Physiological based management of hypoxaemic respiratory failure

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1 Physiological based management of hypoxaemic respiratory failure David Tingay 1. Neonatal Research, Murdoch Children s Research Institute, Melbourne 2. Neonatology, Royal Children s Hospital 3. Dept of Paediatrics, University of Murdoch Children s Research Institute, 2017

2 After a generation of surfactant, steroids, machines and gentleness are preterm respiratory outcomes better? Doyle L et al NEJM

3 Conventional Ventilation in 2018 is confusing CMV/IMV SIMV AC/SIPPV/PTV PSV CPAP PC-APRV MMV Is the discussion regarding the mode to choose the right question? VTV 3

4 Gives a Pressure Via a Flow of gas What does a Ventilator do? Modulates (Limits) the pressure against Time Terminate or Flow Limit PIP To generate an inflation of the lung actively and deflation passively May try to synchronise the start and/or end of this process with the spontaneous Initiate? breathing pattern May try to adapt the inflation pressure to maintain a constant tidal volume Ti All Neonatal Ventilators are TCPL +/- VCPL PEEP PEEP 4

5 What do the lungs do? 1. Oxygenation a) F IO2 b) Adequate recruitment - PEEP, PIP, Ti 2. Ventilation = CO 2 clearance a) Alveolar Minute Ventilation = Rate x (V T V D ) V T influenced by: - DP (PIP PEEP) 3. Diffusion 4. Perfusion - Flow and R RS - Ti - Volume State of the lung (PEEP and C RS ) 5

6 The lung is a mechanical system that requires motion to work The natural state of the lung is deflation (elastic system) Lung inflation requires generating enough pressure (and energy) to overcome the forces E Force M R EQUATION OF MOTION Force = (E x distance) + (R x speed) + (M x acceleration) 6

7 Principles of Lung Mechanics Applying the equation of motion to achieve gas exchange R RS PRESSU RE STAT! C RS = DV/DP 7

8 Volume Inflating the Lung Generating a tidal volume - Compliance Compliance describes the ability of the lung to move when a pressure is applied to it C RS = DV/DP Surfactant PEEP PIP 8

9 Inflating the Lung Takes time - Resistance Compliance, C RS P AO Resistance, R RS ΔV L ΔP L Active Inspiration Inspiratory Flow = constant Higher R RS = Greater Pressure to move the lung for any given period of time P AO = 0 Resistance, R RS ΔV L ΔP L Passive Expiration Inspiratory Flow Compliance, C RS 9

10 Ti and Te need to allow the lung to fully inflate and deflate Time Constant: t (tau) = C RS x R RS Describes the slope of the exponential DV curve Salazar and Knowles J Appl Physio

11 Time constants Normal lung: τ 3 ml/cm H 2 O x 0.04 cm H 2 O/mL/sec 0.12 sec (insp and exp) Parenchymal disease: τ 0.5 ml/cm H 2 O x 0.04 cm H 2 O/mL/sec 0.02 sec (insp and exp) Airway disease: τ 2 ml/cm H 2 O x 0.1 cm H 2 O/mL/sec 0.2 sec (exp > insp) Time Constant: t (tau) = C RS x R RS 11

12 The ventilator tells you how to inflate and deflate the lung 12

13 Understanding Time Constants at the bedside All about the FLOW wave form 13

14 Time is also important in expiration Auto-PEEP 14

15 Not all babies in the NICU are the same HMD Pulmonary Hypoplasia Evolving BPD MAS Atelectasis Hypoplasia Gas Trapping Mixed Disease Different manifestations of disease have different mechanical properties of the lung There can not be a single mode or single (or tight) range of ventilator settings that are always correct 15

16 Disease state, PEEP and Compliance Safe Zone Deflation Limb = Stable homogenous EEV, maximal C RS Zone of Overdistension = High homogenous EEV, Low C RS 100 Sp O2 P max V TRIP V L (%) 50 Region of optimal volume MV HF Tc CO2 VTao 0 P final P initial Optimal P aw range P aw (%) Safe Zone Safe Zone Inflation Limb = Increasing (heterogeneous) EEV, Improving C RS Zone of Atelectasis = Low heterogeneous EEV, Low C RS Dargaville Int Care Med 2010, Tingay Crit Care Med

17 Optimising Volume Targeted Ventilation 1. Correct V T for Min Vent, V Alv and V D 2. Correct Ti and Te to allow V T to be achieved Correct PEEP (volume state) to optimise C RS Klingenberg et al Cochrane Database 2017, Keszler Arch Dis Child Fetal Neo

18 Physiological Rationale for triggering mechanical inflations 6540 inflations (n=10), 42% triggered Triggered PIP 12.9 (4.9) cm H 2 O vs 17.0 (3.3) cm H 2 O McCallion et al ADC F&N 2008; 93: F

19 Rheotrauma impact of flow (volume change over time) In low compliance states low flow (2-4 L/min) more protective than high flow (8-10 L/min) Flow (L/min) a Pre-surfactant b a Post-Surfactant b Wave Power (W/s 2 ) a b a 0.4s b a = inflation b = deflation Red = forward Blue = backward Adapted from J Pillow Smolich Tingay Pilot Data 19

20 Ventilator settings in the NICU 5 fundamental questions 1. What is the right modality for the pathophysiology? 2. What PEEP is appropriate for the lung disease and the desired lung volume? 3. What insp time is appropriate for the time constant of the lung, ± the baby s respiratory pattern? 4. What PIP is needed to produce an appropriate tidal volume? 5. What rate is needed to produce adequate minute ventilation, and therefore CO 2 clearance? 20

21 Initial Ventilatory Approach for the Neonatal Lung Aim for NIV as soon as practical What is the pathophysiological process? Disease State? Mechanical State? Regional? Where possible target V T not PIP and synchronise Ti & Te Ventilation Approach Modality* Atelectasis C RS, R RS N Short HVS CMV/ HFOV Normal Lung C RS N, R RS N Homogeneous Short Cautious HVS+P CMV/ HFOV Gas Trapping C RS N, R RS Normal NVS CMV Hypoplasia C RS, R RS N Heterogeneous Long LVS HFJV/ HFOV In complex mixed regional lung pathophysiology the correct approach is usually dictated by the current primary problem strategy needs frequent re-evaluation. Normal - Long Short N or LVS+P N or LVS HFJV/HFO V/CMV HFJV P = positioning, VS = Volume Strategy; H = high, N = normal, L=low 21

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