presentation overview ards/ali: bundling care … pao 2/fio 2 ratio • user friendly tool • crude...

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Kathleen Vollman MSN, RN, CCNS, CCRN, FCCMKathleen Vollman MSN, RN, CCNS, CCRN, FCCMClinical Nurse Specialist/Educator/ConsultantClinical Nurse Specialist/Educator/Consultant

ADVANCING NURSINGADVANCING NURSINGwww.vollman.comwww.vollman.com

[email protected]@comcast.netDearborn, MichiganDearborn, Michigan

ARDS/ALI: ARDS/ALI: Bundling Care Bundling Care to Impact to Impact OutcomesOutcomes

Presentation OverviewPresentation Overview

Defining Acute Lung Injury/ARDS Defining Acute Lung Injury/ARDS •• Links with the Systematic Inflammatory Response Links with the Systematic Inflammatory Response

SyndromeSyndrome•• Incidence & mortalityIncidence & mortality

PathophysiologicPathophysiologic derangementsderangementsClinical signs & symptomsClinical signs & symptomsSupportativeSupportative care: The 6 Pcare: The 6 P’’s of therapys of therapy•• Prevention, PEEP, Pipes, Pump, Paralysis & Prevention, PEEP, Pipes, Pump, Paralysis &

PositioningPositioningFuture therapiesFuture therapies

ARDS: a Component of the SIRS ContinuumARDS: a Component of the SIRS ContinuumDirect Insult

AcuteRespiratory

Distress Syndrome

CardiacDysfunction

HematologicDysfunction Multiple System

Organ Failure

Multiple OrganDysfunctionSyndrome

Systemic InflammatoryResponse Syndrome (SIRS)

LiverDysfunction

NeurologicalDysfunction

KidneyDysfunction

IndirectInsult

““A syndrome of acute respiratory A syndrome of acute respiratory failure in adults characterized by nonfailure in adults characterized by non--cardiogenic pulmonary edema cardiogenic pulmonary edema manifested by severe hypoxemia manifested by severe hypoxemia caused by right to left shunting caused by right to left shunting through collapsed or fluid filled through collapsed or fluid filled alveolialveoli””..

Ashbaugh, Bigelow, Petty, 1967

Acute Lung Injury: A ContinuumAcute Lung Injury: A Continuum

Normal Lung Acute Lung InjuryNormal Lung Acute Lung Injury ARDSARDS

DefinitionDefinition……Acute Lung InjuryAcute Lung InjuryOxygenation Oxygenation -- PaOPaO2 2 / FiO/ FiO2 2 < 300 < 300

regardless of PEEP regardless of PEEP levelslevels

Chest xChest x--rayray -- Bilateral infiltrates Bilateral infiltrates seen on frontal chest seen on frontal chest xx--rayray

PCWPPCWP -- < 18 mmHg and/or no < 18 mmHg and/or no clinical evidence of clinical evidence of left atrial hypertensionleft atrial hypertension

Bernard et. al. Am J of Respir Crit Care Med 1994;149:818Bernard et. al. Am J of Respir Crit Care Med 1994;149:818--824 824

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PaOPaO22/FiO/FiO22 RatioRatio

•• User friendly toolUser friendly tool•• Crude assessment Crude assessment

of the severity of of the severity of lung injurylung injury

•• Used in the definition Used in the definition of ALI/ARDSof ALI/ARDS–– ALI: ALI: << 300 regardless 300 regardless

of PEEPof PEEP–– ARDS: ARDS: << 200 200

regardless of PEEPregardless of PEEP

PaO2 = 70 torrFiO2 = 60% or .60P/F Ratio = 70/.60Answer: 117

© Vollman 2001

DefinitionDefinition……Acute Lung InjuryAcute Lung InjuryOxygenation Oxygenation -- PaOPaO2 2 / FiO/ FiO2 2 < 300 < 300

regardless of PEEP regardless of PEEP levelslevels

Chest xChest x--ray ray -- Bilateral infiltrates Bilateral infiltrates seen on frontal chest seen on frontal chest xx--rayray



DefinitionDefinition……Acute Respiratory Acute Respiratory Distress SyndromeDistress Syndrome

Oxygenation Oxygenation -- PaOPaO2 2 / FiO/ FiO2 2 < 200 < 200 regardless of PEEP regardless of PEEP levelslevels

Chest xChest x--ray ray -- Bilateral infiltrates Bilateral infiltrates seen on frontal chest seen on frontal chest xx--rayray



Incidence of ARDSIncidence of ARDS

Evans, 1988Evans, 198825 per 100,000/year25 per 100,000/year

Lewandowski, 1995Lewandowski, 19953 per 100,000/year3 per 100,000/year

Goss, 2003Goss, 200364.2 per 100,000/year64.2 per 100,000/year

NHLBI, 1979NHLBI, 197975 per 100,000/year75 per 100,000/year

Author/YearAuthor/YearIncidence of Incidence of ARDSARDS

Goss CH. Crit Care Med 2003;31(6):1607-1611

Mortality TrendsMortality Trends•• 19671967--1987 mortality ranges 551987 mortality ranges 55--65%65%•• 19901990’’s control groups of clinical trials on s control groups of clinical trials on

ARDS mortality ranges 31ARDS mortality ranges 31--44%44%

Mortality Rates Decline in Mortality Rates Decline in ARDS PatientARDS Patient

36%1993

Below 50%1991

Slight decline1989-1990

53-68%1983-1987

Mortality RateYears

Milberg et al. JAMA, 1995;273:306-309

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Declining Mortality RatesDeclining Mortality Rates……Why???Why???

•• Patients are less ill or less severely Patients are less ill or less severely injuredinjured

•• Patient populations are different in Patient populations are different in different studiesdifferent studies

•• Numerous changes in supportive Numerous changes in supportive therapy have had a small but additive therapy have had a small but additive effecteffect

ARDS ARDS GOOD NEWSGOOD NEWS85% WHO RECOVER 85% WHO RECOVER HAVE NEAR NORMAL HAVE NEAR NORMAL

PULMONARY FUNCTION PULMONARY FUNCTION ONE YEAR LATERONE YEAR LATER

OneOne--Year Outcomes In Survivors Year Outcomes In Survivors in ARDSin ARDS

•• 109 ARDS survivors evaluated at 3, 6 & 12 months 109 ARDS survivors evaluated at 3, 6 & 12 months post illnesspost illness

•• Survivors young (45 years), Long ICU LOS (median Survivors young (45 years), Long ICU LOS (median 25 days) and APACHE II > 2325 days) and APACHE II > 23

•• Loss of 18% Body wt at d/c from ICULoss of 18% Body wt at d/c from ICU•• Muscle wasting & fatigue were reasons for Muscle wasting & fatigue were reasons for

functional limitationsfunctional limitations•• Lung function & Lung function & spirometricspirometric’’ss normal 6 monthsnormal 6 months•• CO2 diffusion capacity low for full 12 monthsCO2 diffusion capacity low for full 12 months•• Absence of steroid use, absence of illness acquired Absence of steroid use, absence of illness acquired

during ICU stay & MODS had better functional during ICU stay & MODS had better functional status.status.

Herridge MS. Et al. N Engl J Med. 2003;348:683-693

Common Predisposing Conditions Common Predisposing Conditions Associated With ARDSAssociated With ARDS

Direct Injury:Direct Injury:

Inhalation injuries: PneumonitisAcid Aspiration BacterialNear Drowning Viral (SARS)Smoke Other

Drugs: Pulmonary ContusionParaquat Oxygen ToxicityHeroin Radiation

Common Predisposing Conditions Common Predisposing Conditions Associated With ARDSAssociated With ARDS

Sepsis SyndromeSepsis Syndrome

Multiple TransfusionsMultiple Transfusions

ShockShock

Multisystem TraumaMultisystem Trauma

Pulmonary EmbolismPulmonary Embolism

Fat EmbolismFat Embolism

PancreatitisPancreatitis

Intracranial HypertensionIntracranial Hypertension

BurnsBurns

Bypass SurgeryBypass Surgery

DICDIC

Indirect Injury:Indirect Injury:

Incidence of ARDSIncidence of ARDS

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Pathophysiologic CharacteristicsPathophysiologic Characteristicsin ARDSin ARDS

A permeability defect described as a diffuse, A permeability defect described as a diffuse, nonnon--uniform injury to the alveolar epithelium uniform injury to the alveolar epithelium and alveolar capillary membrane (mediator and alveolar capillary membrane (mediator & ventilator induced)& ventilator induced)Acute changes in the caliber of smaller Acute changes in the caliber of smaller airwaysairwaysDirect injury to pulmonary circulation Direct injury to pulmonary circulation (mediator & ventilator induced)(mediator & ventilator induced)Defect in the bodyDefect in the body’’s ability to transport and s ability to transport and utilize Outilize O22 at tissue levelat tissue level

Ventilator Induced Lung Injury:Ventilator Induced Lung Injury:Parenchymal InjuryParenchymal Injury

Known or Suspected Factors:Known or Suspected Factors:•• Peak lung volume > TLC seen with Peak lung volume > TLC seen with

Pplat >30cmHPplat >30cmH2200•• Lung volume <the alveolar collapse Lung volume <the alveolar collapse

pointpoint•• High rate/frequency of lung inflationHigh rate/frequency of lung inflation•• High FiOHigh FiO22

Wet LungWet Lung

•• Collapsed alveoli and Collapsed alveoli and compression compression atelectasisatelectasis

•• Pooled airway fluidPooled airway fluid•• Inactivation and/or Inactivation and/or

depletion of surfactantdepletion of surfactant

Pathophysiologic ChangesPathophysiologic ChangesContributing to HypoxemiaContributing to Hypoxemia

Acute changes in the caliber of the Acute changes in the caliber of the small airwayssmall airwaysInjury to the pulmonary circulationInjury to the pulmonary circulation

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Changes in the Caliber of the Changes in the Caliber of the Small AirwaysSmall Airways

Early bronchoconstrictionEarly bronchoconstriction

Increased airway resistanceIncreased airway resistance

Altered complianceAltered compliance

Pulmonary Vascular InjuryPulmonary Vascular Injury

Pulmonary Pulmonary hypertension/Right hypertension/Right ventricular dysfunctionventricular dysfunction

Vascular Vascular clogging/obstruction clogging/obstruction (micro emboli)(micro emboli)

Increased PAP & PVRIncreased PAP & PVRUnregulated Unregulated vasoconstriction vasoconstriction (mediators)(mediators)

Leaky membranesLeaky membranesStress fractures of Stress fractures of capillariescapillaries

