thom petty bs rrt lead clinical specialist – east carefusion critical care ventilation
TRANSCRIPT
ADVANCED VENTILATOR
MANAGEMENT
Transpulmonary Guided
VentilationThom Petty BS RRT
Lead Clinical Specialist – East CareFusion Critical Care Ventilation
Objectives
Identify the limitations that current Respiratory Mechanics impose upon the management of mechanical ventilation.
Review the hazards associated with positive pressure ventilation and the sequelae of Ventilator-Induced Lung Injury.
Discuss the role of chest wall, pleura and abdominal pressures during positive pressure ventilation
Introduce the measurement of Transpulmonary Pressure as a valuable ventilation management tool.
Review a Case Study regarding the use of transpulmonary pressures in the management of ventilator settings.
Basic Ventilator
Mechanics
PAO = ( VL / CRS) + ( F x RAW )
PAO = Pressure at the Airway OpeningVL = Volume in the LungCRS = Compliance of the Respiratory System
(Lung + Pleura) F = Flow Rate of Gas in L/sRAW = Resistance of the Airway and ETT
( pressure / flow)
Mechanics 101: Motion of Air Equation
PRESSURE IN THE AIRWAY (PAW) Measured at the circuit wye Not the actual pressure in the lungs but the
pressure of the entire respiratory system Reflects both lung and pleural pressures
PERI-PULMONARY/PLEURAL PRESSURE (PES) Pressure that is imposed upon the lungs by
the Chest Wall and Abdomen Can be approximated by measuring
pressures within the Esophagus
PRESSURE WITHIN THE ALVEOLI (PTP) The TRUE pressure within the lung PTP = PAW – PES
As the Lung Inflates
Paw
Pes Ptp
Inspiratory Hold Measures the Plateau Pressure of the entire Respiratory System
Indicator of end-inspiratory lung distension
Static Compliance Reflects the compliance of the entire Respiratory System
Expiratory Hold Measures the amount of intrinsic PEEP of the entire Respiratory System
Our Current Respiratory Mechanics Toolbox
MECHA
NICAL
VENTIL
ATION?
What’s so bad about
MECHANICAL VENTILATION CAN NO LONGER BE SEEN MERELY AS A
SUPPORTIVE THERAPY IN ALI AND ARDS,
BUT AS A TREATMENT MODALITY CAPABLE OF SIGNIFICANTLY
INFLUENCING THE COURSE OF PULMONARY DISEASE AND
CLINICAL OUTCOME.
VIANA M, JORNAL DE PEDIATRIA, 2004
The Hazard that is Mechanical Ventilation
8
Just What is Positive-Pressure Ventilation?
Just what is it that is delivered by the ventilator to the patients’ lungs?
Volume
Flow
Pressure
The Alveoli – Not Grapes on a Straw
The Alveolar Structure
Adjacent alveoli and terminal bronchioles share common walls
Forces acting on one lung unit are transmitted to those around it (interdependence)
Under conditions of uniform expansion, all lung units will be subject to a similar transpulmonary pressure.
However, if the lung is unevenly expanded, such forces may vary considerably.
Dynamic Alveolar Mechanics in the Uninjured Lung
Healthy alveoli: Undergo relatively small changes in size during ventilation unless they
totally collapse or re-expand. Ventilation may occur primarily with changes in the size of the alveolar
duct or conformational changes as a result of alveolar folding
Alveoli in ALI: Undergo large changes in alveolar size Widespread alveolar recruitment/derecruitment predominate. Can cause significant shear stress-induced lung injury Gross tearing of the alveolar wall Injury to the cell membrane Ultrastructural injury
Wilson, J Appl Physiol, 2001Carney, CCM, 2005
Steinberg, AJRCCM, 2004
The Problems with Positive-Pressure Ventilation
Positive-pressure ventilation departs radically from the physiology of breathing spontaneously. During inhalation positive intrathoracic pressures are created. These inspiratory-phase pressures are not homogenously distributed
throughout the lung: Effectively distributed through compliant lung Flow is attenuated in low-compliant areas
This heterogenocity can result in overdistension of compliant “healthy” lung and underdistension of non-compliant “injured” lung
The Problems with Positive-Pressure Ventilation
Early on in the history of positive-pressure ventilation it was recognized that lungs that were ventilated to high pressures have a propensity to develop air leaks. Thus began the early focus on barotrauma
However, further research has revealed that alveoli that do not overdistend were unlikely to experience injury. Excessive lung volume (volutrauma) rather than excessive airway
pressures produced lung injury.
At the other end of the spectrum, ventilation using low end expiratory volumes that allowed repetitive alveolar opening and collapse (atelectrauma) was also identified as injurious.
