12、lityHigh potential of recruitabilityLower inflection pointNonePresentLinear complianceLowHighHysteresisLowHigh1/3 of patientsNo recruitment maneuverLow PEEP:5 10 cmH2O2/3 of patientsRecruitment maneuverHigh PEEP:10 cmH2ODefinition of a recruitment maneuver Use of a transient increase in transpulmona
13、ry pressure to reopen previously collapsed or non aerated lung units.Justification and goal for RM ARDS is characterized by a natural tendency for lung collapse:lung edema,surfactant dysfunction,low VT,high FiO2,repeated tracheal suctioning Goal:keep the lung open and prevent VILIMethod for RM CPAP
14、method:increase PEEP to 40 cmH2O for 40 s Sighs:periodically increase VT or PINSP Progressive increase in PEEP Prone positioningGrasso.Anesthesiology 2002Pelosi.AJRCCM 1999.Barbas AJRCCM 2001Albert.AJRCCM 2000Borges.AJRCCM 2006Time consuming,no direct monitoringVolume recruited depends on Previous r
15、ecruitment Transpulmonary inflation pressure Duration PEEP setting after the RMPressure and timeAlbert.J Appl Physiol 2009TimeRothen.BJA 199912 anaesthetized patients with healthy lung=2,6 sOptimal duration of the recruitment maneuverArnal.Intensive Care Med 2011 =2,3 1,3 sn=50Optimal duration of th
16、e recruitment maneuverRecruitment maneuver*Arnal.Intensive Care Med 2011 n=50Sustained inflation recruitment maneuverQuick,safe with volume recruited assessmentInspiratoryExpiratory=40 cmH2O pneumotachographPawVolume increase during a sustained inflation recruitment maneuverVolume increase during a
17、sustained inflation recruitment maneuverVRM=100 mLVRM=240 mLVolume increase during a sustained inflation recruitment maneuverClinical caseMr.Be M,63 years oldMrs.Le D,72 years oldVRM=30 mLVRM=220 mLRecruitment maneuver at the bedsideConditions Passive patient:deep sedation paralysis Stable hemodynamic condition:PP 10 cmH20(up to 25)guided by Poeso or SpO2 Recruitment should be an early goal in the management of ARDS.Thank you