EffectEffectCauseCause

Pulmonary HypertensionPulmonary HypertensionIncrease right Increase right

ventricular workventricular work

Increase right Increase right ventricular sizeventricular size

Right ventricular shiftRight ventricular shift

Impedes left ventricle Impedes left ventricle sizesize

Decrease stroke Decrease stroke volumevolume

Decrease cardiac Decrease cardiac outputoutput

Increase right Increase right ventricular workventricular work

Right ventricle failsRight ventricle fails

Decrease flow to left Decrease flow to left ventricleventricle

Decrease stroke volumeDecrease stroke volume

Decrease cardiac outputDecrease cardiac output

Decrease OxygenDecrease OxygenDeliveryDelivery

Direct/Indirect Insult

Acute Inflammatory Response

Production and release of mediators

Peripheral edema

Pulmonary interstitial & alveolar

edema

↓O2

ExtractionSurfactant inactivation

Disruption in cellular metabolism

Alveolar flooding and collapse

Increased capillary permeability both local

and systemic

Injury of epithelial and endothelial cells

Occlusion of the pulmonary vasculature

Pulmonary & systemic vascular congestion by micro

emboli & cellular debris

Initiation of coagulation/fibrinolytic

system

Dead space ventilation

↓ Compliance↑ Shunt

Pulmonary hypertension

Bronchoconstriction Vasoconstriction

Arterial hypoxemia

© Vollman, 1996

ARDS

Pansystemic microvascular injury

Increased permeability of the peripheral circulation

Endothelial injury of the GI tract

Systemic translocation of bacteria

Delivery of endotoxin to hepatic macrophages

Export of cytokines & mediators from the

liver

Cellular anaerobic metabolism

MODS MODSMODS

O2 delivery

O2 extraction

Edema formation

Biochemical Biochemical mediators PMNmediators PMN’’ss

Vollman, 1991

ARDS

Pansystemic microvascular injury

Increased permeability of the peripheral circulation

Endothelial injury of the GI tract

Systemic translocation of bacteria

Delivery of endotoxin to hepatic macrophages

Export of cytokines & mediators from

the liver

Cellular anaerobic metabolism

MODS MODSMODS

O2 delivery

O2 extraction

Edema formation

Biochemical Biochemical mediators PMNmediators PMN’’ss

Vollman, 1991

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Clinical ManifestationsClinical Manifestations

Refractory hypoxemiaRefractory hypoxemiaPulmonary shuntingPulmonary shuntingDecreased lung complianceDecreased lung complianceDiffuse alveolar and interstitial infiltratesDiffuse alveolar and interstitial infiltratesPulmonary hypertensionPulmonary hypertensionOther organ system failuresOther organ system failures

Clinical ManifestationsClinical Manifestations

Refractory HypoxemiaRefractory HypoxemiaPulmonary ShuntingPulmonary Shunting

Incidence of Organ FailureIncidence of Organ FailureWith ARDSWith ARDS

1010--23%23%CardiacCardiac00--26%26%HematologicHematologic77--30%30%GastrointestinalGastrointestinal77--30%30%Central nervous systemCentral nervous system1212--95%95%HepaticHepatic4040--55%55%RenalRenal

Incidence RateIncidence RateOrgan FailureOrgan Failure

Dorinsky & Gadek, Clin Chest Med, 1990;11(4);581

ARDS Treatment PrinciplesARDS Treatment Principles

Prevent further injuryPrevent further injuryMaintain adequate pulmonary Maintain adequate pulmonary oxygenationoxygenation

Optimize oxygen deliveryOptimize oxygen delivery

The Six PThe Six P’’s of ARDS s of ARDS TreatmentTreatment

•• PREVENTIONPREVENTION•• PEEPPEEP•• PUMPPUMP•• PIPESPIPES•• PARALYSISPARALYSIS•• POSITIONPOSITION

PREVENTIONPREVENTION…………..

A PART OF THE NURSES’PATIENT ADVOCACY ROLE © Vollman 2001

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Ventilator Associated PneumoniaVentilator Associated PneumoniaRisk Factor CategoriesRisk Factor Categories

Factors that increase bacterial burden or colonization

Factors that increase risk of aspiration

PREVENTIONPREVENTION…………..

A PART OF THE NURSES’PATIENT ADVOCACY ROLE

© Vollman 2001

PREVENTING THE INVASIONPREVENTING THE INVASION

Oral careOral care

LineLine care care

HandwashingHandwashing

HOBHOB

PEEPPEEP(Positive End Expiratory (Positive End Expiratory

Pressure)Pressure)

Strategies for Ventilating the Strategies for Ventilating the ARDS Lung: Protect From InjuryARDS Lung: Protect From Injury•• Oxygen exposureOxygen exposure

•• Pressure (Pressure (BarotraumaBarotrauma))

•• Volume (Volume (VolutraumaVolutrauma))

•• Shear forces (Reopening & closing of alveoli)Shear forces (Reopening & closing of alveoli)((AtelectraumaAtelectrauma) )

ARDS Network ARDS Network ALI/ARDS Ventilator StudyALI/ARDS Ventilator Study

Methodology:Methodology:–– Inclusion criteria: p/f ratio < 300, bilateral infiltrates, Inclusion criteria: p/f ratio < 300, bilateral infiltrates,

no cardiac cause, receiving mechanical ventilationno cardiac cause, receiving mechanical ventilation–– Outcomes: mortality/VFDOutcomes: mortality/VFD–– 841 patients randomized841 patients randomized–– 12 ml/kg TV group 12 ml/kg TV group –– Plat < 50 cm HPlat < 50 cm H22OO–– 6 ml/kg TV group 6 ml/kg TV group -- Plat < 30 cm HPlat < 30 cm H22OO

ARDS Network, N Engl J Med 2000;342:1301ARDS Network, N Engl J Med 2000;342:1301--8.8.

© Vollman 2000

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ARDS Network ARDS Network ALI/ARDS Ventilator StudyALI/ARDS Ventilator Study

Results:PEEP: no difference in average amount usedPEEP: no difference in average amount usedMortality: 31% ( 6 ml/kg TV) vs. 40% (12 ml/kg Mortality: 31% ( 6 ml/kg TV) vs. 40% (12 ml/kg

TV) p=0.007TV) p=0.007VFD: 12+ 11 vs. 10+11 (p=0.007)VFD: 12+ 11 vs. 10+11 (p=0.007)Greater organ failure free days in protective Greater organ failure free days in protective groupgroupReduction in ILReduction in IL--6 levels by day 36 levels by day 3Difficulty with agitation/high rates in the 6 ml/kg Difficulty with agitation/high rates in the 6 ml/kg groupgroup

ARDS Network, N Engl J Med 2000;342:1301-8.© Vollman 2000

Recruitment StrategiesRecruitment Strategies

•• Optimal PEEPOptimal PEEP•• 3030--40cm of CPAP for 30 seconds*40cm of CPAP for 30 seconds*•• Prone positioningProne positioning

Contraindications: severe bronchospasm, bullousemphysema, untreated pneumothorax, unilateral lung dx, hemodynamic instability, unstable ICP

High Versus Low PEEP StudyHigh Versus Low PEEP Study

•• 549 patients with ALI/ARDS549 patients with ALI/ARDS•• Mechanical ventilation with low or high PEEP Mechanical ventilation with low or high PEEP

set according to predetermined tables of set according to predetermined tables of PEEP levels & FiO2 levelsPEEP levels & FiO2 levels

•• Tidal volume: 6/mL per kg of IBWTidal volume: 6/mL per kg of IBW•• At 171 patient enrollment/changed protocol At 171 patient enrollment/changed protocol

because PEEP amounts were to similar because PEEP amounts were to similar between groupsbetween groups

•• Measured: 28 mortality, VFDMeasured: 28 mortality, VFD

ARDS Network: N Engl J Med 2004;351(4):327-36

Methodology

High Versus Low PEEP StudyHigh Versus Low PEEP Study

•• Trail stopped based on futility ruleTrail stopped based on futility rule•• Group differences at baseline; High PEEP group; Group differences at baseline; High PEEP group;

significantly older & lower PaO2/FiO2 ratiosignificantly older & lower PaO2/FiO2 ratio•• Mean PEEP day 1Mean PEEP day 1--4*4*

–– Low PEEP; 8.3 Low PEEP; 8.3 ++ 3.23.2–– High PEEP; 13.2 High PEEP; 13.2 ++ 3.53.5

•• Mortality; Low PEEP= 27.5% Mortality; Low PEEP= 27.5% (after adjustment)(after adjustment)

High PEEP= 25.1% High PEEP= 25.1% (after adjustment)(after adjustment)

ARDS Network: N Engl J Med 2004;351(4):327-36

Results

*p<.001

Ventilator Strategy Based on Lung Ventilator Strategy Based on Lung MechanicsMechanics

Early Phase Early Phase VentilationVentilation

•• Lower tidal volumes Lower tidal volumes (6ml/kg)(6ml/kg)

•• PEEP/higher levelsPEEP/higher levels•• Prone positionProne position•• Limit pressures < 35cm Limit pressures < 35cm

HH22O (allow higher O (allow higher pressure if chest wall pressure if chest wall stiffer)stiffer)

•• Accept abnormal pH, Accept abnormal pH, allow PaCO2 to rise allow PaCO2 to rise graduallygradually

Late Phase Late Phase VentilationVentilation

•• Reduce PEEPReduce PEEP•• Prone position less Prone position less

effectiveeffective•• Reduce fluidsReduce fluids•• Need more FiONeed more FiO22•• Limit pressures Limit pressures •• High dose steroids over High dose steroids over

3 weeks3 weeks

© Vollman 2000

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ARDS Network: Steroids for ARDS Network: Steroids for Persistent ARDSPersistent ARDS

•• MulticenterMulticenter, randomize controlled trial, randomize controlled trial•• 180 patients with ARDS for 180 patients with ARDS for >>7days to 28 days7days to 28 days•• P/F ratio < 200 on study day entranceP/F ratio < 200 on study day entrance•• Measured mortality at 60 days, VFD & Organ failure Measured mortality at 60 days, VFD & Organ failure

free days, biochemical markers of inflammation, free days, biochemical markers of inflammation, fibroproliferationfibroproliferation & infectious complications& infectious complications

•• Receive a loading dose of 2mg/kg of PBW then Receive a loading dose of 2mg/kg of PBW then .5mg/kg q 6hrs for 14 days or .5mg/kg q 12hrs for 7 .5mg/kg q 6hrs for 14 days or .5mg/kg q 12hrs for 7 days than taperingdays than tapering

•• Weaning protocol utilizedWeaning protocol utilized

ARDS Clinical Trials Network. N Engl Med, 2006;354:1671-84

Methodology

ARDS Network: Steroids for ARDS Network: Steroids for Persistent ARDSPersistent ARDS

•• Mortality:Mortality:–– Steroid group: 29.2 % Steroid group: 29.2 % (95% CI, 20.8 to 39.4%)(95% CI, 20.8 to 39.4%)–– Placebo group: 28.6% Placebo group: 28.6% (95% CI, 20.3% to 38.6%)(95% CI, 20.3% to 38.6%)

•• MethylprednisoloneMethylprednisolone associated with higher mortality associated with higher mortality among patients enrolled at least 14 days post onsetamong patients enrolled at least 14 days post onset

•• MethylprednisoloneMethylprednisolone increased the # VFD (14 vs. 23 increased the # VFD (14 vs. 23 days), ICU free days and Shock free days during the first days), ICU free days and Shock free days during the first 28 days28 days

•• No increase in infectious ratesNo increase in infectious rates•• MethylprednisoloneMethylprednisolone was associated with higher rate of was associated with higher rate of

neuromuscular weaknessneuromuscular weaknessARDS Clinical Trials Network. N Engl Med, 2006;354:1671-84

Results

““SalvageSalvage”” Ventilatory Ventilatory StrategiesStrategies

•• PCPC--IRVIRV

•• ECMOECMO

•• ECCOECCO22 RR--LFPPVLFPPV

•• IVOXIVOX

Pressure ControlPressure Control•• Inspiration is terminated after a present pressure Inspiration is terminated after a present pressure

is obtainedis obtained•• Tidal volumes varyTidal volumes vary•• Increased inspiratory time versus expiratory timeIncreased inspiratory time versus expiratory time•• Sedation/Paralysis may be necessary to achieve Sedation/Paralysis may be necessary to achieve

ventilation if using inverse ratioventilation if using inverse ratioGoal:Goal:

Lung protective strategy lower tidal volumes and Lung protective strategy lower tidal volumes and controlled pressurescontrolled pressuresRecruitment of collapse alveoliRecruitment of collapse alveoli

