Lung Protective Ventilation in patients without ALI/ARDS

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Nick8

Nick8

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Does anybody uses the lung protective ventilation in patients without ALI/ARDS? (Vt=6-8 ml/kg):idea:
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Our ICU typically uses 6-8 ml/kg IBW for TV for all patients, although I don't know of any data to support this practice outside of the ARDS/ALI setting.
 
Nick8 said:
Does anybody uses the lung protective ventilation in patients without ALI/ARDS? (Vt=6-8 ml/kg):idea:
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no. I try to limit my Plateau pressures but that is rarely an issue outside of Ali/ARDS pts, and there is no data to support it's use outside of ARDS.
 
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tkim said:
http://emcrit.org/podcasts/vent-part-1/

http://emcrit.org/podcasts/vent-part-2/
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why would you not use PEEP for obstructive patients in respiratory failure? these are exactly the people who need it when they're severely obstructive. I've seen it too many times that the ER throws them on zero or 5 of peep and they still have a total peep of 15 or more and are desaturating, hell, I've watched medicine residents reintubate an asthmatic for "tube dislodgment" when they failed to give peep to a guy who was clearly auto-peeping.

I don't have time to watch the videos, but several things jumped out at me as things I disagree with in the handout he has. I stick with 8-10mL/kg in non-ards pts, but again this is without data, just anedoctally it helps with pt ventilator syncrony, so why under ventilate them if it isn't needed? especially since you're going to require tons more sedation that's going to increase your time on the ventilator and therefore increase your complication rates and LOS?

If the whole 6mL/Kg is something you don't want to budge on, then you should be using BiLevel to increase synchrony. (although it doesn't work as advertised IMHO)
 
jdh71 said:
I'll ask the boss on rounds in the AM and get back to you.
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my personal bias is, it's simply the hot new thing, and it's begging for a study. I have 1 attending who does this on EVERYONE, including the COPDers, it's not fun to watch them breath like a guppie on the vent. Given the disparity of lung compliance between ALI/ARDS and most of the other pt populations who are on a vent, I don't think this is really for prime time. unfortunately I took a quick gander to see if I could do a retrospective analysis, and it's not easy to do at my institution.
 
so while we're on this topic, if you do use LPV in non-ards pts, what do you do with the peep? do you still follow the peep titration table?

frankly only about 1/3 of my attendings actually follow the peep titration tables and rarely goes above a peep of 15 even on ARDS pts. I've gotten a few dirty looks when they walk in with a pt on 100% and a peep of 20.
 
Nothing's demonstrated a clinical benefit to LPV in non-ALI. There is however, a distinct reduction in inflammatory mediators and stress response when LPV is used in healthy patients (vs normal tidal volumes). This is probably going to be important in patients who have had prior radiation to the chest (think the esophageal and lung cancers). The number one cause of postoperative complications in esophagectomy is pulmonary related, and I'll absolutely use lung protective tidal volumes during those cases. As a pulmonary CCM attending said, there's no reason to use more than 500cc tidal volumes in anyone. I tend to agree.

BTW, VAP is also an issue. You guys should go comment in that thread too.
 
Hernandez said:
my personal bias is, it's simply the hot new thing, and it's begging for a study. I have 1 attending who does this on EVERYONE, including the COPDers, it's not fun to watch them breath like a guppie on the vent. Given the disparity of lung compliance between ALI/ARDS and most of the other pt populations who are on a vent, I don't think this is really for prime time. unfortunately I took a quick gander to see if I could do a retrospective analysis, and it's not easy to do at my institution.
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Essentially, there's really not much of a drawback, UNLESS the patient seems like they are not tolerating it well. It recommended in ARDS and anyone at risk for ARDS which could be almost anyone in the unit.
 
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proman said:
Nothing's demonstrated a clinical benefit to LPV in non-ALI. There is however, a distinct reduction in inflammatory mediators and stress response when LPV is used in healthy patients (vs normal tidal volumes). This is probably going to be important in patients who have had prior radiation to the chest (think the esophageal and lung cancers). The number one cause of postoperative complications in esophagectomy is pulmonary related, and I'll absolutely use lung protective tidal volumes during those cases. As a pulmonary CCM attending said, there's no reason to use more than 500cc tidal volumes in anyone. I tend to agree.

