Why we should care (I)

What the $*!# is Lung Protective Ventilation and Why Should I be Using it in the OR? Disclosures KATHERINE PALMIERI, MD, MBA 64 TH ANNUAL POSTGRADUATE SYMPOSIUM UNIVERSITY OF KANSAS MEDICAL CENTER DEPARTMENT OF ANESTHESIOLOGY APRIL 11, 2014 Why we should care (I) Continuous use of large tidal volumes or periodic deep breaths (hyperinflations) are essential in preventing an increase in variable shunt (atelectasis). Why we should care (II) Elective Surgery and Acute Lung Injury Common 5-10% all surgical patients 30-40% thoracic/abdominal surgeries Serious ICU admission 10-90% higher Mortality as high as 48% Expensive Mean increase LOS 8 days Surgical costs 2-12x higher 1

More % Postop Resp Failure 35 30 25 20 15 10 5 0 Is This You??? Why you will care more in the future PSI #11 Postoperative Respiratory Failure What do we know? Ventilator Associated Lung Injury 2

Ventilator Associated Lung Injury Mechanical Ventilation in ARDS Mechanical Ventilation in ARDS ALI in the OR Do we know what to do? ALI in the OR Do we know what to do? 3

ALI in the OR Do we know what to do? ARDSnet Guidelines Any mode ok Consider using ICU ventilator with TIVA Tidal Volumes 6-8 ml/kg predicted body weight Respiratory Rate Set for a reasonable MV - but not > 35 ARDSnet Goals Plateau Pressure vs Peak Inspiratory Pressures Oxygenation PaO2 55-80 mmhg or SpO2 88-95% PEEP >= 5 cm H20 FiO2 < 70 ph 7.30-7.45 Pplat 30 cm H2O ALI in the OR Do we know what to do? But What About Healthy Lungs? 4

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Outcome of patients mechanically ventilated for >48 hrs before and after protocol introduction More of Multivariate Logistic Regression Odds Ratio 95% CI p Value TV, each 1 ml/kg PBW above 6 mls/kg PBW** 1.29 (1.12-1.51) < 0.001 Blood Transfusion 2.97 (1.56 5.9 ) < 0.001 Patients who subsequently developed ARDS Patients who did not subsequently develop ARDS 6

More Patients who subsequently developed ARDS Patients who did not subsequently develop ARDS Even More Risk Factors Associated with the development of ARDS Odds Ratio 95% CI p Value Tidal volume > 700 mls 2.67 1.94 3.65 <0.001 Ppk >30 cmh2o 1.57 1.16 2.13 0.003 Trauma 1.80 1.11 2.87 0.015 High TV Low TV # Events Total # Events Total Risk Ratio ALI 138 1090 47 1113 0.33 Mortality 115 1077 74 1145 0.64 Pulm Infection 57 665 32 681 0.52 Atelectasis 62 631 43 656 0.62 7

Reminder The Current State of Affairs in the OR Independent Risk Factors Risk Factor? p Value = 0.63 The Current State of Affairs in the OR Changes in TV > 10 ml/kg IBW Changes in use of zero PEEP 28% 16% 27% 18% 8

More IL-1 IL-6 IL-8 PaO2/FiO2 at end of OLV 18 h postop at end of OLV 18 h postop at end of OLV 18 h postop during OLV 1 hr postop Protective Ventilation Conventional Ventilation Time to Extubation (p < 0.001) 115 mins 171 mins 9

Recommendations Do no harm Limit tidal volumes, use PBW Limit pressures Use PEEP Consider recruitment maneuvers Avoid oxygen toxicity Prioritize patient safety 10

Ideal Body Weight Will You Change Your Practice? Will You Change Your Practice? Problem #1 138 42 47% Additional Problems 11