Dual Control within a BreathDual Control within a BreathVolumeVolume--assured supportassured supportPressure augmentationPressure augmentation–– When breath is triggered, ventilator targets When breath is triggered, ventilator targets

pressure supportpressure support–– Ventilator monitors delivered tidal volumeVentilator monitors delivered tidal volume

•• If delivered tidal volume=set tidal volume, the If delivered tidal volume=set tidal volume, the breath is a pressure support breathbreath is a pressure support breath

•• If the tidal volume<set volume when the flow If the tidal volume<set volume when the flow decreases to the set peak flow, flow will remain decreases to the set peak flow, flow will remain constant until the volume is deliveredconstant until the volume is delivered

Amato et al. Chest 1992;102:1225Haas et al, Respir Care 1995;40:716

BiBi--Level VentilationLevel Ventilation•• Establishes 2 levels of PEEPEstablishes 2 levels of PEEP•• Cycle between the 2 pressure levels can be Cycle between the 2 pressure levels can be

synchronized to patients breathing at either synchronized to patients breathing at either levellevel

•• Settings/parameters: PEEP High, PEEP low, Settings/parameters: PEEP High, PEEP low, Release rate and ratio of high to low PEEPRelease rate and ratio of high to low PEEP

•• Timing setting: Time high or time low (ratio)Timing setting: Time high or time low (ratio)•• Breath types: mix spontaneous(pressure Breath types: mix spontaneous(pressure

support) or mandatory (pressure controlled)support) or mandatory (pressure controlled)

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High Frequency VentilationHigh Frequency Ventilation

•• HFJV: frequency<150/minHFJV: frequency<150/min•• HFO: frequency>150/minHFO: frequency>150/min•• HFO ventilation achieves gas exchange HFO ventilation achieves gas exchange

by utilizing subby utilizing sub--dead space tidal dead space tidal volumes providing a less traumatic volumes providing a less traumatic method of recruiting and stabilizing lung method of recruiting and stabilizing lung volumesvolumes

High Frequency Oscillation StudyHigh Frequency Oscillation StudyMethodologyMethodology•• 17 adult patients with ALI who failed 17 adult patients with ALI who failed

conventional ventilationconventional ventilation•• Examined safety and efficacy of a new HFO Examined safety and efficacy of a new HFO

ventilator Measured PaO2/FiO2 ratioventilator Measured PaO2/FiO2 ratio’’s, s, oxygen index and systemic & PA pressuresoxygen index and systemic & PA pressures

Results:Results: 76% of the patients improved their 76% of the patients improved their oxygenation oxygenation Failure to response to HFO was Failure to response to HFO was highly specific for deathhighly specific for death

Fort et al Crit Care Med 1997;25:937-947

PIPESPIPES

PUMPPUMP

Measures to Improve Measures to Improve Oxygen DeliveryOxygen Delivery

•• Fluid AdministrationFluid Administration

•• TransfusionsTransfusions

•• InotropicInotropic agentsagents

•• VasopressorsVasopressors ??

•• Measures to improve SaOMeasures to improve SaO22

Early Goal Directed TherapyEarly Goal Directed Therapy

•• Early GoalEarly Goal--Directed Directed Therapy (EGDT)Therapy (EGDT)–– Continuous ScvO2 Continuous ScvO2

monitoring & monitoring & txtx with fluids, with fluids, blood, blood, inotropesinotropes &/or &/or vasoactivesvasoactives to maintain:to maintain:

••ScvO2 ScvO2 >>70%, SaO2 70%, SaO2 >> 93%, 93%, HctHct >> 30%, CI/VO230%, CI/VO2••CVP CVP >> 88--1212••MAP MAP >> 6565••UO UO >> .5ml/kg/hr.5ml/kg/hr

•• Standard TherapyStandard Therapy–– CVP CVP >> 88--1212–– MAP MAP >> 6565–– UO UO >> .5ml/kg/hr.5ml/kg/hr

Rivers et. al. N Engl J Med. 2001;345;19:1368-1377.

Methodology: 263 severe sepsis patients49.2%

33.3%

0

10

20

30

40

50

60

Standard Therapyn=133

EGDTn=130

P = 0.01*

*Key difference was in sudden CV collapse, not MODS

28-day Mortality

Rivers E. N Engl J Med 2001;345:1368-77.

Early GoalEarly Goal--Directed Therapy ResultsDirected Therapy Results

NNT=7

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Evidence of Early Goal Evidence of Early Goal Directed TherapyDirected Therapy

•• First 6 hours of EGDT:First 6 hours of EGDT:–– 1500cc more fluid 1500cc more fluid –– 64% received blood products vs. 18.5%64% received blood products vs. 18.5%–– 13.7% received 13.7% received inotropesinotropes vs. 0.8%vs. 0.8%–– No difference in No difference in vasopressorvasopressor use or use or

mechanical ventilationmechanical ventilation

Rivers et. al. N Engl J Med. 2001;345;19:1368-1377.

Measures to Improve OMeasures to Improve O2 2 DeliveryDelivery

•• Fluid ManagementFluid Management–– Colloid vs. Colloid vs.

CrystalloidsCrystalloids–– Dry vs. WetDry vs. Wet

ARDS Network: Fluid ARDS Network: Fluid Management Strategies in ALIManagement Strategies in ALI

•• MulticenterMulticenter randomized trialrandomized trial•• 1000 patients1000 patients•• Compared conservative and liberal fluid Compared conservative and liberal fluid

management using explicit protocols over a 7 management using explicit protocols over a 7 day periodday period

•• Primary endpoint: measure mortality at 60 daysPrimary endpoint: measure mortality at 60 days•• Secondary endpoints: VFD, OFD & lung Secondary endpoints: VFD, OFD & lung

physiologyphysiology

Methodology


ARDS Network: Fluid ARDS Network: Fluid Management Strategies in ALIManagement Strategies in ALI

•• Mortality:Mortality:–– Conservative: 25.5%Conservative: 25.5%–– Liberal: 28.4% (95% CI, Liberal: 28.4% (95% CI, --2.6 to 8.4% p=0.30)2.6 to 8.4% p=0.30)

•• Cumulative Fluid balance:Cumulative Fluid balance:–– Conservative: Conservative: --136 136 ++ 491 ml491 ml–– Liberal: Liberal: 6992 6992 ++ 502 ml (p<0.0001)502 ml (p<0.0001)

•• Conservative: Conservative: ↑↑ VFDVFD (14.6 (14.6 ++ 0.5 vs. 12.1 = 0.5 p >0.010.5 vs. 12.1 = 0.5 p >0.01

↓↓ ICU days ICU days (13.4 + 0.4 vs. 11.2 = 0.4 p<0.001(13.4 + 0.4 vs. 11.2 = 0.4 p<0.001

Results


Measures to Improve OMeasures to Improve O2 2 DeliveryDelivery

•• Fluid ManagementFluid Management–– Colloid vs. Colloid vs.

CrystalloidsCrystalloids–– Dry vs. WetDry vs. Wet

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Colloid Versus CrystalloidColloid Versus Crystalloid

•• 6997 critically ill patients6997 critically ill patients•• Randomized to receive 4% albumin or Randomized to receive 4% albumin or

normal saline for intravascular normal saline for intravascular resuscitation over a 28 days periodresuscitation over a 28 days period

•• Outcome measured: Death from any Outcome measured: Death from any cause during the 28 days post cause during the 28 days post randomizationrandomization

Methodology

Safe Study Investigators. N Engl J Med;350:22:2247-2256

Colloid Versus CrystalloidColloid Versus Crystalloid

•• Similar baseline characteristicsSimilar baseline characteristics•• 726 deaths in albumin group726 deaths in albumin group•• 729 deaths in normal saline group (p=0.87)729 deaths in normal saline group (p=0.87)•• Proportion of patients with new single & Proportion of patients with new single &

multiple organ failure were similar (p=0.85)multiple organ failure were similar (p=0.85)•• No difference in #ICU days, # hospital days, No difference in #ICU days, # hospital days,

# of days on vent or days of CRRT# of days on vent or days of CRRT

Results

Safe Study Investigators. N Engl J Med;350:22:2247-2256

Rule of Thumb for Fluid Management

Fluids should be given to the septic type patient as long as there is improvement in CI, DO2, VO2 & clearance of Lactic acid.

When it ceases, inotropic support should be considered.

PARALYSISPARALYSIS

Balancing Balancing Oxygen Oxygen Supply Supply and and DemandDemand

OO22 Supply DebtSupply Debt

© Vollman 2001

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© Vollman 2001

Activities That Increase VOActivities That Increase VO22•• Dressing changeDressing change 10%10%•• Physical examPhysical exam 20%20%•• AgitationAgitation 18%18%•• BathBath 23%23%•• Chest XChest X--rayray 25%25%•• SuctioningSuctioning 27%27%•• Increased work of breathingIncreased work of breathing 40%40%•• Weigh on sling scaleWeigh on sling scale 36%36%•• Position changePosition change 31%31%•• Linen change Linen change –– occupied bedoccupied bed 22%22%•• Chest physiotherapyChest physiotherapy 35%35%

Strategies to Optimize PatientStrategies to Optimize Patient’’s s Tolerance to ActivitiesTolerance to Activities

•• Space activitiesSpace activities•• Monitor for signs of intoleranceMonitor for signs of intolerance•• Pre/post Pre/post hyperoxygenatehyperoxygenate•• Determine if the intervention is essentialDetermine if the intervention is essential•• Control variables that increase consumptionControl variables that increase consumption

–– Pain managementPain management–– Agitation managementAgitation management–– Partial temp regulationPartial temp regulation–– ShiveringShivering

© Vollman 1996

Maximizing effective use of Maximizing effective use of sedation through protocolssedation through protocols

ProtocolProtocol--directed group vs. non protocoldirected group vs. non protocol--directed groupdirected group

Less time on mechanical ventilationLess time on mechanical ventilation

Shorter ICU LOSShorter ICU LOS

Shorter hospital LOSShorter hospital LOS

Decreased need for Decreased need for tracheostomytracheostomy

Brook AD & Ahrens TS et al Brook AD & Ahrens TS et al CritCrit Care Med, 1999;27:2609Care Med, 1999;27:2609--26152615

Potential Negative Consequences of Potential Negative Consequences of ParalysisParalysis

MethodMethod•• CaseCase--controlled study /10 patients with controlled study /10 patients with

prolonged blockadeprolonged blockade•• Examined rate of recovery, outcome, Examined rate of recovery, outcome,

hospital utilization, charges and costs hospital utilization, charges and costs secondary to neuromuscular blockade secondary to neuromuscular blockade weakness (NMW)weakness (NMW)

Rudis M. et al CCM; 1996:24(1):A70.

Potential Negative Consequences of Potential Negative Consequences of Paralysis Paralysis (cont(cont’’d.)d.)

Results:Results:•• No difference between NMW vs. control No difference between NMW vs. control

group in # and duration of paralytic episodes group in # and duration of paralytic episodes or doses usedor doses used

•• Ventilation, ICU and hospital time significantly Ventilation, ICU and hospital time significantly longer in NMW grouplonger in NMW group

•• No difference in mortalityNo difference in mortality•• Hospital charges: NMW/1,320,460,0 vs. Hospital charges: NMW/1,320,460,0 vs.

Control/$214,830.00Control/$214,830.00

Rudis M. et al CCM; 1996:24(1):A70.

14

POSITIONPOSITION

““Minimal Physiologic Minimal Physiologic Mobility RequirementMobility Requirement””

Keane, F.X. Paraplegia, 1978; 16:383-9.