BTW, VAP is also an issue. You guys should go comment in that thread too.
Click to expand...

When did VAP become "an issue"? :D

I saw the thread, just didn't think there was much else to say, but I haven't read the entire article yet. The abstract seems like one big, "duh" to me. Do more right things, get more right outcomes.
 
Hernandez said:
so while we're on this topic, if you do use LPV in non-ards pts, what do you do with the peep? do you still follow the peep titration table?

frankly only about 1/3 of my attendings actually follow the peep titration tables and rarely goes above a peep of 15 even on ARDS pts. I've gotten a few dirty looks when they walk in with a pt on 100% and a peep of 20.
Click to expand...

We keep the PEEP at 5 for most patients, unless, generally, the patient is requiring more than 0.5 FiO2, and anyone needing more than 15 of PEEP just gets put on APRV. Which I like because it's so much more intuitive to mess around with.
 
my attendings as well tend to use low PEEP values, not those from tables. But l disagree on using low tidal volumes on every patient in ICU. Most patients on ventilator can be managed with minimal if any sedation if proper settings are ensued, therefore, if non ARDS pt is fighting the machine, and you calm him/her by increasing Vt up to 10mL/kg IBW with Ppt below 25-30 cm H20, l reckon you did great job, and you've increased chances of weaning him/her sooner. On the other hand, there are patients for whom you need to increase Vt and therefore peak pressure to achieve adequate lung ventilation, for those LPV strategy would be quite harmful actually.
 
jdh71 said:
We keep the PEEP at 5 for most patients, unless, generally, the patient is requiring more than 0.5 FiO2, and anyone needing more than 15 of PEEP just gets put on APRV. Which I like because it's so much more intuitive to mess around with.
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are ya'll using real APRV or just Bilevel that ya'll are calling APRV? one of my research projects is using Bilevel, but I'm not a huge fan of it at the moment to be honest with you, we don't seem to be able to lower our sedation levels with it, so I'll be honest, I don't think we have a great grasp on it's use, which is doesn't make sense since we use a TON of PCV already.
 
Hernandez said:
are ya'll using real APRV or just Bilevel that ya'll are calling APRV? one of my research projects is using Bilevel, but I'm not a huge fan of it at the moment to be honest with you, we don't seem to be able to lower our sedation levels with it, so I'll be honest, I don't think we have a great grasp on it's use, which is doesn't make sense since we use a TON of PCV already.
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All our vents can do real APRV.

You sound like the boss, though. :laugh: Come back after a weekend when he's on and everyone's back on PRVC with higher peeps and inverse ratios.

So far, I've liked it a lot. Modrykamien had a nice recent review in the CCF journal. And patients seem to be tolerating it really well, and it does what I want it to do, so . . .
 
Intensivist said:
my attendings as well tend to use low PEEP values, not those from tables. But l disagree on using low tidal volumes on every patient in ICU. Most patients on ventilator can be managed with minimal if any sedation if proper settings are ensued, therefore, if non ARDS pt is fighting the machine, and you calm him/her by increasing Vt up to 10mL/kg IBW with Ppt below 25-30 cm H20, l reckon you did great job, and you've increased chances of weaning him/her sooner. On the other hand, there are patients for whom you need to increase Vt and therefore peak pressure to achieve adequate lung ventilation, for those LPV strategy would be quite harmful actually.
Click to expand...

I'm with you, because in my mind the question is what's more harmful, the Tidal volume or the pressure? I'm kinda in the pressure camp, but I did run into an article (here) that seems to give some credence to the volume camp, as this PCV vent study ended up with higher TV than set in the VCV protocol in the ARDSNet data.

so based on this, I'll sit by a PCV and try and titrate the driving pressures to get my TV in the 6mL/Kg range even if I'm at 30cm Ppl or lower. but I don't know the answer to this question.
 
jdh71 said:
All our vents can do real APRV.

You sound like the boss, though. :laugh: Come back after a weekend when he's on and everyone's back on PRVC with higher peeps and inverse ratios.

