Managing ARDS 2010

John J. Marini
University of Minnesota

SCCM
Miami Beach 2010
 So, What’s New This Year?
• Conceptual Advances
– VILI causes
Principal Theme:
– Individual Complexity Individually Titrate Rx
• Monitoring • Severity
– Use of Pes for PTP • Timing
– Availability of FRC
• Treatment Options
– Extra-Pulmonary Gas Exchange
• Clinical Trials Evidence / Meta-Analysis
– PEEP
– Proning
 Take-Away Messages-1
• ARDS is a set of problems, not a disease.
• For many treatments, timing is very
important.
• VILI vulnerability is greatest in earliest
phase.
• Both tidal volume and PEEP must be
adjusted empirically based on ventilation
demand, lung capacity, and breathing
effort.
 Take-Away Messages-2

• Reducing demand is essential.

• ‘Open Lungs’ are not for everybody.
• Proning helps ‘severe recruiters’, not
everyone.
• Maintaining net fluid balance is crucial to
outcome.
 The Myth of ARDS
Diverse Etiologies

Common Pathophysiology

Unified Clinical Approach

 ARDS Diversity and
Responsiveness to Rx
• Underlying etiology
• Identification accuracy
• Pathophysiologic expression (Genetics)
– Severity
• Regional mechanics
• Phase of illness
• Background co-morbidities and co-interventions

Need to Individualize
 Plateau

PEEP Tidal Volume

V I L I
Recognized Mechanisms of
Airspace Injury

“Opening & Closure”

“Stretch”

“Shear”
Recognized Mechanisms of
Airspace Injury

Airway Trauma

“Stretch”

“Shear”
 Stress Strain

PEEP Tidal Volume

Strain ≈ (VT+FRC) / FRC

 “Open Lung” Rationale

Fewer Units
at Risk

Less Driving Pressure

Shorter Lever Arm

PEEP

Alveolar Pressure
Primary Goal for PEEP Selection

Minimize the airway pressures

needed to accomplish
simultaneously the goals of lung
protection, gas exchange, and
oxygen delivery.

High PEEP ??
ARDS Rel Risk of Barotrauma…High vs. Low PEEP

Phoenix, Susan; Anesthesiology. 110(5):1098-1105,

Phoenix Anesthesiology May 2009 May 2009 9
Sub-Groups of the ‘Negative’ LOVS Trial
60 PEEP Refractory? P=0.57

50
Not Sick Enough
40

30 LOV
Control
20

10
Severity
Recruitability
0
1st Q 2nd Q 3rd Q 4th Q
Baseline Oxygenation Index (FiO2 x MAP / PaO2)
 Fig. 2

ARDS Relative Risk of Death…High vs. Low PEEP

Phoenix Anesthesiology May 2009 6

Setting Plateau Pressure and PEEP...What
Surrounds the Lung is Important!
Lung Stress is Proportional to
Transalveolar Pressure
Which Plateau Pressure Is Safest?
…Depends on Effort and Chest Wall Stiffness!

Stiff CW Active Inspiration

Good Idea, but…
Esophageal Balloon Estimation of PPL

…Not Always Simple, Accurate, or

Representative
6ml/kg--Could
What About One ‘Size’
Tidal Fit All?
Volume?
PBW = 130 Kg

PBW = 85 Kg

What’s His
Ventilatory
Demand?

Chest Wall
Innate Capacity

PBW = 50 Kg
Adjust Tidal Volume for Demand
Weight Minute 6ml/kg Frequency
(pbw) Kg Ventilation

50 10 300 ml 33
15 500--30 50
20 670--30 67
85 10 510 ml 19
15 500--30 28
20 670--30 38
VTPBW is Not Good Enough…
(VT+FRC ) / FRC

Sick LUNGS Are Not Uniform

Gattinoni AJRCCM 2008

Absolute Aerated Lung Volume
Regional
Global StrainSpectrum of Opening
May Relate Best to (VT+FRC)Pressures
/ FRC Ratio

Opening
Pressure
Superimposed
Pressure Inflated 0

Small Airway 10-20 cmH2O

Collapse

Alveolar Collapse
(Reabsorption) 20-60 cmH2O

Consolidation 

(modified from Gattinoni))

 Best PEEP in 2010? ... Set Lowest
Feasible VT & Titrate Decrementally!
Adjust VT for
Titrate Pressures to Predicted Weight
Physiologic Endpoints
…and Adjust VT for
Minute Ventilation!

Chest Wall
Innate Capacity
 Recruitment is Transient if
PEEP Unchanged Afterward

VOLUME
(% TLC)

Rimensberger ICM 2000

 50

Decremental PEEP Setting

40 After Recruitment
Airway Pressure (cmH2O)

30

20

10

10-15 Minutes
Check Inspiratory PV Shape With Constant
Flow After Setting VT & PEEP
Inspiratory PV Shape Can Be
Characterized By Stress Index
Grasso, Ranieri
Tidal Recruiting OK? Over Distention
Predominates? Predominates?