Move Every 11 Minutes During Sleep

UNDERSTANDING THE UNDERSTANDING THE IMPACT OF A IMPACT OF A

STATIONARY SUPINE STATIONARY SUPINE POSITIONPOSITION

19901990’’s CLRT Researchs CLRT ResearchMethodologyMethodology

12 adult healthy baboons were randomized to 12 adult healthy baboons were randomized to CLRT or control for 11 daysCLRT or control for 11 daysMechanically ventilated, paralyzed and Mechanically ventilated, paralyzed and sedated and received normal supportive sedated and received normal supportive therapytherapyMeasured xMeasured x--ray results, cultures, ray results, cultures, bronchioalveolar lavage, oxygenation indices, bronchioalveolar lavage, oxygenation indices, pulmonary function and lung volumespulmonary function and lung volumes

Anzueto A et al Crit Care Med 1997;25(9):1560-1564

19901990’’s CLRT Researchs CLRT ResearchResultsResults

No significant difference in hemodynamics, gas No significant difference in hemodynamics, gas exchange or pulmonary functionexchange or pulmonary functionDay 7 the control group showed patchy Day 7 the control group showed patchy atelectasisatelectasisDay 11 two animals showed persistent Day 11 two animals showed persistent radiological abnormalities. Bronchoalveolar radiological abnormalities. Bronchoalveolar lavage day 7 and 11 revealed significant increase lavage day 7 and 11 revealed significant increase in neutrophilsin neutrophilsLung pathology in control group showed areas of Lung pathology in control group showed areas of bronchiolitis with 5 of 7 of the control animals bronchiolitis with 5 of 7 of the control animals demonstrating surrounding bronchopneumoniademonstrating surrounding bronchopneumonia

Anzueto A et al Crit Care Med 1997;25(9):1560-1564

Do We Achieve Q2 Hours?Do We Achieve Q2 Hours?

15

““Effect of Frequency of Manual Turning on Effect of Frequency of Manual Turning on PneumoniaPneumonia””

•• Q 2 hour manual turning standard of care still not Q 2 hour manual turning standard of care still not met.met.

•• Patients were turned a mean of 9.64 times out of a Patients were turned a mean of 9.64 times out of a possible 23 timespossible 23 times

•• A turn was defined as movement from supine to A turn was defined as movement from supine to either side, one side to the other side, oreither side, one side to the other side, or from bed from bed to chair. to chair.

•• No degree of turn was quantified.No degree of turn was quantified.•• None of the patients had been proned.None of the patients had been proned.•• Pneumonia occurred in 49% of the patients at the Pneumonia occurred in 49% of the patients at the

end of the 3end of the 3--day periodday period

Shallom,L, Metheny, NA, et. Al., “Effect of Frequency of Manual Turning on Pneumonia", AmericanJournal of Critical Care,14(6) 2005 476-478

Body Position: Clinical Body Position: Clinical Practice vs. StandardPractice vs. Standard

•• MethodologyMethodology–– 74 patients/566 total hours of observation74 patients/566 total hours of observation–– 3 tertiary hospitals3 tertiary hospitals–– Change in body position recorded every 15 minutesChange in body position recorded every 15 minutes–– Average observation time 7.7 hoursAverage observation time 7.7 hours–– Online MD surveyOnline MD survey

•• ResultsResults–– 49.3% of observed time no body position change49.3% of observed time no body position change–– 2.7% had a q 2 hour body position change2.7% had a q 2 hour body position change–– 8080--90% believed q 2 hour position change should 90% believed q 2 hour position change should

occur but only 57% believed it happened in their ICUoccur but only 57% believed it happened in their ICUKrishnagopalan S. Crit Care Med 2002;30:2588-2592

VentilationVentilationMajor Factors Influencing Major Factors Influencing Distribution of VentilationDistribution of Ventilation

Gravity/weight of the lungGravity/weight of the lung

Compliance/airway resistanceCompliance/airway resistance

Heterogeneous lung disease Heterogeneous lung disease

Air Goes To Area of Air Goes To Area of Least ResistanceLeast Resistance

J.B. West, 1997, Ventilation/blood flow and gas exchange(3rd ed.), Oxford: Blackwell, p.28.

16

Supine Position:Supine Position:

Distribution becomes more uniform Distribution becomes more uniform from apex to basefrom apex to base

Dependent lung ventilation > nonDependent lung ventilation > non--dependentdependent

Reduction in FRCReduction in FRC

Amis et al. Respiratory Physiology 1984 56;145Kaneko et al. J of Applied Physiology 1966 21;767

Reduction in FRC in the Supine Reduction in FRC in the Supine PositionPosition

Influence of the abdominal contents Influence of the abdominal contents on the diaphragmon the diaphragm

Position of the heart and Position of the heart and relationship of the supporting relationship of the supporting structures to the lung and its structures to the lung and its influence on pleural pressure influence on pleural pressure gradientsgradients

Malbouisson LM. Et al. Am J Respir Crit Care Med 2000;161:2005-12

Impact of the Abdomen




























































Froese A. and Bryan, A.G. 1974. Effects of anesthesia and paralysis on diaphragmative mechanics in man. Anesthesiology, 41(3), 242-255.

Differences in FRC Based on Differences in FRC Based on PositionPosition

Sitting to Supine PositionSitting to Supine Position: FRC declines: 30%(mean decrease: 800 ml)

Sitting to Lateral Position:Sitting to Lateral Position: FRC declines 15-20%(mean decrease: 450 ml)

Sitting to Prone Position:Sitting to Prone Position: FRC declines: 15-20%(mean decrease: 450 ml)

17

PERFUSIONPERFUSION

Factors Influencing Regional Factors Influencing Regional Distribution of PerfusionDistribution of Perfusion

Cardiac outputCardiac output

Pulmonary vascular Pulmonary vascular resistanceresistance

Gravity/body positionGravity/body position

Distribution of PerfusionDistribution of Perfusion

Upright Position: Upright Position: Blood flow decreases as it moves Blood flow decreases as it moves from base to apex with virtually from base to apex with virtually little or no flow at the apiceslittle or no flow at the apices

Blood Flow Changes with PositionBlood Flow Changes with Position

Supine position: Supine position: Distribution becomes more Distribution becomes more uniform. Zone 3 maintained uniform. Zone 3 maintained throughout the lung. Greater throughout the lung. Greater vertical perfusion gradient.vertical perfusion gradient.

Lateral position:Lateral position: Similar to supine except lung Similar to supine except lung transforms to zone 2 transforms to zone 2 approximately 18 cm above the approximately 18 cm above the most dependent part of the chest.most dependent part of the chest.

Prone position:Prone position: Zone 3 maintain throughout the Zone 3 maintain throughout the lung. Reduced gravitational flow lung. Reduced gravitational flow notednoted

CLINICAL RESEARCHCLINICAL RESEARCH

•• Supine vs. Head ElevationSupine vs. Head Elevation

•• Supine vs. LateralSupine vs. Lateral

•• Supine vs. ProneSupine vs. Prone

Supine vs. Degrees of Head Supine vs. Degrees of Head Elevation ResearchElevation Research

•• RabowRabow, et. al., et. al. 19721972•• Vaughan, et. al. Vaughan, et. al. 19761976•• DalrympleDalrymple, et. al., et. al. 19791979•• RussellRussell 19811981•• CiresiCiresi, et. al., et. al. 19811981•• GuiGui, et. al., et. al. 19821982•• Marti & UlmerMarti & Ulmer 19821982•• Minh, et. al.Minh, et. al. 19861986•• Burns, et. al.Burns, et. al. 19941994

18

Position to Facilitate Weaning in Position to Facilitate Weaning in Patients with Large AbdomensPatients with Large Abdomens

19 19 intubatedintubated patientspatientsLarge abdomens r/t obesity, distention Large abdomens r/t obesity, distention & & ascitesascitesCPAP &/or PSVCPAP &/or PSVPositioned: 0Positioned: 0°°, 45, 45°°, 90, 90°°, & RT at 45, & RT at 45°°

Results: RT at 45°significantly larger tidal volumes & lower respiratory rates than 90°

Burns S. et al. Amer J Crit Care, 1994:3:102-106

Lateral Positioning ResearchLateral Positioning Research

•• Patients with predominantly unilateral Patients with predominantly unilateral lung disease improved their PaOlung disease improved their PaO22 when when positioned with the GOOD LUNG DOWNpositioned with the GOOD LUNG DOWN

•• Patients with more bilateral involvement Patients with more bilateral involvement showed higher PaOshowed higher PaO22’’s in the right lateral s in the right lateral positionposition

Zach MB. Et al. Am Rev Respir Dis 1974;110:149


•• Good lung down mean PaOGood lung down mean PaO22 : 106.1 : 106.1 ++ 12.7 mmHg12.7 mmHg

•• Supine mean PaOSupine mean PaO22 : 66.8 : 66.8 ++ 3.3 mmHg3.3 mmHg

•• Bad lung down mean PaOBad lung down mean PaO22 : 58.5 : 58.5 + + 2.7 mmHg2.7 mmHg

Remolina C. et al. N Engl J Med. 1981;304:523

Take Home PointsTake Home Points: : Positioning for Unilateral Lung DiseasePositioning for Unilateral Lung Disease

Patients with unilateral lung disease from a Patients with unilateral lung disease from a consolidated pneumonia type process consolidated pneumonia type process oxygenate better with the good lung down.oxygenate better with the good lung down.Patients with other types of unilateral lung Patients with other types of unilateral lung dysfunction may not benefit from this positioning dysfunction may not benefit from this positioning techniquetechniqueCABG patients should be repositioned at least CABG patients should be repositioned at least every 2 hoursevery 2 hoursMore research is necessary looking at specific More research is necessary looking at specific unilateral lung disease populationsunilateral lung disease populations

Supine vs. Degrees of Head Supine vs. Degrees of Head Elevation Research for Prevention of Elevation Research for Prevention of

VentilatorVentilator--Associated PneumoniaAssociated Pneumonia

Risk Factor Categories for Risk Factor Categories for Nosocomial Pneumonia Nosocomial Pneumonia

•• Factors that increase risk of Factors that increase risk of aspirationaspiration

•• Factors that increase Factors that increase bacterial burden or bacterial burden or colonizationcolonization

19

HOB ResearchHOB Research

•• 86 patients86 patients•• Randomly assigned to supine position or HOB 45 Randomly assigned to supine position or HOB 45

degrees (39 semi recumbent, 47 supine)degrees (39 semi recumbent, 47 supine)•• Monitored clinical suspected & microbiologically Monitored clinical suspected & microbiologically

confirmed nosocomial pneumoniasconfirmed nosocomial pneumonias

Drakulovic MB. et. al. Lancet. 1999;354:1851-1858

Methodology:Methodology:

Results:Results:•• Microbiologically confirmed Microbiologically confirmed nosocomialnosocomial pneumonia pneumonia

lower in the semi recumbent group 2/39 (5%) vs. lower in the semi recumbent group 2/39 (5%) vs. 11/47 (23%)11/47 (23%)

•• Supine position & Supine position & enteralenteral nutrition were independent nutrition were independent risk factors for VAP & had the greatest number of risk factors for VAP & had the greatest number of VAPVAP’’ss 14/28 (50%)14/28 (50%)

HOB ResearchHOB Research•• MethodologyMethodology

–– Prospective Prospective multicentermulticenter trial randomly assigned to targeted trial randomly assigned to targeted 4545°° vs.10vs.10°° HOBHOB

–– 112 to targeted 45112 to targeted 45°° vs. vs. 109 patients to 10109 patients to 10°°–– Continuous measurement of backrest elevation first wk of Continuous measurement of backrest elevation first wk of