Whitehead, Thorax, 2002Diaz, Crit Care Med 2010
Ventilator-Induced Lung InjuryVolutrauma & Inflammation
Study investigating the release of “Lung Flooding” factors in Rodents ventilated with three modes:
HiP/HiV High Pressure (45 cmH2O) High Volume
LoP/HiV Low Pressure (neg.pres.vent) High Volume
HiP/LoV High Pressure (45 cmH2O) Low Volume (chest bound)
Dreyfuss,D ARRD 1988;137:1159
Mechanical and Biochemical in nature
Caused by excessive End-Inspiratory Volumes Indicated by elevated end-inspiratory (Plateau) pressures May result from a combination of “Safe” Vt + PEEP
Even “safe” Vt’s may severely over-inflate normal alveoli due to heterogenicity of airflow within the lung
QUESTION: How can a clinician determine if alveoli are over-distended at end-inspiration?
Ventilator-Induced Lung InjuryTake-Home Points - Volutrauma
Research has revealed that repeated cyclical collapse & re-expansion of alveoli results in a release of cytokines and the reinforcement and amplification of the local and systemic inflammatory response.
Interleukin-6 Interleukin-11 Interleukin-γ Tissue Necrosis Factor-α
Ventilator-Induced Lung InjuryAtelectrauma
Associated with repeated opening and closing of alveoli during ventilatory phasing
Associated with regional differences in ventilation
Worsens surfactant dysfunction
Release of inflammatory mediators into alveolar spaces and into the systemic circulation
QUESTION: How can the clinician determine what PEEP is necessary to keep the alveoli open at end-exhalation
Ventilator-Induced Lung InjuryTake-home Points - Atelectrauma
Presumed Mechanism for VILI
Mechanical Disruption of Pulmonary Epithelium
Mechanotransduction Cell & Tissue Disruption
Upregulation & release of Cytokines &, Chemokines
Subsequent leucocyte attraction and activation
Pulmonary Inflammation: VILI
Systemic Spillover:SIRS / MODS
MECHANOTRANSDUCTION – Conversion of Mechanical Stimiuls into Chemical ReactionSIRS – systemic inflammatory Response SyndromeMODS – Multi Organ Dysfunction syndrome
Lung-Protective Ventilation
Safer Ventilator Management
Lung-Protective Ventilation Theory
1987 - Gattinoni’s CT studies of ALI/ARDS lungs revealed that ALI/ARDS lung is not a stiff organ made up of homogeneously stiff lung units with low static compliance but is a multi-compartmental heterogeneous structure in which there is a portion of aerated normal tissue with normal compliance (baby lung).
Limiting VILI should be accomplished through an Lung Protective approach to ventilator management which includes:
Volume & pressure limitation Modest PEEP & Plateau pressures
The challenge is to maintain acceptable gas exchange while avoiding harmful mechanical ventilation practices. The need for potentially injurious pressures, volumes, and FiO2’s must be weighed against the benefits of gas exchange support.
Lung-Protective Ventilation Research
There have been six randomized controlled trials evaluating the effect of lung-protective ventilation in comparison with conventional approaches:
1988 Amato et al Brazil
29 pts: Vt < 6ml/kg, Pplat < 20cmH2O24 pts: Vt = 12ml/kg, PaCO2 35-38 mmHg
38% Mortality71% Mortality
1998 Stewart et alCanada
60 pts: Vt < 8ml/kg, Ppeak < 30cmH2O60 pts: Vt 10-15ml/kg, Ppeak < 50cmH2O
50% Mortality at disch47% Mortality at disch
1998 Brochard et alMultinational
58 pts: Vt 6-10ml/kg, Pplat < 25-30 cmH2O58 pts: Vt 10-15ml/kg, PaCO2 38-42 mmHg
47% Mortality at 60 days38% Mortality at 60 days
1999 Brower et alUSA
26 pts: Vt 5-8ml/kg, Pplat <30 cmH2O26 pts: Vt 10-12ml/kg, Pplat < 45-55 cmH2O
50% Mortality at disch46% Mortality at disch
2000 ARDSnetworkUSA
432 pts: Vt 6ml/kg, Pplat < 30 cmH2O429 pts: Vt 12ml/kg, Pplat < 50 cmH2O
31% Mortality at disch/180 d40% Mortality at disch/180 d
2006 Villar et alSpain
50 pts: Vt 5-8ml/kg, PEEP @ LIP + 2cmH2O53 pts: Vt 9-11ml/kg, PEEP >5 cmH2O
32% Mortality in ICU53% Mortality in ICU
The Handful of Ventilator Settings
Tidal Volume Accurately measured
Respiratory RateAccurately measured
FiO2 Accurately measured
PEEP Measured but not accurate
Plateau PressureMeasured but not accurate
A key limitation to mechanical ventilators is that they report peak airway pressures
without distinguishing compliance that reflects intrinsic lung mechanics or chest wall
and abdominal pressures
Piraino T, Respiratory Care, April 2011
The Problem with Airway Pressures
The Two Settings We Estimate
PEEP Measured but not accurate
Plateau PressureMeasured but not accurate
The Two Settings we Estimate: PEEP
Measured at the end of exhalation PEEP is the pressure that is exerted by the volume of gas that is remaining in the lungs (FRC)
Although ventilation with Low Vt’s & Plateau Pressures is generally accepted by the critical-care community, the optimal level of PEEP at which to ventilate remains unclear. PEEP levels exceeding the “traditional” values of 5-12 cmH2O have
been shown to minimize cyclical alveolar collapse and the corresponding shearing injury.
