Driving Pressure. What is it, and why should you care?

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1 Driving Pressure What is it, and why should you care? Jonathan Pak MD March 2, 2017

2 Lancet 1967; 290:

3 Traditional Ventilation in ARDS Tidal Volume (V T ) = ml/kg PBW PEEP = 5-12 cm H 2 O

4 Ventilator-Induced Lung Injury PIP: 14 PEEP: 0 PIP: 45 PEEP: 10 PIP: 45 PEEP: 0 Am Rev Respir Dis 1974; 110:

5 Ventilator-Induced Lung Injury High Volume High Pressure VILI Low Volume Low Pressure VILI

6 Ventilator-Induced Lung Injury Lung Volume Time

7 Ventilator-Induced Lung Injury Lung Volume VILI from Overdistension VILI from Open/Close Time

8 N Engl J Med 2000; 342:

9 V T 6 and 4 ml/kg PBW* P plat 30 PEEP 5 * Okay to increase V T up to 8 ml/kg PBW if P plat 30 N Engl J Med 2000; 342:

10 Ventilator-Induced Lung Injury Lung Volume VILI from Overdistension VILI from Open/Close Time

11 Ventilator-Induced Lung Injury Lung Volume VILI from Overdistension VILI from Open/Close Time

12

13 N Engl J Med 2004; 351:

14 Lower PEEP Group (same as ARMA) Higher PEEP Group (adapted from Amato et al, NEJM, 1998) N Engl J Med 2004; 351:

15 N Engl J Med 2004; 351:

16

17

18 V T 6 and 4 ml/kg PBW* P plat 30 PEEP 5 * Okay to increase V T up to 8 ml/kg PBW if P plat 30

19 V T 6 and 4 ml/kg PBW* P plat 30 PEEP 5 * Okay to increase V T up to 8 ml/kg PBW if P plat 30

20

21

22 Lower PEEP Group (same as ARMA) Higher PEEP Group (adapted from Amato et al, NEJM, 1998) N Engl J Med 2004; 351:

23 Protective Approach V T < 6 ml/kg High PEEP Driving Pressure (P plat - PEEP) < 20 cm H 2 O N Engl J Med 1998; 338:

24 Driving Pressure ( P) Driving Pressure PEEP Time

25 N Engl J Med 1998; 338:

26 Retrospective analysis APACHE II Mean PEEP in first 36 hours Driving Pressures in first 36 hours N Engl J Med 1998; 338:

27 N Engl J Med 2015; 372:

28

29 Model Variables Patient Variables Days on vent Age Apache III # Organ Failures Arterial ph PaCO 2 PaO 2 /FiO 2 ratio Tidal Compliance Ventilator Variables Tidal Volume (V T ) P plat PEEP FiO 2 Respiratory Rate P aw Driving Pressure ( P)

30 Matched PEEP Matched P Matched P Plat

31 Survival in Patients with Protective Vent Settings All with P plat 30 cm H 2 O and V T 7 ml/kg PBW Driving Pressure Median: 13 cm H 2 0 Plateau Pressure Median: 26 cm H 2 0 Tidal Volume Median: 6 mg/kg PBW

32 Combined Mortality by P

33 Survival Predicted by P in ALVEOLI

34 Barotrauma predicted by P, not VT

35 Essential Question Is driving pressure just a measure of disease severity, or can it be used to improve outcomes?

36 Driving Pressure ( P) Driving Pressure PEEP Time

37 Compliance (C) = V P C RS = V T P plat - PEEP

38 C RS = V T P plat - PEEP P = V T C RS

39 V T C RS > V T PBW

40 Determinants of P are V T and C RS Compliance Volume P V T Airway Pressure

41 Determinants of P are V T and C RS P Compliance Volume P V T Airway Pressure

42 Determinants of P are V T and C RS Compliance Volume P P V T Airway Pressure

43 Ventilator-Induced Lung Injury Lung Volume VILI from Overdistension VILI from Open/Close Time

44 Ventilator-Induced Lung Injury Lung Volume VILI from Overdistension VILI from Open/Close Time

45 Use P to Optimize PEEP Volume V T = 6 PEEP = 10 P = 18 Airway Pressure

46 Use P to Optimize PEEP Volume V T = 6 PEEP = 14 P = 14 Airway Pressure

47 Use P to Optimize PEEP Volume V T = 6 PEEP = 18 P = 18 Airway Pressure

48 Use P to Optimize PEEP Volume V T = 6 PEEP = 14 P = 14 Airway Pressure

49 Use P to Optimize V T Volume V T = 6 PEEP = 14 P = 16 Airway Pressure

50 Use P to Optimize V T Volume V T = 5 PEEP = 14 P = 14 Airway Pressure

51 Ventilator-Induced Lung Injury Lung Volume VILI from Overdistension VILI from Open/Close Time

52 Technical Questions What size increments to adjust PEEP? How long to wait before checking P after change in PEEP or V T? Role for recruitment maneuvers? How often to check P daily?

53 What Can You Do Today? Calculate P on ARDS patients Chart it

54 Ventilator Flowsheet

55 Ventilator Flowsheet

56 What Can You Do Today? Calculate P on ARDS patients Chart it (update EMR to calculate it) If P is high (>14-15): adjust PEEP decrease V T discuss neuromuscular blockade, proning, or transfer to an ECMO center

57 Conclusions P is easy to measure and track Increased P is associated with higher mortality in ARDS patients Adjustments in PEEP and V T can lower P Optimizing vent settings to lower P could improve outcomes, but has not been studied

58

59 P = P plat - PEEP = V T C RS

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