So far, I've liked it a lot. Modrykamien had a nice recent review in the CCF journal. And patients seem to be tolerating it really well, and it does what I want it to do, so . . .
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I'm going to be a bit of an condescending butt for a second as there is huge confusion on what is the difference between APRV and Bilevel, the only difference between Bilevel and APRV is the release time is very short in APRV and it is synchronized to not allow spontaneous breaths on the lower PEEP, So oversimplified, I look at APRV as PCV with overlapping spontaneous breathing with an inversed I:E,

I've read the review and read all PB's training docs on it, the guys who use it the most here are the trauma surgeons, and half the time they end up giving paralytics with it, and at that point, I ask what's the point?

and yeah, I've probably done more 2:1 than APRV since they won't let me bust out the HFOV
 
Hernandez said:
I'm going to be a bit of an condescending butt for a second as there is huge confusion on what is the difference between APRV and Bilevel, the only difference between Bilevel and APRV is the release time is very short in APRV and it is synchronized to not allow spontaneous breaths on the lower PEEP, So oversimplified, I look at APRV as PCV with overlapping spontaneous breathing with an inversed I:E,

I've read the review and read all PB's training docs on it, the guys who use it the most here are the trauma surgeons, and half the time they end up giving paralytics with it, and at that point, I ask what's the point?

and yeah, I've probably done more 2:1 than APRV since they won't let me bust out the HFOV
Click to expand...

I promise I understand what APRV is as compared with Bilevel, and what I hear you saying is that you don't mind using APRV, you simply refuse to call it that :laugh:

You really seriously think HFOV would be a better alternative?

EDIT: And surgeons tend to use paralytics way too much in my experience, so I don't know if the meat-head's use of paralytics is necessarily an honest assessment of the situation.
 
what about patients in severe asthma, those in status? What is your determinant, if you're using volume modes, providing acceptable plateau up to which level of peak would you reckon is safe for most asthmatics to provide ventilation?
 
jdh71 said:
I promise I understand what APRV is as compared with Bilevel, and what I hear you saying is that you don't mind using APRV, you simply refuse to call it that :laugh:
Click to expand...

:laugh: you miss understand me, people use the terms interchangably and they're not, here it's universally called Bilevel since we have PB 840s, even when they have very short release times. I get tired of explaining that I'm using APRV not bilevel when I'm actually using the short release time.

well, they actually bastardized lots of the terminology here, A/C = VCV here, and when I correct the residents that PCV is also A/C I just get a dumb deer in the headlight look. :smuggrin:

jdh71 said:
You really seriously think HFOV would be a better alternative?
Click to expand...

I don't think that it'll ever be the primary mode, but if it's at least equivalent it may make a decent salvage therapy at centers who don't have ECMO, especially with the data from the recent trial with nimbes that showed at least some paralytics early on may help. so my thinking is if you use a mode that is claimed to have lower volu/barotrauma events than conventional ventilation and paralytics, it could be another tool in our pockets. BMJ just had a review and meta-analysis of the current data on HFOV in ards and there are currently 3 larger trials looking at HFOV vs the ARDSnet style ventilation, so we may have an answer soon. (one, two, three) mostly I just want to play with an oscillator dammit......
 
Intensivist said:
what about patients in severe asthma, those in status? What is your determinant, if you're using volume modes, providing acceptable plateau up to which level of peak would you reckon is safe for most asthmatics to provide ventilation?
Click to expand...

most reccomend (if you can do an exp pause and get a good value) applying 80% of measured peep as extrinsic peep to prevent further hyperinflation or BP issues.

Petrof BJ, Legare M, Goldberg P , Milic-Emili J, Gottfried SB. Continuous positive airway pressure reduces work of breathing and dyspnea dur-ing weaning from mechanical ventilation in severe chronic obstructive pulmonary disease. Am Rev Respir Dis 1990; 141:281–289.

Georgopoulos D, Giannouli E, Patakas D. Effects of extrinsic positive end-expiratory pressure on mechanically ventilated patients with chronic obstructive pulmonary disease and dynamic hyperinflation. Intensive Care Med 1993; 19:197–203.
 