However, potential adverse consequences including circulatory depression and lung overdistension may outweigh the benefits
Use of PEEP < 10cmH2O leads to an increase in mortalityAmato M., 8th World Congress, Sydney, Australia
Dreyfuss, Crit Care Med, 1998Gattinoni, NEJM, 2006
Muscedere , Am J Respir Crit Care Med. 1994
The Two we Estimate: PEEP Research
There have been three randomized controlled trials comparing higher versus lower levels of PEEP in ALI/ARDS:
2010 – Briele Meta-Analysis Differences in hospital mortality not statically significant Significant reduction of death in the ICU in the High PEEP group
2004ARDSNetALVEOLIUSA
276 pts: Mean PEEP = 14.7cmH2O273 pts: Mean PEEP = 8.9cmH2O
25% Mortality at disch27.5% Mortality at disch
2008MeadeLOVSMultinational
508 pts: Mean PEEP = 15.6cmH2O475 pts: Mean PEEP = 10.1cmH2O
36% Mortality at disch40% Mortality at disch
2008MercatEXPRESSFrance
382 pts: Mean PEEP = 14.6cmH2O385 pts: Mean PEEP = 7.1cmH2O
35% Mortality at 60 days39% Mortality at 60 days
Low PEEP/High FiO2 ProtocolFiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0PEEP 5 5 8 8 10 10 10 12 14 14 14 16 16 18-24
High PEEP/Low FiO2 ProtocolFiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.5-0.8 0.8 0.9 1.0 1.0PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24
The Two we Estimate: The PEEP Controversy
The Two we Estimate: Optimal PEEP
• Ideal PEEP is defined as:
• High enough to induce alveolar recruitment, keeping the lung more aerated at end-exhalation, while not distending “good”alveoli
• Low enough to prevent hemodynamic impairment & overdistension
PEEP TABLE Table of FiO2 & PEEP combinations to achieve PaO2 or SpO2 in target range
MAXIMAL PEEP WITHOUT OVERDISTENSION
Use of highest PEEP while maintaining Pplat < 30 cmH2O
GAS EXCHANGE Lowest shunt (highest PaO2), lowest deadspace (lowest PaCO2), best oxygen delivery (CaO2 x C.O.)
COMPLIANCE Use of the highest PEEP that results in the highest respiratory-system compliance
STRESS INDEX Observe the Pressure/Time Curve during constant flow inhalation for signs of tidal recruitment and overdistension
PRESSURE/VOLUME CURVE Set PEEP slightly higher than Lower Inflection Point
IMAGING Computed tomography, Electrical impedence tomography, Ultrasound
ESOPHAGEAL PRESSURE MONITORING
Estimate the intra-pleural pressure with the measurement of Esophageal Pressure then determine optimal PEEP
The Two we Estimate: Alveolar Recruitability
• Briele also suggests that the beneficial impact of reducing intra-tidal alveolar opening and closing by increasing PEEP prevailed over the effects of increasing alveolar distention in ALI/ARDS patients with higher lung recruitability• In ALI/ARDS patients with low potential for recruitment, the
resulting over-distension associated with PEEP increases was harmful
• How To Determine Lung Recruitability:• Non-Recruitable – If PEEP is and Plateau Pressure then in an
equal or greater increment.• Recruitable – If PEEP is and Plateau Pressure then in a lesser
increment
The Two We Estimate
PEEP Measured but not accurate
Plateau PressureMeasured but not accurate
The Two We Estimate: Plateau Pressure
Plateau Pressure is the pressure exerted by the volume of gas in the lungs after an inhalation. Indicator of “lung fullness”
Plateau Pressure Goal: Keep < 30 cmH2O
The Two We Estimate: Plateau Pressure
Check PPLAT (with a minimum 0.5 second inspiratory pause) at least q 4h and after each change in PEEP or VT.