MVMV–– DxDx of VAP by of VAP by bronchoscopicbronchoscopic techniquestechniques

•• ResultsResults–– Baseline characteristics similarBaseline characteristics similar–– Average elevationsAverage elevations

•• 1010°° group day 1 & 7: 9.8 & 16.1 group day 1 & 7: 9.8 & 16.1 •• 4545°° group day 1 & 7: 28.1 & 22.6*group day 1 & 7: 28.1 & 22.6*

–– Target 45Target 45°° not achieved 85% of the timenot achieved 85% of the time–– VAP: 10VAP: 10°° = 6.5% vs. 45= 6.5% vs. 45°° = 10.7%= 10.7%

Van Nieuwenhoven CA, et al. Crit Care Med, 2006;34:396-402*p < .001

Lateral PositioningLateral PositioningResearchResearch

Bilateral lung diseaseBilateral lung disease

Unilateral lung diseaseUnilateral lung disease


Immobile for 6Immobile for 6--10 hours10 hours•• Significantly lower PaOSignificantly lower PaO2 2 & higher shunts& higher shunts

Hourly alternate lateral position:Hourly alternate lateral position:•• Moderate elevations in PaOModerate elevations in PaO22 & lower & lower

shuntsshuntsQ30 minutes:Q30 minutes:•• Highest increase in PaOHighest increase in PaO2 2 & lowest shunt& lowest shunt

KEANEKEANE™™ III Mobility BedIII Mobility BedMetaMeta--Analysis CLRTAnalysis CLRTMethodologyMethodology•• 419 Patients419 Patients•• 6 Studies:6 Studies:

–– Gentiello L. Crit Care Med 1998;16:783Gentiello L. Crit Care Med 1998;16:783–– Fink MP. Chest, 1990:97:132Fink MP. Chest, 1990:97:132–– Narayan RK, Conference proceeding 1988, Kelley RE. Narayan RK, Conference proceeding 1988, Kelley RE.

Stroke, 1987;18:638Stroke, 1987;18:638–– Nelson LD. Clin Inten Care, 1992;3:248Nelson LD. Clin Inten Care, 1992;3:248–– Summer WR, J Crit Care, 1989;4:45Summer WR, J Crit Care, 1989;4:45

•• Outcomes Measured:Outcomes Measured:–– Pneumonia, embolus, pressure sores, ARDS, Pneumonia, embolus, pressure sores, ARDS,

atelectasis, mortality hours intubated ICU days, atelectasis, mortality hours intubated ICU days, ICU charges, hospital daysICU charges, hospital days

Choi & Nelson Jo of Crit Care 1992;7:57-62

20

MetaMeta--Analysis CLRTAnalysis CLRT

ResultsResults•• CLRT vs. Conventional TurningCLRT vs. Conventional Turning

–– 50% reduction in incidence of pneumonia 50% reduction in incidence of pneumonia (p <0.002)(p <0.002)

–– 35% reduction in time intubated (p <0.04)35% reduction in time intubated (p <0.04)–– 24% reduction in ICU stay (p<0.02)24% reduction in ICU stay (p<0.02)

Choi & Nelson J of Crit Care 1992;7:57-62

CLRT ResearchCLRT ResearchMethodologyMethodology•• 106 medical ICU patients106 medical ICU patients•• Assigned to 5 DRG groups (sepsis, stroke, Assigned to 5 DRG groups (sepsis, stroke,

COPD, metabolic coma, drug OD)COPD, metabolic coma, drug OD)•• Randomly assigned CLRT vs. conventional Randomly assigned CLRT vs. conventional

bed with DRG groupbed with DRG group•• Rotated > 18 hours per dayRotated > 18 hours per day•• Measured morbidity, time on vent, ICU, LOS, Measured morbidity, time on vent, ICU, LOS,

hospital LOS, incidence of pneumoniahospital LOS, incidence of pneumonia•• Higher APACHE II scores in bed therapy Higher APACHE II scores in bed therapy

groupgroupDeBoisblanc BP et al Chest 1993;103:1543

CLRT ResearchCLRT ResearchResultsResults•• Significant reduction in nosocomial Significant reduction in nosocomial

pneumonia in CLRT group (9% vs. pneumonia in CLRT group (9% vs. 22%)* 22%)*

•• Greatest in sepsis DRG (3% vs. 22%)**Greatest in sepsis DRG (3% vs. 22%)**•• With higher APACHE II scores no With higher APACHE II scores no

difference in LOS, morbidity, mortality, difference in LOS, morbidity, mortality, or time on ventilatoror time on ventilator

DeBoisblanc BP et al Chest 1993;103:1543* p=0.05**p=0.04


••37 patients mechanically ventilated long term37 patients mechanically ventilated long term••Randomized assigned to CLRT or q 2 hour turningRandomized assigned to CLRT or q 2 hour turning••CLRT > 18 hours, 30 degreeCLRT > 18 hours, 30 degree’’s, q 2hr s, q 2hr percussion/vibration for 10 minutespercussion/vibration for 10 minutes

••HOB at 30 degreeHOB at 30 degree’’s s ResultsResults

•• Development of pneumonia (p=0.03)Development of pneumonia (p=0.03)••CLRT 17.6%CLRT 17.6%••Control 50%Control 50%

•• Longer time to develop pneumonia if it appearedLonger time to develop pneumonia if it appeared••29 days 29 days ++ 8 vs. 12 days 8 vs. 12 days ++ 22

•• No difference in mortalityNo difference in mortalityKirschenbaum L. et. al. Crit Care Med, 2002;30(9):1983-1986


••35 mechanically ventilated patients in MICU vs. 35 35 mechanically ventilated patients in MICU vs. 35 match control patients receive routine positioningmatch control patients receive routine positioning

••Experimental group: CLRT for 5 daysExperimental group: CLRT for 5 days••Measured: VAP, Measured: VAP, ABGABG’’ss, Chest x, Chest x--ray, ICU LOSray, ICU LOS

ResultsResults•• Improvement in P/F ratio 31 Improvement in P/F ratio 31 ++ 42 42 vsvs 6 6 ++ 76 (p=.03)76 (p=.03)•• Lower VAP rate 0 Lower VAP rate 0 vsvs 5 (p < .001)5 (p < .001)•• Shorter ICU LOS 22 Shorter ICU LOS 22 ++ 8 days 8 days vsvs 27 27 ++ 12 days (p 12 days (p

=.09)=.09)•• No difference in mortalityNo difference in mortality

Wang JY et al. J of Formosan Medical Association, 2003;102(11):788-792

21


••234 Medical234 Medical--SurgicalSurgical--Trauma patientsTrauma patients••137 control, 97 rotation, 22 did not tolerate137 control, 97 rotation, 22 did not tolerate••Dialed 40 degrees, > 18hrs, 10min/5min/10min cycle vs. Dialed 40 degrees, > 18hrs, 10min/5min/10min cycle vs. q 2hr with pillowsq 2hr with pillows

••HOB degree not mentionedHOB degree not mentioned••Measured incidence of VAP, lobar atelectasis & costMeasured incidence of VAP, lobar atelectasis & costResultsResults•• Incidence of VAP p=.002Incidence of VAP p=.002•• Incidence of lobar atelectasis p=.02Incidence of lobar atelectasis p=.02•• No difference in ICU LOS, Hospital LOS or mortalityNo difference in ICU LOS, Hospital LOS or mortality•• Rotation average of 5 daysRotation average of 5 days

Ahrens, T et al Am J of Crit Care, 2004;13:376-383

Quality Improvement ProjectQuality Improvement Project

Union HospitalUnion HospitalUnion, NJUnion, NJ

November 1999November 1999--March 2000 March 2000 Presented at 2001 NTI/AACNPresented at 2001 NTI/AACN

PrePre--Union Hospital Project Union Hospital Project DataData……Driving the ChangeDriving the ChangeSituation AnalysisSituation Analysis•• Placement on CLRT was latePlacement on CLRT was late•• Inconsistent protocol usageInconsistent protocol usage•• No internal monitoring of outcomesNo internal monitoring of outcomes•• Lack of staff education on CLRTLack of staff education on CLRT•• Cost of care for pneumonia was risingCost of care for pneumonia was rising•• Concern about spending on CLRT bedsConcern about spending on CLRT beds•• Data collection on nonData collection on non--rotated patientsrotated patients

The Union Hospital ProjectThe Union Hospital Project

The ProcessThe Process•• Literature reviewLiterature review•• Evaluate patient populationEvaluate patient population•• Redesigned existing protocol Redesigned existing protocol •• PredicusPredicus™™ Pneumonia Risk Evaluation tool Pneumonia Risk Evaluation tool •• Empowered nursing to order CLRTEmpowered nursing to order CLRT•• Posted algorithm in all patient roomsPosted algorithm in all patient rooms•• CLRT tracking toolCLRT tracking tool•• Team to follow & measure outcomesTeam to follow & measure outcomes

Union Hospital Ventilator DaysUnion Hospital Ventilator Days

0

50

100

150

200

250

300

350

CLRT 23 Pts NON-CLRT 23 Pts.

86 Fewer Vent Days

Union Hospital ICU LOSUnion Hospital ICU LOS

0

50

100

150

200

250

300

350

400

CLRT 23 Pts. NON-CLRT 23 Pts.

79 Fewer ICU Days

22

Union Hospital Hospital LOSUnion Hospital Hospital LOS

360

380

400420

440460

480500

520


80 Fewer Hospital Days

Union Hospital Total Care ChargesUnion Hospital Total Care Charges

$2,798,147

$5,086,676

$0

$1,000,000

$2,000,000

$3,000,000

$4,000,000

$5,000,000

$6,000,000


$2.2 MM fewer dollars

Union HospitalUnion HospitalEfica Charges Vs. Total Charges for CLRT Efica Charges Vs. Total Charges for CLRT

PatientsPatients

$32,096

$2,798,147

$0

$500,000

$1,000,000

$1,500,000

$2,000,000

$2,500,000

$3,000,000

EFICA Charges Total Charges

Efica Costs = 1.1% Total Cost

Implementing a CLRT Protocol: Implementing a CLRT Protocol: Evaluation of the Outcomes Evaluation of the Outcomes

•• Retrospective/ post protocol prospective Retrospective/ post protocol prospective analysisanalysis

•• Acuity impact on length of stay and cost of Acuity impact on length of stay and cost of care control through use of APACHE IIcare control through use of APACHE II

•• Placed within 24Placed within 24--48 hours based on meeting 48 hours based on meeting initiation criteriainitiation criteria

•• Demographic characteristics of pre (n=22) & Demographic characteristics of pre (n=22) & post (n=36) were similar except for time of post (n=36) were similar except for time of placement of CLRT 13.6% vs. 61%placement of CLRT 13.6% vs. 61%

Washington GT et al. J Nurs Care Qual, 2005;20(3):273-283

Implementing a CLRT Protocol: Implementing a CLRT Protocol: Evaluation of the Outcomes Evaluation of the Outcomes

Washington GT et al. J Nurs Care Qual, 2005;20(3):273-283

NSNS14.814.819.119.1Mean ICU Mean ICU daysdays

NSNS11.711.718.518.5Mean VentMean VentDaysDays

P < .001P < .00161.1%61.1%13.6%13.6%Appropriate Appropriate placementplacement

StatsStatsPostPost--ProtocolProtocolN= 36N= 36

Chart Chart Review Review N=22N=22

Rotation Therapy Outcome StudiesRotation Therapy Outcome Studies

Decrease Vent Days, Decreased Hospital LOS, Decrease Vent Days, Decreased Hospital LOS, Decrease ICU LOS by 5Decrease ICU LOS by 5--6 days. 6 days.

