ICU Management

(1)

ICU management of the Acute

Respiratory Distress Syndrome

Jean-Daniel Chiche, MD, PhD

Medical

Medical ICU & ICU & DeptDept. of . of Cell BiologyCell Biology H

(2)

Acute Respiratory Distress Syndrome

•

• HighHigh--permeability permeability type type pulmonary edemapulmonary edema

•

• Acute Acute onset onset

•

• PaOPaO₂₂/FiO/FiO₂₂ < 200 < 200 mmHgmmHg •

• Bilateral infiltratesBilateral infiltrates •

• No No history history / / sign sign of of left left ventricular dysfunction

ventricular dysfunction

Consensus

(3)

Reviewing 40 years of ARDS research

What did we learn ?

Reviewing 40 years of ARDS research

What did we learn ?

• Pathophysiology:

– Animal models: relevance ? – A complex entity

•

• Pathophysiology

Pathophysiology

:

–

– Animal models: relevance ? Animal models: relevance ? –

(4)

Ware

Ware &&MatthayMatthay NEJM 2000

(5)

Reviewing 40 years of ARDS research

What did we learn ?

Reviewing 40 years of ARDS research

What did we learn ?

• Pathophysiology:

• Clinical evaluation

– Pulmonary / extrapulmonary ARDS – Early / late ARDS

– Other failing organs: a systemic disease ?

•

• Pathophysiology:

Pathophysiology:

–

– A A complex entitycomplex entity

•

• Clinical evaluation

Clinical evaluation

–

– Pulmonary Pulmonary // extrapulmonary extrapulmonary ARDSARDS –

– Early Early // late late ARDSARDS –

(6)

ARDS:

pulmonary

or

systemic disease

?

Ullrich

(7)

Stratification System of Acute

Lung Injury

Letter

Letter MeaningMeaning ScaleScale DefinitionDefinition G

G Gas exchangeGas exchange 00 PaOPaO₂₂/FiO/FiO₂₂ ≥≥ 301301 1

1 PaOPaO₂₂/FiO/FiO₂₂ 201201--300300 2

2 PaOPaO₂₂/FiO/FiO₂₂ 101101--200200 3

3 PaOPaO₂₂/FiO/FiO₂₂ ≤≤ 100100 G

G Gas exchangeGas exchange AA spontaneous breathingspontaneous breathing, ZEEP, ZEEP

(to

(to be combinedbe combined)) BB assisted breathingassisted breathing, PEEP 0, PEEP 0--5 cmH5 cmH₂₂OO

C

C assisted breathingassisted breathing, PEEP 6, PEEP 6--10 cmH10 cmH₂₂OO D

D assisted breathingassisted breathing, PEEP , PEEP ≥≥ 10 cmH10 cmH₂₂OO O

O Organ failureOrgan failure 00 lung onlylung only 1

1 lung lung + 1+ 1 organorgan 2

2 lung lung + 2+ 2 organsorgans 3

3 lung lung + + ≥≥ 33 organsorgans C

C CauseCause 00 unknownunknown 1

1 directdirect lung injurylung injury 2

2 indirectindirect lung injurylung injury A

A Associated diseaseAssociated disease 00 nono disease causing death within disease causing death within 55 years years 1

1 coexisting disease coexisting disease ((prognosis prognosis 6 m6 m-- 5 y)5 y) 2

2 coexisting disease coexisting disease ((prognosis prognosis < 6< 6 monthsmonths) )

AJRCMM 1998

(8)

Reviewing 40 years of ARDS research

What did we learn ?

Reviewing 40 years of ARDS research

What did we learn ?

• Pathophysiology:

• Clinical evaluation

– Pulmonary / extrapulmonary ARDS – Early / late ARDS

– Other failing organs: a systemic disease ?

• Specific treatment: no breakthrough !

•

• Pathophysiology:

Pathophysiology:

–

– A A complex entitycomplex entity

•

• Clinical evaluation

Clinical evaluation

–

– Pulmonary Pulmonary // extrapulmonary extrapulmonary ARDSARDS –

– Early Early // late late ARDSARDS –

– Other failing organsOther failing organs: a : a systemic disease systemic disease ??

