Running head: BILEVEL VENTILATION

BiLevel Ventilation Jason Duberville Collin College Respiratory Care Program Fall 2011

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Abstract Shunting, cardiac output, and ventilator associated pneumonia, are three aspects of patient care that can benefit from BiLevel ventilation. This paper will cover the basic technical aspects of the BiLevel mode, followed by highlights from three clinical articles in which the mode was used to improve patient outcomes. Finally, a brief reader's critique will end the paper.

BILEVEL VENTILATION Technical Aspects of BiLevel Ventilation

BiLevel is a trademarked term used to describe a mode of ventilation in the Puritan Bennett 840 ventilator. According to documentation from Puritan Bennett, the mode is designed for two ventilating strategies; Airway Pressure Release Ventilation (APRV) and Biphasic. From the pressure-time scalar below, it is possible to see the elements of these two strategies, and how they are related and similar. (Covidien 2011)

Figure 1: Components of a Biphasic wave form. (Covidien 2011) Above is a Biphasic wave form, where inspiration is supported at a high pressure level (PEEPH) and exhalations occurs at a lower level (PEEPL.) The factor which differentiates Biphasic ventilation from APRV ventilation is the inspiration and expiration time. In Biphasic mode, exhalation time (Etime) is long enough for spontaneous breaths to occur relatively frequently, whereas in APRV mode, Etimes are very short, typically less than 1 second. APRV typically has 4 second inspiration times (Itime), with 1 second Etimes. This is commonly called an inverse I:E ratio.

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In addition to the basic function above, BiLevel is designed to further provide pressure support to spontaneous breaths of the patient. From the chart below we can see how the spontaneous breath support works. (Covidien 2011)

The purpose of this feature is to allow easier patient weaning from the APRV mode of ventilation. Figure 2 shows weaning from the APRV mode can take the form of both reducing the PEEPH level, and, increasing the Etime. In this way a smooth transition from APRV, through Biphasic, to pressure supported spontaneous breathing, is made. The technical aspects of how each of these settings can be implemented on the actual Puritan Bennett 840 ventilator are listed in appendix A. Overall, spontaneous breathing of the patient is never unsupported. A default level of 1.5 cmH2O of pressure support is given to spontaneous breaths above both PEEPH and PEEPL levels respectively. Throughout the remainder of the paper BiLevel and APRV will be used interchangeably, as well as the combined term BiLevel APRV. This serves to bridge the gap between proprietary branding and clinical research in the area of APRV ventilation.

BILEVEL VENTILATION Shunting and BiLevel APRV

To understand the value of using BiLevel ventilation it helps to look at cases where the mode was successful. Hirani, Marik, and Plante (2009) published two such clinical cases, in Respiratory Care, that demonstrated successful outcomes in two pregnant patients with acute respiratory distress syndrome (ARDS.) The first case involved a 19-year-old patient at 30 weeks gestation, transferred to Thomas Jefferson University Hospital, after a week stay in a regional hospital for cough, fever, and shortness of breath. Upon arrival her PaO2/FiO2 ratio was 87, and she was receiving ceftriaxone, ampicillin, and azithromycin. She had bilateral infiltrates. Bronchoalveolar lavage (BAL) was performed and it was discovered Enterobacter cloacae was the source of her pneumonia. (Hirani et. al. 2009) The patient was given a tracheostomy, and, after no improvement for a two week period, the decision was made to go from conventional ventilation to BiLevel APRV. Before the mode change her FiO2 was at 0.9, with PEEP of 10cmH2O on assist control ventilation (A/C.) (Hirani et. al. 2009) Table 2, below, shows the pre and post ventilation changes.
A/C Vt 8ml/kg IBW PEEP 10cmH2O FiO2 0.90 (1hr prior to APRV) pH PaO2 torr Pco2 torr PaO2/FiO2 RR Mean arterial Pressure torr Paw cm H2O Paw torr PAO2 torr Pa/PA ratio Estimated Shunt Expected PaO2 7.45 79 40 87 20 76 16.62 12 602.5 13% 87% BiLevel APRV HiPEEP 28cmH20 LPEEP 8cmH2O TimeLow 1.0 sec. FiO2 0.90 (6hr after APRV) 7.47 131 36 145 121 91 24 17.64 612.57 21% 79% 79.63

Table 2: Case #1. (Modified from Hirani et. al. 2009)

1 2

Set rate used as spontaneous breaths in APRV do not change Itimes or Etimes. Estimated PIP of 30 cmH2O, Itime 1, Etime 2 seconds.