Conclusion REFERENCES The Acute Respiratory Distress Syndrome Network. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome, NEJM, May 4, 2000, Vol 342, No 18. Bendixen HH, et al. Impaired Oxygenation in Surgical Patients During General Anesthesia with Controlled Ventilation: A Concept of Atelectasis, NEJM, Nov 7, 1963, Vol 269, No 19. Blum JM, et al. A Description of Intraoperative Ventilator Management in Patients with Acute Lung Injury and the Use of Lung Protective Ventilation Strategies, Anesthesiology. 2011 Jul;115(1):75-82. Chiawat O, et al. Intraoperative Adherence to a Low Tidal Volume Ventilation Strategy in Critically Ill Patients with Preexisting Acute Lung Injury, J Crit Care. 2011 Apr;26(2):144-51. Della Rocca G, Coccia C. Acute Lung Injury in Thoracic Surgery, Curr Opin Anaesthesiol. 2013 Feb;26(1):40-6 REFERENCES (cont.) REFERENCES (cont.) De Oliveira RP, et al. Mechanical Ventilation with High Tidal Volume Induces Inflammation in Patients Without Lung Disease. Critical Care 2010, 14:R39. Determann RM, et al. Ventilation with Lower Tidal Volumes as Compared with Conventional Tidal Volumes for Patients Without Acute Lung Injury: a Preventive Randomized Controlled Trial, Critical Care 2010, 14:R1. Dreyfuss D, Saumon G. Ventilator-induced Lung Injury: Lessons from Experimental Studies, Am J Respir Crit Care Med. 1998 Jan;157(1):294-323. Ferguson ND, et al. Acute Respiratory Distress Syndrome: Underrecognition by Clinicians and Diagnostic Accuracy of Three Clinical Definitions, Crit Care Med 2005;33(10):2228-2234. Fernandez-Perez ER, et al. Intraoperative Ventilator Settings and Acute Lung Injury After Elective Surgery: a Nested Case Control Study, Thorax, 2009 Feb; 64(2):121-7. Futier E, et al. A Trial of Intraoperative Low-Tidal-Volume Ventilation in Abdominal Surgery, NEJM, 2013;369:428-37. Gajic O, et al. Ventilator-associated Lung Injury in Patients Without Acute Lung Injury at the Onset of Mechanical Ventilation, Crit Care Med 2004; 32:1817-1824. Gajic O, et al. Ventilator Settings as a Risk Factor for Acute Respiratory Distress Syndrome in Mechanically Ventilated Patients, Intensive Care Med (2005) 31:92-926. Hess DR, et al. A 5-year Observational Study of Lung-protective Ventilation in the Operating Room: A Single-center Experience Jaber S, et al. A Multicentre Observational Study of Intra-operative Ventilatory Management During General Anaesthesia: Tidal Volumes and Relation to Body Weight, Anaesthesia 2012, 67, 999-1008. Lellouche F, et al. High Tidal Volumes in Mechanically Ventilated Patients Increase Organ Dysfunction after Cardiac Surgery, Anesthesiology 2012;116:1072-82. Michelet P, et al. Protective Ventilation Influences Systemic Inflammation after Esophagectomy, Anesthesiology 2006; 105:911-9. REFERENCES (cont.) REFERENCES (cont.) Needham DM, et al. Lung Protective Mechanical Ventilation and Two Year Survival in Patients with Acute Lung Injury: Prospective Cohort Study, BMJ 2012;344:e2124. Petrucci N, DeFeo C. Lung Protective Ventilation Strategy for the Acute Respiratory Distress Syndrome (Review), Cochrane Database Syst Rev. 2013 Feb 28 Putensen C, et al. Meta-analysis: Ventilation Strategies and Outcomes of the Acute Respiratory Distress Syndrome and Acute Lung Injury, Ann Intern Med. 2009 Oct 20;151(8):566-76. Rubenfeld GD, et al. Barriers to Providing Lung-Protective Ventilation to Patients with Acute Lung Injury, Crit Care Med. 2004;32(6);1289-1293. Serpa Neto et al. Association Between Use of Lung-Protective Ventilation with Lower Tidal Volumes and Clinical Outcomes Among Patients Without Acute Respiratory Distress Syndrome, JAMA. 2012;308(16):1651-1659. Sundar S, et al. Influence of Low Tidal Volume Ventilation on Time to Extubation in Cardiac Surgical Patients, Anesthesiology. 2011 May;114(5):1102-10. Tremblay L, et al. Injurious Ventilatory Strategies Increase Cytokines and c-fos m-rna Expression in an Isolated Rat Lung Model, J Clin Invest. 1997; 99(5):944-952. Wolthuis EK, et al. Mechanical Ventilation with Lower Tidal Volumes and Positive End-expiratory Pressure Prevents Pulmonary Inflammation in Patients without Preexisting Lung Injury, Anesthesiology 2008; 108:46-64. Yilmaz M, et al. Toward the Prevention of Acute Lung Injury: Protocol-guided Limitation of Large Tidal Volume Ventilation and Inappropriate Transfusion, Crit Care Med. 2007 Jul;35(7);1660-6. Good Website for Lung Protective Ventilation How Tos: http://www.ardsnet.org 12