•

(9)

(10)

Corticosteroids for Early ARDS

Corticosteroids

for

Early

ARDS

Crit Care Med 2003; S253

Crit

Crit Care Med 2003; S253Care Med 2003; S253

•

• Corticosteroids should Corticosteroids should not not be used be used in in early early ARDS.ARDS. •

• Consider supplementation Consider supplementation of of septic septic patients patients with with relative relative adrenal insuffisiency

(11)

Corticosteroids for Late ARDS

Corticosteroids

for

Late

ARDS

after after D14, D21, D14, D21, D28 to D32 D28 to D32 0.5 mg/kg 0.5 mg/kg q6q6 x14 dx14 d 0.5 mg/kg 0.5 mg/kg q12q12 x7 dx7 d 2 mg/kg x14 d 2 mg/kg x14 d 1 mg/kg x 7d 1 mg/kg x 7d 88 % 88 % 24 24 1998 1998 Meduri Meduri clinical clinical response response 1 1--2 mg/kg 2 mg/kg q6q6 4 4--8 mg/kg8 mg/kg 83 % 83 % 6 6 1995 1995 Biffl Biffl after extubation after extubation or D14 or D14 0.5 0.5--0.75 mg/kg 0.75 mg/kg q6q6 2 2--3 mg/kg3 mg/kg 76 % 76 % 25 25 1991,94 1991,94 Meduri Meduri after after D3D3--D4 as D4 as tolerated tolerated 125 125--250 mg 250 mg q6q6 0,5 0,5--1 g/day1 g/day 81 % 81 % 26 26 1990,96 1990,96 Hooper Hooper after

after D5 for 21 D5 for 21 days days 1 1--2 mg/kg 2 mg/kg q6q6 4 4--8 mg/kg8 mg/kg 80 % 80 % 10 10 1985 1985 Ashbaugh Ashbaugh Tapering Tapering Schedule Schedule Daily dose Daily dose Survival Survival n n Year Year Author Author

(12)

†

(13)

•

• 4 4 after after ICU ICU discharge

discharge

• 4 after

crossover to MP

(14)

N=180

(15)

(16)

Decreased

ARDS

mortality

--

the Success

of ICU Management

-

-0 20 40 60 80 100 1975 1980 1985 1990 1995 2000 Abraham Ullrich NIH ARDSNet Brower Ranieri Stewart Brochard Amato Amato Anzueto Bernard Bone Bone Morris Villar Fowler Sloane Montgomery Bell Suchyta Zapol Suchyta

(17)

Treatment Strategies for ARDS

Treatment Strategies

for ARDS

• Treat ARDS etiology +++

– Suspected H5N1 infection: oseltamivir – Community-acquired pneumonia

• Improve O

₂

delivery and support failing

organs

– Hemodynamics

• Fluid resuscitation

• Vasopressors & inotropes

– Renal function

• Nutritional support

• Deep sedation

•

• Treat

Treat

ARDS

etiology

+++

–

– Suspected Suspected H5N1 infection: H5N1 infection: oseltamiviroseltamivir –

– CommunityCommunity--acquired pneumoniaacquired pneumonia

•

• Improve

Improve

O

₂₂

delivery and

support

failing

organs

–

– HemodynamicsHemodynamics

•

• Fluid resuscitationFluid resuscitation •

• Vasopressors Vasopressors & & inotropesinotropes

–

– Renal functionRenal function

•

• Nutritional

Nutritional

support

•

(18)

Crit

Crit Care MedCare Med 2004;32:8582004;32:858--873873 Intensive Care Med

Intensive Care Med 2004;30:5362004;30:536--555555

www.springerlink.com www.springerlink.com www.sccm.org www.sccm.org www.sepsisforum.com www.sepsisforum.com

(19)

Guidelines for Management

A. Initial resuscitation B. Diagnosis C. Antibiotic therapy D. Source control E. Fluid therapy F. Vasopressors G. Inotropic therapy H. Steroids I. rH Activated Protein C

J. Blood product administration

K.