Stress index is not well suited

for heterogeneous lungs or
abnormal chest walls….
 CONSTANT
FLOW
0.08

0.06
UPPER LUNG
IMPEDANCE CHANGES

0.04 TOTAL LUNG

0.02

0.00

-0.02

-0.04

-0.06

-0.08
LOWER LUNG
-0.10

0 30 60 90
Amato
Time (seconds)
 APRV and HFV
• Both are ‘open lung’ approaches [ ↑ mPaw]
– APRV
• Emphasizes spontaneous breathing
• One mode for all phases
– HFV
• Requires deep sedation
• Best used early
• In experienced hands, both are attractive options
• Neither has proven benefit vs. optimized ‘lung
protective’ (open lung?) ventilation
VT , Plateau Pressure, and PEEP…
Is That All We Need to Know??

I
Conditionally Important to VILI During
High Stress / Strain Ventilation

• PaCO2 and pH
Off-Radar ‘Stealth’ Factors??
• Minute Ventilation and
Flow
• Frequency
• Position
• Vascular Pressures
• Temperature
• Other
– dP/dt (Inspiratory Flow)
– I:E (Adverse Tension-Time
Product)
Conditional Benefit of Hypercapnia
Stress Severity

Kregenow, Crit Care Med 2006

A Fluid Conservative Strategy
Reduces Time On Ventilator

Lung-Protective Ventilation

NEJM June 2006

Have We Ignored Airway Flow?
 Flow Damage to the Baby Lung?

For Any Given Minute

Ventilation

• >3 times effective Stretch

• >3 times the Air Flow

??????
70 >3
Specific Flow L/min
x 70 = 210 L/min!!
How Might We Modify Specific Flow
Through The Baby Lung?

• Decrease the Driving Pressure (PCV)

• Alter the Flow Profile (ACV)
• Adjust the Flow Amplitude (I:E Ratio)
• Reduce the Minute Ventilation Need
– Sedation / Paralysis
– Fever reduction
– Extrapulmonary CO2 Elimination
• Nova Lung, TGI
 Importance of Flow to VILI
…Two Components
• Minute Ventilation
– Cumulative Volume Over Time
• Determines Average Inspiratory Flow -- VE/Ti
• Inspiratory Flow Characteristics
– Settings
• Flow (ACV)
• Driving Pressure and I:E ratio (PCV)
– Waveform
Lower Frequency & VE Reduce
VILI
 Inflation Patterns
Airway Pressure vs. Time

Extended Time at Pmax Reduced dP/dT

Lower Breathing Frequency

Rich, J Trauma, 2000
 Low Pressure
Control

High Pressure
Normal Rate
Normal f

Low f
High Pressure
Extended I:E

Stretch?

High Pressure
Short I:E Ratio

Shear? Mean PAW?

High Pressure
Low Insp. Flow

Rich, J. Trauma, 2000

Arterio-Venous Gradient Drives Flow
(Passive)

Nova-Lung
Pump-Powered Veno-Venous Flow

Hemo-lung

Pump Regulated Blood Flow

Two Birds…One Stone

Terragni Crit Care Med 2009

Therapeutic Hypothermia For ARDS?

↓ O2 Demand

↓ Inflammation
 Regional High PEEP-like Effect
Sustained Traction of “Supine Dependent” Units
Recruiters (?) Benefited From Proning

100
Gattinoni Crit Care2 (115
DPaCO Med pz)
2003
90
80 DPaCO2
Survival %

70
60
50 p=0.01
40
30
0 7 14 21 28
Days
 Proning May Benefit the Most
Seriously Ill ARDS Subset
0.5 Supine
Prone
Mortality Rate

0.4
* p<0.05
0.3
*
0.2

0.1

0.0
> 49 40- 49 31- 40 0 - 31
Quartiles of SAPS II
Kaplan-Meier Survival Curves of the Prone-Supine II Study Population: Entire Population and
Patients With Moderate and Severe Hypoxemia

Taccone et al, JAMA 2009

Copyright restrictions may apply.

Proning Improves O2 Exchange
in All Patient Categories

Sud et al., Int Care Med 2010

Proning May Improve Mortality in
Severely Ill Patients with ARDS

Sud et al., Int Care Med 2010

Proning Favors Lymphatic Drainage
And Helps Drain Airway Secretions

Supine Supine

Prone Prone

Albert & Hubmayr, AJRCCM 2000

Proning May Reduce VAP
The Environment Changes
Impressively Over Time

Recruitability, VILI risk, &

Advisability of Therapies
Pneumonia—Day 1
 “Primary ARDS”

Day 2 Day 7
Before Proning
Propagation After Proning
 Non-Symmetrical Disease

Shorter Lever Arm

Fewer Units at Risk

PEEP
PEEP

Alveolar Pressure
 Hospital-Acquired ARDS?

Dependent Position
Low PEEP
High Driving Pressure

Shorter Lever Arm

PEEP

Alveolar Pressure
 Propagation Prevention

Non-Dependent Position
High PEEP
Shorter Lever Arm
Low Driving Pressure

Fewer Units at Risk

PEEP

Alveolar Pressure
 Take-Away Messages
• ARDS is a set of problems, not a disease.
• For many treatments, timing is very important.
• VILI vulnerability is greatest in earliest phase.
• Both tidal volume and PEEP must be adjusted
empirically based on demand and lung capacity.
• Reducing demand is essential.
• Proning is helpful for some, not all.
• Maintaining net fluid balance is crucial to
outcome.
• High PEEP and “Open Lungs” are for early &
sickest
End of this Long Story?
Thank You
Impact of Steroids—Impressive or Not ?
Conditional on Timing