Medical Center of Medical Center of GeorgiaGeorgia20022002

Decreasing LAG time resulted in 14% decrease in Decreasing LAG time resulted in 14% decrease in HLOS, Vent Days, & 20% decrease of SMR HLOS, Vent Days, & 20% decrease of SMR [standard mortality ratio][standard mortality ratio]

Sarasota Sarasota MemorialMemorial20012001

Decreased H & ICU LOS, Decreased Vent DaysDecreased H & ICU LOS, Decreased Vent Days48 fewer NP year of the 6 month bed study48 fewer NP year of the 6 month bed studyLag time effect: decreased days on therapyLag time effect: decreased days on therapy

Cape Fear Valley Cape Fear Valley MCMC1994: 1994:

Decreased ICU LOS by 5.2 daysDecreased ICU LOS by 5.2 daysDecreased Days of Pneumonia by 52%Decreased Days of Pneumonia by 52%

Stanford Stanford UnivUniv MCMC1994: MICU 1994: MICU

KEY MEASURES

23

Systematic method of approaching placement & removal of rotational therapy

Lateral Rotation: Summary of Lateral Rotation: Summary of Research FindingsResearch Findings

Lateral rotation is effective in reducing the Lateral rotation is effective in reducing the incidence of pneumonia, atelectasis, time on the incidence of pneumonia, atelectasis, time on the vent and stay in the ICUvent and stay in the ICUThe earlier the patient is placed on the therapy The earlier the patient is placed on the therapy during their acute illness the better the responseduring their acute illness the better the responseCLRT appears to have some benefit on CLRT appears to have some benefit on oxygenation variables, however more research is oxygenation variables, however more research is requiredrequiredThe absolute answer on the degree of rotation The absolute answer on the degree of rotation and the frequency of rotation to achieve the and the frequency of rotation to achieve the beneficial effect is not availablebeneficial effect is not available

24

MethodsMethodsRetrospective analysis of data collected on 62 CLRT Retrospective analysis of data collected on 62 CLRT patientspatientsMean Apache III score 76.74 Mean Apache III score 76.74 ++ 33.65/Median 71.533.65/Median 71.545% overall mortality rate45% overall mortality rateDxDx: ARDS, pneumonia & respiratory failure: ARDS, pneumonia & respiratory failureMedical Critical Care area, Trauma & Thoracic SurgeryMedical Critical Care area, Trauma & Thoracic SurgeryExamined change in PaOExamined change in PaO22/FiO/FiO22 ratios based on:ratios based on:–– Number of hours spent in rotation over course of Number of hours spent in rotation over course of

therapytherapy–– Degree of rotation (defined as highest degree patients Degree of rotation (defined as highest degree patients

achieved while on therapy)achieved while on therapy)Cagle, Pieper & Vollman NTI 1993

ResultsResults58% improved oxygenation status58% improved oxygenation statusAverage days spent in rotation 4.6 Average days spent in rotation 4.6 ++ 2.32.3Mean hours in rotation 68.45 Mean hours in rotation 68.45 ++ 48.5748.57Positive correlation between hours spent in Positive correlation between hours spent in rotation and improvement in PaOrotation and improvement in PaO22/FiO/FiO22 statusstatusMean degree of rotation 29.5 Mean degree of rotation 29.5 ++ 6.816.81No correlation noted between degree & No correlation noted between degree & improvement in ratioimprovement in ratio

Cagle, Pieper & Vollman NTI 1993

Comparison of Clinical Outcomes in Comparison of Clinical Outcomes in Pulmonary Complications for CLRT via 2 Pulmonary Complications for CLRT via 2

Therapeutic BedsTherapeutic Beds

•• Compare outcomes of VAP and Vent LOS Compare outcomes of VAP and Vent LOS with CLRT using 2 different bedswith CLRT using 2 different beds

•• 12 bed Mixed ICU, 99 12 bed Mixed ICU, 99 intubatedintubated patientspatients•• Retrospective analysis of 100% of patients Retrospective analysis of 100% of patients

receiving CLRT over a 2 year period (single receiving CLRT over a 2 year period (single reviewer)reviewer)

•• Compared outcomes in patients receiving Compared outcomes in patients receiving CLRT via CLRT via TriaDyneTriaDyne and SpOand SpO22RTRT

Fortune D. 2003, White PaperChandler Regional Hospital Catholic Health Care West

Comparison of Clinical Outcomes in Comparison of Clinical Outcomes in Pulmonary Complications for CLRT via 2 Pulmonary Complications for CLRT via 2

Therapeutic BedsTherapeutic Beds

•• TriaDyneTriaDyne–– Mean LOS 3.12 daysMean LOS 3.12 days–– Incidence of VAP Incidence of VAP

while on the Bed: 3while on the Bed: 3–– VAP % during use of VAP % during use of

TriaDyneTriaDyne 8.8%8.8%

•• SpOSpO22RTRT–– Mean LOS 2.68 daysMean LOS 2.68 days–– Incidence of VAP Incidence of VAP

while on the bed: 1while on the bed: 1–– VAP % during use of VAP % during use of

the SpOthe SpO22RT 1.5%RT 1.5%

Fortune D. 2003, White PaperChandler Regional Hospital Catholic Health Care West

Marik PE. Et al. Crit Care Med,2002;30(9):2147-2148

ChlorhexidineChlorhexidine vs. vs. PovidonePovidone Iodine Iodine for Catheter Site Carefor Catheter Site Care

Ann Intern Med 2002:136:792Ann Intern Med 2002:136:792--801801

25

Review of Inventions to Reduce Review of Inventions to Reduce VAP in Critically Ill PatientsVAP in Critically Ill Patients

•• EvidenceEvidence--based systematic review of the based systematic review of the literature 1966 literature 1966 -- 20012001

•• Data extract on study design, intervention & Data extract on study design, intervention & outcomesoutcomes

•• Results: Strategies that reduce VAPResults: Strategies that reduce VAP–– SemirecumbentSemirecumbent positionposition–– Stress ulcer prophylaxisStress ulcer prophylaxis–– Aspiration of Aspiration of subglotticsubglottic secretionssecretions–– Selective digestive decontaminationSelective digestive decontamination–– Rotational therapyRotational therapy

Collard HR. et al Ann Intern Med, 2003; 138:494-501

WHEN TO STOP CLRTWHEN TO STOP CLRT•• When the patient no When the patient no

longer fits the criteria longer fits the criteria that placed them on that placed them on CLRTCLRT

•• When the patient can When the patient can be mobilized into an be mobilized into an upright position without upright position without hemodynamic hemodynamic compromisecompromise

What is Your Next Move!!!!What is Your Next Move!!!!

CombateCombate deconditioningdeconditioning through through progressive positioning when progressive positioning when CLRT treatment is completedCLRT treatment is completed

In the ResearchIn the Research…… 1997 and 2000 1997 and 2000 Maximize Therapeutic InterventionMaximize Therapeutic Intervention

•• UpUp--inin--chair positioningchair positioning–– Branson, ACCP 1997Branson, ACCP 1997

•• Pulmonary mechanicsPulmonary mechanics•• Lung volumesLung volumes•• Gas exchangeGas exchange

–– Hospital Research Association, SCCM Hospital Research Association, SCCM 20002000•• 92% standard of care92% standard of care•• 90% not completed as ordered90% not completed as ordered

Airway ClearanceAirway ClearancePart of the Complete Part of the Complete

Preventive & Treatment Preventive & Treatment Pulmonary StrategiesPulmonary Strategies

Manual vs. Mechanical Bed CPTManual vs. Mechanical Bed CPTMethodologyMethodology

••24 patients with respiratory failure 24 patients with respiratory failure demonstrating segmental, lobular or unilateral demonstrating segmental, lobular or unilateral entire lung atelectasisentire lung atelectasis

••Ventilated or spontaneously breathingVentilated or spontaneously breathing••17 patients rotated with q 4 hour percussion 17 patients rotated with q 4 hour percussion at 9 beats for 20 min/18hours per dayat 9 beats for 20 min/18hours per day

••7 patients turned q 2 hours with q 2hr CPT 7 patients turned q 2 hours with q 2hr CPT

Raoof S. et al. Chest 1999;115:1658-1666

26

Manual vs. Mechanical Bed CPTManual vs. Mechanical Bed CPTResultsResults

Raoof S. et al. Chest 1999;115:1658-1666

••Complete or partial resolutionComplete or partial resolutionCLRT 14/17 (82%)*CLRT 14/17 (82%)*Control 1/7 (14%)Control 1/7 (14%)

••P/F ratio changes over 4 daysP/F ratio changes over 4 daysCLRT 207 to 318CLRT 207 to 318Control 181 to 112Control 181 to 112

••BroncoscopyBroncoscopy requiredrequiredCLRT 0**CLRT 0**Control 3Control 3

*p < 0004*p < 0004**p < 0.002**p < 0.002

HFCWOHFCWO•• Increased sputum mobilizationIncreased sputum mobilization**•• Improved pulmonary functionImproved pulmonary function**•• Cost effectivenessCost effectiveness

–– Decreased hospitalizationsDecreased hospitalizations**, ICU , ICU daysdays

–– Decreased antibiotic/oxygen needsDecreased antibiotic/oxygen needs•• Safety / efficacy in multiple Safety / efficacy in multiple

disease statesdisease states**•• Safety in ICU/post cardiac Safety in ICU/post cardiac

surgerysurgery**•• Improved weaning from ventsImproved weaning from vents•• Combining with other airway Combining with other airway

clearance therapiesclearance therapies**

King, Warwick, Landon, Plypolis, Allen, Brierley

Positioning CLRT, Bed P&V Positioning CLRT, Bed P&V and HFCWOand HFCWO

In the ICU setting:In the ICU setting:•• For prevention of pulmonary complications use For prevention of pulmonary complications use CLRTCLRT•• For patients requiring CLRT that have infiltrates/atelectasis For patients requiring CLRT that have infiltrates/atelectasis

provide provide CLRT w/ P&V Therapy from the SurfaceCLRT w/ P&V Therapy from the Surface•• If CLRT with P&V module does not help improve or If CLRT with P&V module does not help improve or

effectively address airway clearance therapy, provide the effectively address airway clearance therapy, provide the Vest for Vest for HFCWO along with CLRTHFCWO along with CLRT

In the MedicalIn the Medical--Surgical care area:Surgical care area:•• For airway clearance therapy provide the Vest for For airway clearance therapy provide the Vest for HFCWOHFCWO•• Use Use CLRTCLRT for select immobile patientsfor select immobile patients

2005 2005 -- Progressive Patient Progressive Patient PositioningPositioning

•• Old wayOld way–– Admission, bed, immobilized, supine, complicationsAdmission, bed, immobilized, supine, complications

•• New wayNew way–– Lateral rotationLateral rotation–– HOB elevationHOB elevation–– FullFull--chair positionchair position–– Bed egress/weight bearingBed egress/weight bearing–– Bedside chairBedside chair–– AmbulationAmbulation–– Enhanced recoveryEnhanced recovery

Where Does The Prone Where Does The Prone Position Fit into A Mobility Position Fit into A Mobility

Program?Program?When the patientWhen the patient’’s alveoli have been s alveoli have been recruited through conventional means & recruited through conventional means & the FiO2 remains in an unsafe rangethe FiO2 remains in an unsafe range

The goal of prone positioning is to reduce the The goal of prone positioning is to reduce the iatrogenic complications of mechanical ventilationiatrogenic complications of mechanical ventilation

27

Review of Prone Research Review of Prone Research Research up to 2004Research up to 2004•• 651 patients turned prone (1105 total)651 patients turned prone (1105 total)

–– 17 studies (46 total)17 studies (46 total)–– 58% abdomen free (versus 80%)58% abdomen free (versus 80%)–– 50% volume ventilation (versus 93%)50% volume ventilation (versus 93%)–– 50% pressure controlled50% pressure controlled

RESULTS:RESULTS: 71% reported a response >20% change in 71% reported a response >20% change in P/F ratio or 10mmHg increase in PaO2 P/F ratio or 10mmHg increase in PaO2 within 1 to 2 hourswithin 1 to 2 hoursTime in prone position 30 minutes to 20 Time in prone position 30 minutes to 20 hourshoursTrend of complications associated with > Trend of complications associated with > time spent in the prone positiontime spent in the prone position

Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3):319-336.