K. Mechanical Ventilation of SepsisMechanical Ventilation of Sepsis- -induced ALI & ARDS

induced ALI & ARDS

L.

L. Sedation, analgesia & NM blockadeSedation, analgesia & NM blockade M.

M. Glucose controlGlucose control N.

N. Renal replacementRenal replacement O.

O. Bicarbonate therapyBicarbonate therapy P.

P. Deep vein thrombosisDeep vein thrombosis Q.

Q. Stress ulcer prophylaxisStress ulcer prophylaxis R.

R. Consideration for limitation of supportConsideration for limitation of support S.

(20)

Treat early

Treat everything

Treat well

(21)

Mechanical

ventilation for ARDS

_{ventilation for ARDS}

--

Rationale

for changes

-

-•

• The mechanical properties The mechanical properties of of the respiratory the respiratory system system

are

are altered during altered during ARDSARDS

–

– Decrease Decrease in FRC= in FRC= reduced lung reduced lung volumevolume –

– Decrease Decrease in in compliancecompliance –

(22)

0 0.5 1 1.5 2 0 0.5 1 1.5 2 T I S S U E (L) 0 1 2 3 LOWER LOBES TOTAL LUNG UPPER LOBES

HV ARDS HV ARDS HV ARDS

2 LUNGS

2 LUNGS SUP LOBES SUP LOBES INF LOBESINF LOBES

ARDS

ARDS CTLCTL CTLCTL ARDSARDS

CTL

ARDS

⇒

Increased lung

_{Increased lung}

tissue

_tissue

Found

Found in in dependent dependent & & nondependent lung regionsnondependent lung regions

Lung tissue :

- Extravascular lung water - Thoracic blood volume - Lung inflammation

Lung

Lung tissue :tissue :

-- Extravascular lung waterExtravascular lung water

-- Thoracic blood Thoracic blood volumevolume

-- Lung Lung inflammationinflammation

L

L Puybasset Puybasset et al, Intensive Care et al, Intensive Care MedicineMedicine,26,857,2001,26,857,2001

T I S S U E (L) 0 1 2 3 TOTAL LUNG HV ARDS 2 LUNGS 2 LUNGS ARDS ARDS CTL CTL

(23)

L OW E R L O B E S T O T A L LU N G U P P E R L O B E S 0 0 .5 1 1 .5 2 0 0.5 1 1.5 2 (L) 0 1 2 3 4 H V A R D S H V A R D S H V A R D S F R C 2 LUNGS

2 LUNGS SUP LOBES SUP LOBES INF LOBES INF LOBES

ARDS

ARDS CtlCtl CtlCtl ARDSARDS Ctl

Ctl

Focal ARDS

•

• Always present Always present in in inferior inferior lobeslobes •

• Often missing Often missing in in the dependent the dependent lobes

lobes

2

2 different different situations :situations :

ARDS

⇒

Decreased lung aeration

L

L Puybasset Puybasset et al, Intensive Care et al, Intensive Care MedicineMedicine,26,857,2001,26,857,2001

Diffuse ARDS

(24)

Mechanical

ventilation for ARDS

_{ventilation for ARDS}

--

Rationale

for changes

-

-•

• The mechanical properties The mechanical properties of of the respiratory the respiratory system system are

are altered during altered during ARDSARDS

–

– Decrease Decrease in FRCin FRC –

– Decrease Decrease in in compliancecompliance –

– Increase Increase in in resistanceresistance

•

• ARDS ARDS lungs lungs are are heterogeneousheterogeneous

•

(25)

0 0 2 2 4 4 6 6 8 8 10 10 Qwl Qwl/BW (ml/kg)/BW (ml/kg) HiP-HiV

HiP-HiV LoPLoP-HiV-HiV HiP-HiP-LoVLoV 00

0.3 0.3 0.6 0.6 0.9 0.9 1.2 1.2 DLW/BW (g/kg) DLW/BW (g/kg) HiP-HiV

HiP-HiV LoPLoP-HiV-HiVHiP-HiP-LoVLoV

0 0 20 20 40 40 60 60 80 80 100 100 Alb Alb. . SpSp. (%). (%) HiP-HiV

HiP-HiV LoPLoP-HiV-HiV HiP-HiP-LoVLoV

**

** ****

**

Dreyfuss

(26)