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The important number to note on Table 2 is the "Expected PaO2." Based on the patient's level of shunt, 87%, on conventional ventilation, APRV generating PAO2 of 612.57torr should produce PaO2 of 79.63 torr. In fact we see a better PaO2, of 131 torr, from APRV. Where did this extra 51 of PaO2 come from? APRV pushed out some of the fluid in the lungs to gain more working lung space. The BiLevel APRV mode pushed back 8% of the shunted area in 6 hours. This is a key statistic to look at when explaining why APRV can be a good ventilation mode and measuring therapeutic outcomes. A similar story occurs in the second patient presented by Hirani et. al.(2009.) A 24-yearold patient at 31 weeks presented with fever, shortness of breath, palpations and diarrhea. She was given fluids, broad-spectrum antibiotics, and a chest x-ray revealed left lower lobe pneumonia. The patient continued to decline and within 2 days intubation and mechanical ventilation were required. Chest x-ray revealed lobar collapse and worsening consolidation. Hypoxemia persisted despite PEEP of 14cmH2O and FiO2 of 1.0, with PaO2/Fio2 of 47mmHg. At this point the decision was made to switch to APRV mode and within two hours significant improvement in oxygenation and PaO2/FiO2 gains to 118mmHg occurred. Table 3, below, provides a full account of the pre and post APRV ventilation. Again, expected PaO2, based on almost identical FiO2 and Paw, is should be about 47 torr, and APRV is able to bring in an extra 71 torr of PaO2 by reducing the amount of the shunting. The conventional ventilation had and almost 93% shunt, which reduced to 83% within 90 minutes of starting APRV. This is a significant improvement.

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Table 3: Case #2. (Modified from Hirani et. al. 2009)

A/C Vt 7.5ml/kg IBW PEEP 14cmH2O FiO2 1.0 (prior to APRV)

BiLevel APRV HiPEEP 33cmH20 LPEEP 10cmH2O TimeLow 0.9 sec. FiO2 0.90 (1.5hr after APRV) 7.33 118 32 118 14 77 28.0 20.58 686 17.2% 83% 47.33

pH PaO2 torr Pco2 torr PaO2/FiO2 RR Mean arterial Pressure torr Paw cm H2O Paw torr PAO2 torr Pa/PA ratio Estimated Shunt Expected PaO2

7.24 47 38 47 20 67 213 15.44 680.94 6.9% 93% --

In conclusion, both mothers were able to deliver viable births while on ventilation. Both were able to recover, wean from ventilation, and return home. Both the children returned home within a period of weeks in good condition. In these cases, BiLevel APRV proved to be a tool for use at critical oxygenation levels, allowing the mother to be ventilated while at the same time the infant to remain in the womb until the 32 week mark, where surfactant production typically begins. Had BiLevel APRV gains in oxygenation not been achieved, early delivery may have been required.

PIP 35cmH2O, I:E ratio 1:2.

BILEVEL VENTILATION Cardiac Output and BiLevel APRV Kaplan, Bailey, & Formosa (2001) produced a study for the journal Critical Care

demonstrating the benefit of BiLevel APRV ventilation on cardiac performance with acute lung injury (ALI) and acute respiratory distress patients (ARDS.) The study looked at 12 patients receiving pressure control ventilation (PCV), and noted changes in cardiac output and sedation needs after change to BiLevel APRV. The initial settings of PCV were titrated to maintain PaO2 above 60, with FiO2 at or below 60. In addition, PaCO2 target levels were between 35-45 torr. Table 4, below, shows PCV settings compared with APRV.
Pawpk/PEEPH cmH2O Pawmean cmH2O Paralytics (% of patients) Sedative use (% of PCV patients) Pressors (% of patients) Lactate mmol/l Cardiac Index l/min/m 2 DO2 ml/min SvO2 (%) CVP mmHg Urine Output cc/kg per h PCV 38+/- 3 18+/- 3 74 100 92 2.2 +/- 0.4 3.2+/- 0.4 997+/- 108 72+/- 4 18 +/- 4 0.83 +/0.2 APRV 25+/-3 12+/-2 4 68 45 1.8+/-0.3 4.6+/-0.3 1409+/-146 80+/-5 (not significant) 12+/-5 0.96+/-0.3

Table 4: Median and % values. Modified from Kaplan et. al. 2001. APRV PEEPH levels were initially set at 75% of PCV peak airway pressure (Pawpk) and titrated after 30 minutes. The interesting aspect of table 3 is that BiLevel APRV was able to obtain the same targeted PaO2 > 60 with a lower mean airway pressure (12cmH2O verses 18cmH2O with P/C.) Unfortunately, the blood gas values and mean FiO2s are not reported in the data, so it is difficult to see exactly how this result did occur.