PurposesPurposes•• Identify a safe, maneuverable and Identify a safe, maneuverable and

effective technique to position patients effective technique to position patients proneprone

•• Determine if the suspended prone Determine if the suspended prone position improves oxygenation in the position improves oxygenation in the adult patient with acute respiratory adult patient with acute respiratory failurefailure

© Vollman1992

PHASE IPHASE I

PRODUCT EVALUATION PRODUCT EVALUATION STUDYSTUDY

28

19801980’’s Prone Positioning s Prone Positioning ResearchResearch……MethodologyMethodology

15 critically ill ARDS patients15 critically ill ARDS patientsServed as their own controlServed as their own controlRandomly assigned positionRandomly assigned positionABGABG’’ss at baseline & 20 at baseline & 20 minsminsRespiratory & Respiratory & hemodynamicshemodynamicsmeasuredmeasuredManual turning performed with a frame Manual turning performed with a frame using 3 individual/abdomen unrestrictedusing 3 individual/abdomen unrestricted

Vollman & Bander Inten Care Med 1996: 22(10):1105© Vollman 1996

Ventilator SettingsVentilator Settings

Tidal Volume:Tidal Volume:Oxygen:Oxygen:A / C rate:A / C rate:PEEP:PEEP:

600 to 900cc600 to 900cc40% to 100%40% to 100%10 to 25 / min10 to 25 / min5 to 20 cm of H2O5 to 20 cm of H2O

© Vollman1996

19801980’’s Prone Positioning Researchs Prone Positioning ResearchResults:Results:

Responders (9): Responders (9): PaOPaO2 2 89.189.1++14.114.1 toto 122.0122.0++27.427.4Shunt 32.2Shunt 32.2++ 5.35.3 toto 27.127.1++ 5.35.3

NonNon--Responders (6): Responders (6): PaOPaO2282.882.8++15.3 to15.3 to 72.672.6++10.310.3Shunt 31.7Shunt 31.7++11.3 to 11.3 to 34.734.7++12.012.0

No difference in hemodynamics seen between positions

Vollman & Bander et al. Inten Care Med 1996: 22(10):1105© Vollman1996

RR NRNR PPPIPPIP (cmH(cmH22O)O)

SupineSupine 45.8 45.8 ++10.410.4 61.0 61.0 ++ 11.6 0.0211.6 0.02ProneProne 47.6 47.6 ++ 8.78.7 65.0 65.0 ++ 14.8 0.0214.8 0.02

PPPlatPlat (cmH(cmH22O)O)SupineSupine 37.4 37.4 ++ 10.210.2 52.6 52.6 ++ 15.015.0

0.040.04ProneProne 37.4 37.4 ++ 9.59.5 55.0 55.0 ++ 17.5 0.0317.5 0.03

PaCOPaCO22 (mmHg)(mmHg)SupineSupine 31.5 31.5 ++ 3.93.9 41.8 41.8 ++ 4.3 0.00014.3 0.0001ProneProne 32.0 32.0 ++ 4.14.1 44.0 44.0 ++ 3.43.4

0.00010.0001MPAP (mmHg)MPAP (mmHg)

SupineSupine 27.0 27.0 ++ 7.17.1 36.4 36.4 ++ 5. 0.025. 0.02ProneProne 25.4 25.4 ++ 6.06.0 34.9 34.9 ++ 6.1 0.016.1 0.01

Differences in Pulmonary & Hemodynamic Variables between R& NR

Vollman & Bander. Inten Care Med 1996;22(16):1105© Vollman 1996

Demographic Differences of NonDemographic Differences of Non--RespondersResponders

Additional lung pathologiesAdditional lung pathologies

Trend toward longer stay in ICU & time on Trend toward longer stay in ICU & time on ventvent

Vollman & Bander. Inten Care Med 1996;22(16):1105© Vollman 1996

29

2001 Prone Positioning2001 Prone PositioningGattinoni et. al.Gattinoni et. al.

Study Period: 1996Study Period: 1996--19991999304 patients with Acute Lung Injury/Acute 304 patients with Acute Lung Injury/Acute Respiratory Distress Syndrome Respiratory Distress Syndrome randomized to receive 6 hours of prone randomized to receive 6 hours of prone positioning q 24 for 10 days or supine positioning q 24 for 10 days or supine position with q 2 hour lateral positioningposition with q 2 hour lateral positioningEntrance criteria: modified ALI/ARDS Entrance criteria: modified ALI/ARDS definitionsdefinitions

Methodology

Gattinoni L. et. al. N Engl J Med 2001;345:568-73© Vollman 2001


Measured: Primary endpoints: mortality at Measured: Primary endpoints: mortality at 10 days, hospital D/C & 6 months 10 days, hospital D/C & 6 months Secondary endpoints: PaOSecondary endpoints: PaO22/FiO/FiO2, 2, ratio ratio reduction, organ failure & incidence of reduction, organ failure & incidence of complicationscomplications

Methodology



10 day mortality: 21% vs. 25%10 day mortality: 21% vs. 25% (RR 0.84 CI 0.56 to 1.27)(RR 0.84 CI 0.56 to 1.27)

Hospital d/c mortality: 50.7% vs. 48% Hospital d/c mortality: 50.7% vs. 48% ( RR 1.05 CI 0.84 to ( RR 1.05 CI 0.84 to 1.32)1.32)

6 months mortality: 62.5% vs. 58.6% 6 months mortality: 62.5% vs. 58.6% ( RR 1.06 CI 0.88 to ( RR 1.06 CI 0.88 to 1.28)1.28)

Significant increase in PaO2/FiO2 ratio in the prone Significant increase in PaO2/FiO2 ratio in the prone groupgroupNo difference in organ dysfunctionNo difference in organ dysfunction% of patients with new or worsening pressure ulcers % of patients with new or worsening pressure ulcers per patient was worse in the prone groupper patient was worse in the prone group

Results


Study ConcernsStudy ConcernsWas the study methodology Was the study methodology relevant?relevant?–– Testing an intervention using Testing an intervention using

19961996--1999 ventilator 1999 ventilator managementmanagement

•• TV: 10.3/ml/kg TV: 10.3/ml/kg ++ 2.9 (s)2.9 (s)•• TV: 10.3/ml/kg TV: 10.3/ml/kg ++ 2.7 (p)2.7 (p)•• Average PEEP: <10cmAverage PEEP: <10cm

–– Majority of patients entered into Majority of patients entered into the study were primary respiratory the study were primary respiratory pathology vs. secondarypathology vs. secondary

Were the patients in the Were the patients in the prone position a sufficient prone position a sufficient period of time?period of time?–– Average time prone: 7.0 Average time prone: 7.0 ++ 1.81.8

© Vollman 2001

Study ConcernsStudy Concerns•• Was the study powered sufficiently?Was the study powered sufficiently?

–– Stopped early with recruitment problems Stopped early with recruitment problems –– Deviations from the protocol/41 patients Deviations from the protocol/41 patients

nonnon--compliant with the study protocolcompliant with the study protocol

•• Were the most appropriate patients Were the most appropriate patients study?study?–– Altered ALI/ARDS criteriaAltered ALI/ARDS criteria–– PostPost--hoc analysis showed sicker hoc analysis showed sicker

patients had a significant improvement patients had a significant improvement in mortalityin mortality

© Vollman 2001

Prone Positioning 2004Prone Positioning 2004Guerin C. et alGuerin C. et al

•• Study conducted: Dec 1998Study conducted: Dec 1998--2002 2002 •• 791 ARF patients, 791 ARF patients, multicentermulticenter trial, unblended, trial, unblended,

randomizedrandomized•• 413 prone, 378 supine (8 hours per day)413 prone, 378 supine (8 hours per day)•• Patient in supine group could cross over to prone if P/F Patient in supine group could cross over to prone if P/F

ratio < 100 for > 12 hours, or < 60 for 1 hr or on 100% ratio < 100 for > 12 hours, or < 60 for 1 hr or on 100% FiO2FiO2

•• P/F ratio <300, P/F ratio <300, hemodynamicallyhemodynamically stable & no stable & no contraindications to the prone positioncontraindications to the prone position

•• Measured 28 day all cause mortality, duration of Measured 28 day all cause mortality, duration of mechanical ventilation, incidence of VAP & oxygenationmechanical ventilation, incidence of VAP & oxygenation

Methodology

Guerin C. et al JAMA 2004;292:2379-2387

30

Prone Positioning 2004Prone Positioning 2004Guerin C. et alGuerin C. et al

•• No difference in mortalityNo difference in mortality•• No difference in ventilation daysNo difference in ventilation days•• Reduction in VAP in the prone group*Reduction in VAP in the prone group*•• Significantly higher P/F ratio for 28 days in the prone Significantly higher P/F ratio for 28 days in the prone

groupgroup

•• Most patientMost patient’’s in supine group crossed overs in supine group crossed over•• Mechanical ventilation was not performed using a preMechanical ventilation was not performed using a pre--

determined algorithm determined algorithm (Tidal volume 8 ml/kg & tidal volume in (Tidal volume 8 ml/kg & tidal volume in pressure control 11ml/kg)pressure control 11ml/kg)

•• Only in prone position for 8.6 hours for total of 4.6 daysOnly in prone position for 8.6 hours for total of 4.6 days

Results

Guerin C. et al JAMA 2004;292:2379-2387*P < 0.045

Limitations

Barriers to Mobility StrategiesBarriers to Mobility Strategies

•• Human or Human or Technological Technological ResourcesResources

•• Hemodynamic Hemodynamic instabilityinstability

•• Knowledge/PriorityKnowledge/Priority

Human & Technological Human & Technological ResourcesResources

•• PainPain•• PersonnelPersonnel•• Aging personnelAging personnel•• Use of Lift teamsUse of Lift teams•• FearFear•• Lines and tubesLines and tubes

HemodynamicHemodynamicInstabilityInstability

Is it a Barrier toIs it a Barrier toPositioning?Positioning?

Hemodynamic StatusHemodynamic Status•• No differences noted in No differences noted in hemodyanmichemodyanmic

variables between supine & positionsvariables between supine & positions•• Lateral turn results in a 3Lateral turn results in a 3--9% decrease in 9% decrease in

SVO2 which takes 5SVO2 which takes 5--10 minutes to return to 10 minutes to return to baselinebaseline

•• Appears the act of turning has the greatest Appears the act of turning has the greatest impact on any instability seenimpact on any instability seen

•• Minimize factors which contribute to Minimize factors which contribute to imbalances in oxygen supply & demand imbalances in oxygen supply & demand

•• Perform a trial turn?Perform a trial turn?Winslow, E.H. Heart and Lung, 1990 Volume 19, 557Winslow, E.H. Heart and Lung, 1990 Volume 19, 557--561.561.