Mechanical Ventilation for ARDS

Setting the Goals

-•

• «« AdequateAdequate »» gas exchangesgas exchanges

–

– SaOSaO₂₂ 8888--94 %94 % –

– «« PermissivePermissive »» hypercapniahypercapnia –

– pH>7.25pH>7.25

•

• Prevent ventilatorPrevent ventilator--induced lung induced lung injury

injury (VILI)(VILI)

–

– «« VolutraumaVolutrauma »» –

(27)

CONSENSUS CONFERENCE ON

MECHANICAL VENTILATION

ACCP

-

_-

SCCM

_SCCM

-

_-

ESICM

_ESICM

«

There

are no

convincing

data

indicating

that any

mode

of

ventilatory

support

is

superior

to

others

for ARDS patients

»

Chest

(28)

Mechanical

ventilation for ARDS

•

• Which

Which

mode ?

•

• Settings

Settings

?

–

V

_T_T

(ou

P

_plat_plat

)

–

FiO

₂₂

–

PEEP

–

RR

–

I/E

(29)

VILI: How to estimate the risk ?

•

• OverdistensionOverdistension

Edema fluid accumulation

Surfactant degradation

High oxygen exposure

Mechanical disruption

(30)

Reducing

V

_T_T

from

12 to 6 mL/kg

decreases mortality

in ARDS

NIH ARDS Network. NEJM 2000

(31)

Reducing

V

_T_T

from

12 to 6 mL/kg

decreases mortality

in ARDS

NIH ARDS Network. NEJM 2000

(32)

Interpretation

of

PRCTs

in ARDS

0,01 0,1 1 10

Stewart

Stewart BrochardBrochard BrowerBrower

NIH

NIH AmatoAmato

LL 95% CI LL 95% CI OR OR UL 95% CI UL 95% CI

(33)

N.I.H.

Interpretation

(34)

N.I.H.

Interpretation

(35)

15 20 25 30 35 40 45 0 1 2 3 Plateau pressures (cmH Plateau pressures (cmH₂₂O)O) R e la ti v e r is k o f d e a th R e la ti v e r is k o f d e a th

(36)

Mechanical

ventilation for ARDS

•

• Which

Which

mode ?

•

• Settings

Settings

?

–

V

_T_T

(or

P

_plat_plat

)

–

FiO

₂₂

–

(37)

VILI: How to estimate the risk ?

•

• OverdistensionOverdistension

Edema fluid accumulation

Surfactant degradation

High oxygen exposure

Mechanical disruption Mechanical disruption • • AtelectasisAtelectasis Surfactant inhibition Surfactant inhibition Hypoxemia Hypoxemia Maldistribution Maldistribution of Vof V_T_T

Repeated opening / closure

(38)

QuickTime™ et un décompresseur

(39)

Regional Recruitment and

Inflation in ARDS

0 2 4 6 8 1 0 1 2 1 4 Recruitment (g) 0 5 1 0 1 5 2 0 End inspiration End expiration PEEP (cmH₂O) Pplat (cmH₂O) 21 ± 1.8 26 ± 1.4 31 ± 1.8 38 ± 2.1 46 ±3.2 Gattinoni

Gattinoni, AJRCCM 1995, AJRCCM 1995

*

* *

*

(40)

How to set PEEP ?

«

« PEEP trialPEEP trial »»

•

• Stepwise Stepwise ↑↑↑↑↑↑↑↑ of PEEP of PEEP •

• Evaluation Evaluation criteria criteria • • Oxygenation Oxygenation ?? • • Compliance Compliance ?? • • Hemodynamics Hemodynamics ??