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Table 3 also shows that lower mean airway will increase cardiac output, by reducing systemic vascular resistance on venous return and pulmonary capillary resistance in the lungs. This factor is focused on by Kaplan et. al. and shows the potential value of BiLevel APRV in many clinical situations where cardiac output is a priority issue for the patient. In ARDS patients cardiac function itself is not the primary issue, rather fluid outs, driven by hydrostatic pressures, is a closely monitored factor. In this sense the increase cardiac output provides necessary support for the reduction of edema. Because oxygenation is also an issue, CaO2 can be analyzed from the table using the basic equation CIxCax10=DO2 and plugging in the numbers. Table 3 shows CaO2 for PVC would be about 31.5 ml/dl, and APRV to be 30.63ml/dl. The normal CaO2 range is 15-24ml/dl, however some slight polycythemia may be occurring due to diuretic therapy often used with ARDS/ALI patients. Finally, an important additional benefit of BiLevel APRV is decreased sedation requirements, as well as decreased paralytics and pressor needs for the patients. Table 3 shows improvement in these areas. In the study lorazapam and midazolam, titrated to 65-70 on the BIS index (see appendix B), use was reduced. Also, vecuronium and cis-atracurium, the paralytics used, were discontinued in almost all the patients on BiLevel APRV. Pressors were titrated to achieve a MAP of 75torr or greater and Kaplan et. al. (2001) write... "Almost half the patients were successfully weaned off pressors when transitioned to APRV. The probable explanation for the enhanced cardiac performance with reduced pressors stems from reduced peak and mean airway pressures." (p.224)

BILEVEL VENTILATION Ventilator Associated Pneumonia and BiLevel APRV

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Walkey, Nair, and Papadopoulos, et. al. (2011) recently published a study showing ventilator associated pneumonia (VAP) likelihood can be reduced using APRV. Specifically, in pulmonary contusion situations, which carry a high VAP rate of 18.3 occurrences per 1000 ventilator days (verses 7.7/1000 non contusion patients), APRV was shown to significantly reduce the patients chances of acquiring VAP. (Walkey et.al. 2011.) The amount of improved patient outcomes can be seen in Figure 3.

Figure 3. (Walkey et. al. 2011.) As the number of ventilator days increase, one can see a dramatic benefit to APRV ventilation compared with conventional ventilation in regards to VAP. This study was developed at the Boston Medical Center, a 629 bed, inner city, level 1 trauma center. The subjects were those patients with pulmonary contusions that required mechanical ventilation for longer than 48 hours. The study was done during a period when the VAP ventilator bundle was also being used, so results may be considered as above and beyond what is gained by the VAP bundle. (Walkey et. al. 2011)

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The two factors highlighted by Walkey et. al. contributing to the results are reduced sedation needs, as measured by the Riker Sedation Agitation Scale, and improved PaO2/FiO2 ratios. The Riker Sedation Agitation Scale is a 7 point scale nursing used to assess the need for sedation. A goal of 3-4 is typical being "calm and cooperative." A score of 7 is the worst: "patient attempting to get ET tube." The full scale is listed in appendix C. For APRV patients, 72.2 percent of the time they were within the 3-4 range verses 47.2 percent of the time with conventional ventilation. Walkey et. al. (2011) are careful to note..."there were no differences in total dosage of sedative or narcotic medications" (p. 44) between APRV and conventional ventilation. Median per ventilator day sedation and narcotic needs between the two groups are listed below in table 5. APRV (n = 31) Benzodiazepine 5.8 (0.74 - 24) Propofol 1212 (236 -2062 ) narcotic (mg fentanyl equivalents.) 2.5 (1.7-3.4) Table 5. Conventional (n = 33) 4.3 (0.85 - 19) 1340 (226-2363) 2.3 (1.2 - 3.3)

No explanation for the discrepancy between the SAS scoring difference, but the same amount of sedation given overall, is provided by the authors. There may be an answer to be found from an experienced clinician, however, this information is outside the current scope of this paper. Walkey et. al.(2011) also point out studies by Putensen et.al (2001) and Rathberger et. al. (1997) have supported the notion APRV does reduce the overall amount of required sedation compared with conventional ventilation. PaO2/FiO2 ratio improvement with APRV can be readily explained by the astute clinician, because the mean airway pressure (Paw) in APRV is likely to be significantly higher. In short, APRV pumps up the PaO2 with what amounts to extra PEEP. Table 5, below, shows the estimated median Paw for the APRV and conventional ventilation groups in this study.