Patients at Risk for Intolerance to Patients at Risk for Intolerance to PositioningPositioning

•• Elderly Elderly •• Diabetes with neuropathyDiabetes with neuropathy•• Prolonged Prolonged bedrestbedrest•• Low Low HbHb an cardiovascular reservean cardiovascular reserve•• Prolonged gravitational equilibriumProlonged gravitational equilibrium

Vollman KM. Crit Care Nurs Clin of North Amer, 2004;16(3):319-336.

31

Reported Complications for 746 Reported Complications for 746 Prone Turn CyclesProne Turn Cycles

12 studies noted critical events12 studies noted critical events> 12 hours in the prone position > 12 hours in the prone position associated with more complicationsassociated with more complicationsOneOne--half of the studies reported cutaneous half of the studies reported cutaneous & structural problems& structural problems

dependant edemadependant edemapressure ulcers : chin & chestpressure ulcers : chin & chestcontractures (9 days prone, 56 days prone)contractures (9 days prone, 56 days prone)

Curley M. AJCC, 1999;8:397-405

Reported Complications for 746 Reported Complications for 746 Prone Turn Cycles (contProne Turn Cycles (cont’’d.)d.)

8 episodes of hemodynamic instability (1.1)8 episodes of hemodynamic instability (1.1)3 episodes of extubation (.4%)3 episodes of extubation (.4%)2 episodes of in SaO2 (.3%)2 episodes of in SaO2 (.3%)2 atypical atelectasis (.3%)2 atypical atelectasis (.3%)1 obstructed ET tube (.1%), 1 kinked ETT 1 obstructed ET tube (.1%), 1 kinked ETT (.1%), 1 CVC dislodgment (.1%), 1 femoral (.1%), 1 CVC dislodgment (.1%), 1 femoral hemodialysis catheter dislodgment (.1%), 1 hemodialysis catheter dislodgment (.1%), 1 SVT (.1%)SVT (.1%)

Curley M. AJCC, 1999;8:397-405

Prone

Positioning

Evidence

Based

Medicine

Evidence

Based

Practice

Clinical

Effectiveness

IHI/VHA Change StrategyIHI/VHA Change Strategy

•• Care BundlesCare Bundles–– Grouping of care elements for Grouping of care elements for

particular symptoms, procedures particular symptoms, procedures or treatmentsor treatments

–– Strong science, good Strong science, good methodology, poor processmethodology, poor process

–– Bundle characteristicsBundle characteristics•• Solid evidenceSolid evidence•• Relatively easy & inexpensiveRelatively easy & inexpensive•• Individual components Individual components

defined welldefined well•• Process not defined wellProcess not defined well

The Vent BundleThe Vent Bundle……Getting StartedGetting Started

•• Applying evidenceApplying evidence--based practicebased practice•• 5 activities that when done 100% of the time 5 activities that when done 100% of the time

has shown a reduction inhas shown a reduction in–– VAPVAP–– LOSLOS–– Time on VentTime on Vent–– CostCost

•• HOB 30HOB 30°° , DVT prophylaxis, PUD , DVT prophylaxis, PUD prophylaxis, Sedation vacation, Spontaneous prophylaxis, Sedation vacation, Spontaneous breathing trial (added components in some breathing trial (added components in some areas of the country (oral care & mobility)areas of the country (oral care & mobility)

32

What does the DVT Science Tell Us?What does the DVT Science Tell Us?•• Patients who are critically ill Patients who are critically ill

or mechanically ventilated or mechanically ventilated are at high risk for DVT and are at high risk for DVT and should receive some form should receive some form of thromboprophylaxisof thromboprophylaxis

•• Multiple therapies for DVT Multiple therapies for DVT prophylaxis were prophylaxis were consistently reported to consistently reported to reduce the risk of DVTreduce the risk of DVT

•• With prevention we can With prevention we can reduce mortality, hospital reduce mortality, hospital LOS and associated costsLOS and associated costs Attia J. et al. Arch Intern Med.

2001;161(10):1268-79

DVT Prevention: DVT Prevention: SCDSCD’’ss vs. Aspirinvs. Aspirin

•• Methodology: 122 patients unilateral or bilateral Methodology: 122 patients unilateral or bilateral total knee total knee arthroplastyarthroplasty–– Compared efficacy of 2 methods for DVT prevention; Compared efficacy of 2 methods for DVT prevention;

pneumatic planter compression & aspirin or aspirin alonepneumatic planter compression & aspirin or aspirin alone–– VenogramsVenograms performed on postperformed on post--op day 4 & 7op day 4 & 7–– Compliance assessed via internal timing deviceCompliance assessed via internal timing device

•• Results:Results:–– 59% prevalence with aspirin alone59% prevalence with aspirin alone–– 27% prevalence with aspirin & pneumatic compression27% prevalence with aspirin & pneumatic compression–– Study group 0% proximal thrombi, 14% in controlStudy group 0% proximal thrombi, 14% in control–– Compliance: In study group patients those with no Compliance: In study group patients those with no DVTDVT’’ss wore wore

the device 19.2 hours/day compared with 13.4 hours/daythe device 19.2 hours/day compared with 13.4 hours/day

Westrich GH. Journal of Bone & Joint Surgery, 1996;78-A:826-34

DVT Prevention: DVT Prevention: SCDSCD’’ss vs. LMWHvs. LMWH

•• Methodology: 121 patientsMethodology: 121 patients–– Compared efficacy of 2 methods for DVT prevention; Compared efficacy of 2 methods for DVT prevention;

pneumatic compression (pneumatic compression (ActiveCareActiveCare™™ DVT) / aspirin & LMWH DVT) / aspirin & LMWH alonealone

–– Total knee and hip replacement patientsTotal knee and hip replacement patients–– VenogramsVenograms performed on postperformed on post--op day 5 & 8op day 5 & 8–– Compliance assessed via internal timing deviceCompliance assessed via internal timing device

•• Results:Results:–– DVT incidence 6.6% with DVT incidence 6.6% with ActiveCareActiveCare™™ DVT) / aspirin groupDVT) / aspirin group–– DVT incidence 28.3% with LMWHDVT incidence 28.3% with LMWH–– Lower rate of proximal DVT 1.6% vs. 10% in LMWH groupLower rate of proximal DVT 1.6% vs. 10% in LMWH group

Gelfer Y et al. Israeli Orthopedic Conference, Zefirin Israel, Dec 2002

What does the PUD Science Tell What does the PUD Science Tell Us?Us?

•• Patients who are Patients who are mechanically ventilated are at mechanically ventilated are at high risk for upper GI bleed high risk for upper GI bleed and evidence supports and evidence supports prophylaxis.prophylaxis.

•• Multiple therapies for PUD Multiple therapies for PUD have proven effectivehave proven effective

•• GI bleed results in an GI bleed results in an additional 5 day LOS and additional 5 day LOS and there is a 13% relative there is a 13% relative increase in mortality with increase in mortality with significant GI bleed.significant GI bleed.

Cook DJ. Et al. N Engl J Med. 1994;330(6):377-81

What does the Sedation What does the Sedation Evaluation Science Tell Us?Evaluation Science Tell Us?

•• Daily interruption of Daily interruption of sedative drug infusions sedative drug infusions decreases the duration of decreases the duration of mechanical ventilation and mechanical ventilation and LOS in the ICULOS in the ICU

•• In the group that had daily In the group that had daily interruption, the duration of interruption, the duration of mechanical ventilation was mechanical ventilation was reduced by 33% (2.4 days) reduced by 33% (2.4 days) and ICU LOS was reduced and ICU LOS was reduced by 35% (3.5 days). by 35% (3.5 days).

Kress JP. Et al. N Engl J Med. 2000;342:1471-1477

What does the Daily Spontaneous What does the Daily Spontaneous Breathing Trial Science Tell Us?Breathing Trial Science Tell Us?

•• Daily screening of respiratory Daily screening of respiratory function followed by a trial of function followed by a trial of spontaneous breathing if the spontaneous breathing if the patient meets the criteria can patient meets the criteria can result in a reduction of time on result in a reduction of time on the ventilator, reduced the ventilator, reduced complications and costscomplications and costs

•• In a study that look at daily In a study that look at daily screening alone vs. daily screening alone vs. daily screening followed by a trial if screening followed by a trial if criteria met resulted in 1.5 days criteria met resulted in 1.5 days less on the ventilator. less on the ventilator. Complications post extubation Complications post extubation were less in the SBT groupwere less in the SBT group Ely EW. Et al. N Engl J Med.

1996;335:1864-9

33

TheTheFutureFuture

Pharmacological ManagementPharmacological Management•• Modulation TherapiesModulation Therapies

AntioxidantsAntioxidantsNSAIDS NSAIDS ILIL--1 receptor antagonist1 receptor antagonistNeutrophilNeutrophil ElastaseElastase InhibitorInhibitorXigrisXigris (Activated Protein C) if in Severe Sepsis(Activated Protein C) if in Severe Sepsis

© Vollman 2001

* Relative risk reduction at 28 days.

Drotrecogin Alfa (Activated) Significantly Drotrecogin Alfa (Activated) Significantly Improved Survival in PROWESSImproved Survival in PROWESS

•• 31% mortality for drotrecogin alfa (activated) patients 31% mortality for drotrecogin alfa (activated) patients vs 44% for standard therapy patients at 28 days.vs 44% for standard therapy patients at 28 days.

See important safety information in this presentation.See important safety information in this presentation.Data on file, Eli Lilly and Company.

Surfactant ReplacementSurfactant Replacement

Goal:Goal: Lowers surface tensionLowers surface tensionDecrease atelectasisDecrease atelectasisProvides a greater area for gas Provides a greater area for gas exchangeexchange

Concerns:Concerns: CostCostDelivery methodDelivery methodDose requiredDose required

MulticenterMulticenter Surfactant TrialSurfactant Trial

Spragg RG. Et al N Engl J Med;351:884-92.

34

Phase III Multicenter Nitric Oxide StudyPhase III Multicenter Nitric Oxide Study

Methodology:Methodology:•• 385 ARDS patients385 ARDS patients•• Randomized to receive 5 ppm of NO or placeboRandomized to receive 5 ppm of NO or placebo•• Measured: alive & off assisted breathing Measured: alive & off assisted breathing

(extubated for 72 hours)(extubated for 72 hours)

Results: Results: No difference in population demographicsNo difference in population demographicsTreatment: 10.70 days alive/off assisted breathingTreatment: 10.70 days alive/off assisted breathing

Mortality: 23%Mortality: 23%Placebo:Placebo: 10.64 days alive/off assisted breathing10.64 days alive/off assisted breathing

Mortality: 20%Mortality: 20%

SCCM Conference 2000SCCM Conference 2000

Liquid VentilationLiquid VentilationEnhances recruitment of atelectatic lung Enhances recruitment of atelectatic lung regionsregionsLavages exudate from peripheral Lavages exudate from peripheral airwaysairways

Partial Liquid Ventilation:Partial Liquid Ventilation:a Nona Non--Controlled Phase 1 StudyControlled Phase 1 Study

MethodologyMethodology10 adult patients with ARDS10 adult patients with ARDSReceiving ECMOReceiving ECMODose range 2.5 to 10 ml/kgDose range 2.5 to 10 ml/kg

ResultsResultsReduction in shuntReduction in shuntImproved complianceImproved compliance50% survival50% survivalComplications: 1 pneumothorax and 1 Complications: 1 pneumothorax and 1 mucus plugmucus plug

Learn the value of team work and Learn the value of team work and how much people contribute to how much people contribute to each othereach other’’s success. s success.

presentation overview ards/ali: bundling care … pao 2/fio 2 ratio • user friendly tool • crude...

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