(41)

PEEP / FiO

₂₂

algorithms

ALVEOLI

•

• Reminder Reminder of of the the objectivesobjectives •

• Simple & Simple & «« validatedvalidated »»

=

(42)

(43)

(44)

(45)

How to set PEEP ?

«

•

• Evaluation Evaluation criteria criteria • • Oxygenation Oxygenation ?? • • Compliance Compliance ?? • • Hemodynamics Hemodynamics ?? 0 500 1000 1500 0 10 20 30 40 A B PEPi Pressure (cmH ₂O) UIF UIF LIF LIF Lung mechanics Lung mechanics

(46)

Amato et al. D A Y S 0 2 4 6 8 P E E P (c m H2 O ) 4 6 8 10 12 14 16 18 Brochard et al. D A Y S 0 2 4 6 8 Stewart et al. D A Y S 0 2 4 6 8 Brower et al. D A Y S 0 2 4 6 8 P E E P ( c m H2 O ) 0 2 4 6 8 N.I.H. DAYS Protective Control

Interpretation

(47)

BROCHARD & BROWER & STEWART & AMATO 4 6 8 10 12 14 16 18 0.0 0.5 1.0 1.5 2.0 2.5 R e la ti v e ri s k o f d e a th PEEP (cm H₂O) n = 331 P = 0.001

(48)

BROCHARD & BROWER & STEWART & AMATO 4 6 8 10 12 14 16 18 0.0 0.5 1.0 1.5 2.0 2.5 R e la ti v e ri s k o f d e a th PEEP (cm H₂O) n = 331

(49)

BROCHARD & BROWER & STEWART & AMATO 4 6 8 10 12 14 16 18 0.0 0.5 1.0 1.5 2.0 2.5 R e la ti v e ri s k o f d e a th PEEP (cm H₂O) n = 331

(50)

How to set PEEP ?

0 500 1000 1500 0 10 20 30 40 A B PEPi Pressure (cmH ₂O) UIF UIF LIF LIF «

•

• Evaluation Evaluation criteria criteria • • Oxygenation Oxygenation ?? • • Compliance Compliance ?? • • Hemodynamics Hemodynamics ??

(51)

How to set PEEP ?

--

a

practical

alternative

-

-•

• Hypothesis Hypothesis #1#1 There is

There is a a potential potential for for alveolar recruitment during the alveolar recruitment during the acute

acute phase of ARDS (< D2phase of ARDS (< D2--D4).D4).

•

• Hypothesis Hypothesis #2 #2 P

PEEEEP P keeps keeps openopen unstable alveoli recruited during unstable alveoli recruited during previous

previous inspirations.inspirations.

•

• Hypothesis Hypothesis #3#3 Effective

Effective alveolar alveolar recrutement recrutement improves oxygenation improves oxygenation and enables

(52)

Decremental PEEP trials

• Volume difference can represent

either recruited or de-recruited volume.

• CRF measurements during a

decremental PEEP trial following a recruitment maneuver can

identify:

the response to recruitment

manœuver

the level of PEEP where

(53)

FRC-guided PEEP setting in ALI -1

800 1000 1200 1400 1600 1800 6 8 10 12 14 16 PEEP (cmH2O) 86 88 90 92 94 96 6 8 10 12 14 16 PEEP (cmH2O)

(54)

FRC-guided PEEP setting in ALI -1

800 1000 1200 1400 1600 1800 6 8 10 12 14 16 PEEP (cmH2O) 6 7 8 9 10 6 8 10 12 14 16 PEEP (cmH20)

(55)

FRC-guided PEEP setting in ALI -2

82 84 86 88 90 92 94 6 8 10 12 14 16 PEEP (cmH2O) 800 1000 1200 1400 1600 1800 2000 2200 6 8 10 12 14 16 PEEP (cmH2O)

(56)

FRC-guided PEEP setting in ALI -2

800 1000 1200 1400 1600 1800 2000 2200 6 8 10 12 14 16 PEEP (cmH2O) 4 5 6 7 8 6 8 10 12 14 16 PEEP (cmH20) Volume expansion 1500 mL saline serum

