targets in ards management blood gases · targets in ards management blood gases antonio pesenti,...
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Targets in ARDS
management
Blood Gases
Antonio Pesenti, MDUniversità di Milano
Fondazione IRCCS Ca’ Granda
Ospedale Maggiore Policlinico
Milan, Italy
CCCF 2017
ACUTE RESPIRATORY
DISTRESS SYNDROME IN
ADULTS
By D.G. Ashbaugh et al. The Lancet, 1967.
“THE CLINICAL PATTERN, … INCLUDES
SEVERE DYSPNOEA, TACHYPNOEA,
CYANOSIS THAT IS REFRACTORY TO OXYGEN
THERAPY, LOSS OF LUNG COMPLIANCE, AND
DIFFUSE ALVEOLAR INFILTRATION SEEN ON
CHEST X-RAYS”
At first it was :
try to get the best PaO2
• Intermittent positive-pressure respiration.-
Patient 9 was ventilated with an
experimental volume-cycled respirator
incorporating deep breath at regular
intervals.
• Continuous positive-pressure respiration.
End-expiratory pressures were maintained
at 5-10 cm. water. All 5 patients
demonstrated a rise in P a02 or oxygen
saturation with the use of end-expiratory
pressure.
1988
Guerin C neJM 2013 368:2159
ARDSNet NEJM 2000
Lung protective ventilation
vs. 12 ml/kg
6 ml/kg and/or
Pplat <30
P/F 158±73 176±76 160±68 177±81 165±71 164±88
PaO2 76±23 77±19 74±22 76±23 73±17 75±21
DAY 1 DAY 3 DAY 7
Low VT High VT Low VT High VT Low VT High VT
Oxygenation in the ARMA trial
NEJM 342: 1341: 2000
• A
At 1 hr
At 7 days
Minerva Anestesiol 2010;76:1043
Minerva Anestesiol 2010;76:1043
Minerva Anestesiol 2010;76:1043
Lung Safe Sp O2
• All 95% (94-95) 8.4 (8.3- 8.6)
• Mild 97% (97-98) 7.4 (7.2-7.6)
• Moderate 95% (95-96) 8.3 (8.1-8.5)
• Severe 90% (89-91) 10.1 (9.8-10.4)
Bellani G et al. JAMA. 2016;315(8):788-800.
SpO2% PEEP
15
Permissive Hypoxemia
• How low can we tolerate a PaO2?
• 80% Sat?
• A wise compromise between what we get and what we pay
Grocott et al : N Engl J Med 2009;360:140
Grocott et al N Engl J Med 2009;360:140-9
ADAPTATION TO HYPOBARIC HYPOXEMIA
Large leftward shift of dissociation curve
Hyperventilation, bicarbonate loss, high pH
Control 1
Control 2
ARDS 1
ARDS 2
Mikkelsen et al 2012 AJRCCM
Mikkelsen et al 2012 AJRCCM
Hyperoxemia is bad:
• In cardiac arrest ( Kilgannon J JAMA 2010)
• In AMI (Stub D Circulation 2015)
• In Brain Injury (Helmerhorst H CCM 2015
• etc
GIRARDIS M, JAMA 2016
94-98% 97- 100%
Right oxemia
• How low/ High can we tolerate a PaO2?
• 87% - 97%Sat?
• No supranormal values ( Hb%!!!!!!)
• A wise compromise between what we get and what we pay
Carbon Dioxide: an innocuous gas?
PaO2 min PaCO2 max
Courtesy of Dr Gilles Capellier
Baseline Characteristics of Patients With ARDS
RR
VT
PEEP
PPLAT
VE
20.8
(21.5-21.2)
19.5
(19.0-19.9)
20.7
(20.3-21.1)
22.7
(21.5-23.8)
7.6
(7.5-7.7)
7.8
(7.6-7.9)
7.6
(7.5-7.7)
7.5
(7.3-7.6)
8.4
(8.3-8.6)
7.4
(7.2-7.6)
8.3
(8.1-8.5)
10.1
(9.8-10.4)
23.2
(22.6-23.7)
20.5
(19.8-21.3)
23.1
(22.6-23.7)
26.2
(25.2-27.1)
10.8
(10.6-11.0)
9.3
(9.1-9.6)
10.7
(10.5-11.0)
12.8
(12.3-13.3)
All
(N = 2377)
Mild
(N = 714)
Moderate
(N = 1106)
Severe
(N = 557)
Bellani G et al. JAMA. 2016;315(8):788-800.
Baseline Characteristics of Patients With ARDS
PaO2/FIO2
FIO2
PaCO2
pH
161
(158-163)
246
(244-248)
149
(147-150)
75
(74-77)
0.65
(0.64-0.65)
0.48
(0.47-0.50)
0.62
(0.61-0.63)
0.90
(0.88-0.91)
PEEP8.4
(8.3-8.6)
7.4
(7.2-7.6)
8.3
(8.1-8.5)
10.1
(9.8-10.4)
46.0
(45.4-46.6)
41.5
(40.7-42.2)
45.8
(44.9-46.6)
52.2
(50.7-53.7)
7.33
(7.32-7.33)
7.36
(7.36-7.37)
7.33
(7.32-7.33)
7.27
(7.26-7.29)
Bellani G et al. JAMA. 2016;315(8):788-800.
All
(N = 2377)
Mild
(N = 714)
Moderate
(N = 1106)
Severe
(N = 557)
NEJM 2002:346: 1281
Is permissive Hypercapnia the best solution to
prevent VILI?
Hyperventilation of the “baby lung”80% Dead Space means that the baby lung is
severely hypoperfused.
The rest is ventilated 12 l/min i.e several times normal
ARDS :a pulmonary
microvascular disease