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PaO2 for pre and post APRV data is not reported in this study, nor is FiO2, making further analysis difficult. However, it is reasonable to assume FiO2 was not significantly different in both groups and merely a reporting oversight. Table 6 clearly shows APRV will improve PaO2/FiO2 ratios simply based on higher alveolar air pressures. APRV I:E estimation 4:1 PIP cm H2O 25.8 PEEP cm H2O 1.2 Paw cm H2O 20.88 Table 6. Conventional 1:3 25.4 5.8 10.7

Walkey et. al. (2011) conclude, tentatively, that with this group of pulmonary contusion patients, a reduced risk of VAP is likely the result of increased lung recruitment with APRV ventilation.

BILEVEL VENTILATION Discussion and Reader's Critique

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Three possible benefits of BiLevel ventilation have been demonstrated in this paper. First, ARDS treatment with BiLevel APRV can gain precious PaO2 increments by reducing shunt, while at the same time protecting lung tissue from repeated high peak pressures stresses during inspiration. Second, BiLevel can be used to improve cardiac output by titrating PEEPH significantly below peaks pressures of conventional ventilation, and thereby protecting blood flow. Third, ventilator associated pneumonia is shown to be reduced with BiLevel APRV ventilation in higher risk populations due to reduced sedation needs related to improved patient-ventilator asynchrony, and lung recruitment. Although each of these studies provided excellent data in regards to BiLevel ventilation, some areas of improvement for future work should be noted. First, Hirani et. al. (2009) neglected to put in the peak pressures for the conventional modes of ventilation for their patients. A preread by a respiratory therapist in future might add this improvement to the excellent work of these fine physicians. Second, Kaplan et. al. (2001) did not put the pre and post median blood gas values for the move to BiLevel from pressure control ventilation. Hopefully future studies will include this information. And third, Walkey et. al. (2011) might integrate a better metric than the PaO2/FiO2 (P/F) ratio when comparing BiLevel APRV to conventional ventilation. The P/F ratio does not take into account PEEP levels, and thus is an unclear gauge for comparing one patient to another, or one group to another, in terms of better or worse from a respiratory standpoint. It is acceptable for this study, but future work might incorporate the oxygen index ratio, or the arterial to alveolar pressure (a/A) ratios.

BILEVEL VENTILATION References Covidien (2011) Puritanbennett.com, Retrieved from http://www.puritanbennett.com/serv/TechSup.aspx

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Hirani, A., Marik, P., Plante, L., (2009) Airway Pressure-Release Ventilation in Pregnant Patients With Acute Respiratory Distress Syndrome: A Novel Strategy. Respiratory Care, October 2009 Vol 54, No. 10 Kaplan, L., Bailey, H., Formosa, V., (2001) Airway Pressure Release Ventilation Increases Cardiac Performance in Patients with Acute Lung Injury/Adult Respiratory Distress Syndrome. Critical Care 2001, 5:221-226 Putensen, C., Zech, S., Wrigge, H. (2001) Long-Term Effects of Spontaneous Breathing during Ventilatory Support in Patients with Acute Lunge Injury. American Journal of Respiratory and Critical Care Medicine 2001, 164:43-49 Rathberger, J., Schorn, B., Falk, V., Kazmaier, S., Spiegel, T., Burchardi, H., (1997) The Influence of Controlled Mandatory Ventilation (CMV), Intermittent mandatory Ventilation, and Biphasic Intermittent Positive Airway Pressure (BIPAP) on Duration of Intubation and Consumption of Analgesic and Sedatives. A Prospective Analysis in 596 Patients Following Adult Cardiac Surgery. European Journal of Anaesthesiology 1997; 14:576-582 Walkey, A., Nair, S., Papadopoulos, S., Agarwal, S., Reardon, C., (2011) Use of Airway Pressure Release Ventilation is Associated with a Reduced Incidence of Ventilator-Associated Pneumonia in Patients with Pulmonary Contusion. The Journal of TRAUMA Injury, Infection, and Critical Care. 2011, Vol 70, No. 3

BILEVEL VENTILATION Appendix A(1)

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Appendix A(2)

A.2A.2

BILEVEL VENTILATION Appendix B

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The bispectral index (BIS) is measure of consciousness. It is based on electromyographic waveforms generated by neuronal activity. Leads on the patient's frontal and parietal plates generate the wave forms. The scale is a proprietary number, describing various states of consciousness as listed in Figure 1. It is used to replace or supplement Guedel's classification system for determining depth of anesthesia. (Images in from Google public image search.)

Figure 1: BIS descriptors.

Figure 2: BIS leads.

Figure 3: BIS user interface.

BILEVEL VENTILATION Appendix C

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