(57)

FRC-guided PEEP setting in ALI -2

800 1000 1200 1400 1600 1800 2000 2200 6 8 10 12 14 16 PEEP (cmH2O) 82 84 86 88 90 92 94 96 98 100 6 8 10 12 14 16 PEEP (cmH2O)

(58)

Fluid Resuscitation Strategy in ARDS

Fluid Resuscitation Strategy

in ARDS

_{in ARDS}

• Hypoprotidemia predicts the

development of ARDS and death in septic patients

• EVLW correlates with mortality in ARDS • Fluid resuscitation may improve

cardiac output and O₂ delivery

• Treatment with albumin + furosemide might decrease mortality in ARDS

•

• Hypoprotidemia predicts the Hypoprotidemia predicts the development

development of ARDS of ARDS and death and death in in septic

septic patientspatients •

• EVLW EVLW correlates with mortality correlates with mortality in ARDSin ARDS •

• Fluid resuscitation may improve Fluid resuscitation may improve cardiac

cardiac output output and and OO₂₂ deliverydelivery •

• Treatment with albumin Treatment with albumin + + furosemide furosemide might decrease mortality

might decrease mortality in ARDSin ARDS

Volume ?

Fluid

(59)

N=1000

(60)

(61)

Currently

Currently no no reason reason to to implement implement an an algorithmalgorithm--controlled controlled fluid

(62)

•

• FiOFiO₂₂ 1 1 - PaO- ₂ 45 mmHg

•

• PEEP 16 PEEP 16 cmHcmH₂₂OO - PaCO- ₂ 112 mmHg

•

• PP_plat_plat 38 38 cmHcmH₂₂OO - pH 7.02

-•

(63)

Optimised Ventilatory Strategies

For

Severe

_Severe

ARDS

_ARDS

•

• Heating chambersHeating chambers •

• Closed suctioning systemsClosed suctioning systems •

• Recruitment maneuversRecruitment maneuvers, , sightsight…… •

• Prone positioningProne positioning •

• NONO •

(64)

Mechanical

Ventilation for ARDS

Conclusions

-

_-

1 ₁

•

• No No specific treatment specific treatment have been have been shown shown to to be be effective in

effective in the treatment the treatment of ARDS.of ARDS. •

• No No reason reason to use to use highhigh--dose steroids dose steroids in in early early / / late late ARDS

ARDS

•

• Treat the Treat the cause of ARDS !cause of ARDS !

–

– Consider early antimicrobial treatment Consider early antimicrobial treatment for CAP for CAP and and oseltamivir

oseltamivir if suspicion of influenza infectionif suspicion of influenza infection

•

• Follow current Follow current guidelines for guidelines for supportive treatment supportive treatment of of patients

(65)

Mechanical

Ventilation for ARDS

Conclusions

-

_-

2 ₂

•

• Mechanical

Mechanical

ventilation

can

injure

the lung

in

experimental and clinical

conditions

–

– Barotrauma Barotrauma !! –

– Pulmonary edemaPulmonary edema –

– Biotrauma Biotrauma ??

•

• Reduction

Reduction

of V

_T_T

and tight

control of

P

_plat_plat

decrease mortality

(66)

Mechanical

Ventilation for ARDS

Conclusions

-

_-

3 ₃

•

• Alveolar recruitment and Alveolar recruitment and PEEP PEEP levels optimized levels optimized according

according to to the etiology and the severity the etiology and the severity of ARDS (of ARDS (lung lung mechanics

mechanics) ) may improve gas exchange and outcomemay improve gas exchange and outcome.. •

• The The use of use of alveolar recruitment strategies alveolar recruitment strategies mandates mandates preload optimization and

preload optimization and close close hemodynamic hemodynamic monitoring.monitoring. •

• DonDon’’t forget t forget «« detailsdetails »»: : suctioningsuctioning, no HME,, no HME,……and treat and treat ARDS

ARDS etiology etiology !!!!!!

•

• Consider Consider alternative alternative strategies and strategies and multimodal multimodal therapies