Hernandez said:
:laugh: you miss understand me, people use the terms interchangably and they're not, here it's universally called Bilevel since we have PB 840s, even when they have very short release times. I get tired of explaining that I'm using APRV not bilevel when I'm actually using the short release time.

well, they actually bastardized lots of the terminology here, A/C = VCV here, and when I correct the residents that PCV is also A/C I just get a dumb deer in the headlight look. :smuggrin:



I don't think that it'll ever be the primary mode, but if it's at least equivalent it may make a decent salvage therapy at centers who don't have ECMO, especially with the data from the recent trial with nimbes that showed at least some paralytics early on may help. so my thinking is if you use a mode that is claimed to have lower volu/barotrauma events than conventional ventilation and paralytics, it could be another tool in our pockets. BMJ just had a review and meta-analysis of the current data on HFOV in ards and there are currently 3 larger trials looking at HFOV vs the ARDSnet style ventilation, so we may have an answer soon. (one, two, three) mostly I just want to play with an oscillator dammit......
Click to expand...

HFOV huh . . . I haven't really paid ANY attention to it all, but I'll check out your articles. Sounds interesting. We won't use where I'm at now, but surely next year . . . it will at least be an option.

And yeah I get what you're saying about the modes and the lingo. I was at one time guilty of this myself :oops:
 
Hernandez said:
:laugh: you miss understand me, people use the terms interchangably and they're not, here it's universally called Bilevel since we have PB 840s, even when they have very short release times. I get tired of explaining that I'm using APRV not bilevel when I'm actually using the short release time.

well, they actually bastardized lots of the terminology here, A/C = VCV here, and when I correct the residents that PCV is also A/C I just get a dumb deer in the headlight look. :smuggrin:



I don't think that it'll ever be the primary mode, but if it's at least equivalent it may make a decent salvage therapy at centers who don't have ECMO, especially with the data from the recent trial with nimbes that showed at least some paralytics early on may help. so my thinking is if you use a mode that is claimed to have lower volu/barotrauma events than conventional ventilation and paralytics, it could be another tool in our pockets. BMJ just had a review and meta-analysis of the current data on HFOV in ards and there are currently 3 larger trials looking at HFOV vs the ARDSnet style ventilation, so we may have an answer soon. (one, two, three) mostly I just want to play with an oscillator dammit......
Click to expand...

HFOV is becoming more popular in my area of the country. During a neonatal rotation last month, we ended up spending about half our time in the adult surgical ICU because there were more adults on HFOV than neonates at that time.
 
Thank you for your answers! :)

I've found an article about LPV in patients without ALI/ARDS. According to this article there is a difference between cytokines production. However it is still unknown if conventional ventilation increases duration of mechanical ventilation and mortality.

Ventilation with lower tidal volumes as compared with conventional tidal volumes for patients without acute lung injury: a preventive randomized controlled trialDetermann et al. Critical Care 2010, 14:
http://ccforum.com/content/14/1/r1

I think it's one of the most interesting articles covers this problem. According to the authors:

• Mechanical ventilation with conventional tidal volumes
in patients without ALI is associated with sustained
cytokine production, as measured in plasma.
• Our data at least suggest that mechanical ventilation
with conventional tidal volumes contributes to the
development of lung injury in patients without ALI at
the onset of mechanical ventilation.
• The use of lower tidal volumes is not associated with
higher sedation needs or vasopressor use.
• The use of lower tidal volumes is not associated with
requirements for higher PEEP or additional FiO2.
• Larger randomized controlled trials are needed to
confirm whether reducing tidal volumes benefits
patients with respect to shorter duration of mechanical
ventilation and lower mortality rates.
 
Hernandez said:
I'm with you, because in my mind the question is what's more harmful, the Tidal volume or the pressure? I'm kinda in the pressure camp, but I did run into an article (here) that seems to give some credence to the volume camp, as this PCV vent study ended up with higher TV than set in the VCV protocol in the ARDSNet data.
Click to expand...

I'm at ATS and they showed sOme sub group analysis from the ardsnet data that showed it seemed those with lower tv and ppl had better Outcomes than even those with ppl less than 30 with higher TV. I'll have to see if I cm find those slides.
 
there's a decent point-counterpoint I'm chest this month. the Italian guy is well written. I'll pull up the podcast later and watch the whole thing
 
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