If PPLAT >30 cmH2O: VT by 1ml/kg to minimum of 4 ml/kg.
If PPLAT < 25 cmH2O and VT< 6 ml/kg: VT by 1 ml/kg until PPLAT > 25 cmH2O or VT = 6 ml/kg.
If PPLAT < 30 but patient/ventilator dysynchrony is evident: VT by 1ml/kg to a VT of 7-8 ml/kg if PPLAT remains < 30 cm
Transpulmonary Guided
Ventilation
REMEMBER: Airway pressures displayed by ventilators do not reflect pressures within the lung but within the Entire Respiratory System
To truly know the pressure within the lung (Transpulmonary Pressure) it is necessary to measure and account for the pressures outside of the lung (Peripulmonary Pressures) Very difficult to directly measure pressure in the pleura
A number of historic studies have demonstrated reasonable correlation between Esophageal Pressures and Pleural Pressures Pressure in the pleura adjacent to the esophagus is transmitted to the
esophagus. Pressure within the pleural space is not uniform Pressure in the dependent & basal regions is greater than in the
upper regions of the thoracic cage
Solving The Problem with Airway Pressures
Solving The Problem with Airway Pressures
Patients on mechanical ventilation are usually supine or semi-recumbent so it is important to account for the effect that mediastinal structures such as the heart have on esophageal pressures.
Washko (2006) and Talmor (2008) have recommended that approximately 2-5 cmH2O be subtracted from the esophageal pressure to more accurately reflect pleural pressures.
Stiff Lung or Stiff Chest Wall?
30 = 15 + 1530 = 25 + 5PAW = PTP + PES
Gattinoni, Crit Care, Oct 2004;
PAW = PTP + PES
How Common are Increased Intra-Abdominal Pressures?
Malbrain et al, Intensive Care Med (2004) 30:822–829
Abdominal Pressure Total Prevalence MICU Prevalence SICU Prevalence
>12 mmHg 58.8% 54.4% 65%
>15 mmHg 28.9% 29.8% 27.5%
>20 mmHg 8.2% 10.5% 5.0%
13 ICU’s, 6 countries, 97 patients
Can High Intra-abdominal Pressures Really Affect Ventilation?
Rigid Abdomen in ACS S/P Decompressive Laparotomy
To exploit the potential for alveolar recruitment, a transpulmonary pressure that is greater than the opening pressure of the lung must be applied to the lung.
To avoid alveolar collapse after recruitment, a PEEP that is greater than the compressive forces operating on the lung and alveolar ventilation that is sufficient to prevent absorption atelectasis must be provided.
Avoidance of stretch (by maintaining a low plateau pressure) and prevention of cyclic collapse and reopening (by maintaining adequate PEEP and alveolar ventilation) are the physiologic cornerstones of mechanical ventilation in acute lung injury/acute respiratory distress syndrome.
Gattinoni et al,CritCareMed2003Vol.31,No.4(Suppl.)
Transpulmonary-Guided Ventilation3 Basic Concepts
45
The Talmor/Ritz Study
Survival of ALI/ARDS patients has improved in recent years with the advent of low Vt’s and the use PEEP Optimal level of PEEP is difficult to determine.
Could the use of Transpulmonary Pressure Measurements (as estimated by esophageal pressure measurements) enable the clinician to determine a PEEP value that would maintain oxygenation while preventing lung injury due to repeated alveolar collapse and/or overdistention?
Mechanically-ventilated ALI/ARDS patients randomly assigned to one of two groups: CONTROL GROUP: PEEP adjusted as per ARDSNet recommendations PES-GUIDED GROUP: PEEP was adjusted to achieve a PTP PEEP of 0 to
+10 cmH2O
The Results
• The primary end point of the study was improvement in oxygenation.• Secondary end points respiratory-system compliance & pt outcomes.
• The study reached its stopping criterion and was terminated after 61 patients had been enrolled.
• The PaO2/FiO2 ratio at 72 hours was 88 mmHg higher in the Pes-group than in the control group
• This effect was persistent through the 24, 48 & 72 hour follow-up time.
• Respiratory-system compliance was also significantly improved at 24, 48, and 72 hours in the Pes-guided group
Outcomes
Basing ventilator settings on a maximum allowable airway plateau pressure may leave large portions of the lung under-inflated and at risk of VILI from repeated airway opening and closing.
It is logical that estimating pleural pressures from PES and setting PEEP to achieve a target PTP may allow higher PEEP in many patients without overdistending lung regions that are already recruited.
A Sampling of What’s in the Journals
Systematic use of esophageal manometry has the potential to improve ventilator management in acute respiratory failure by providing more direct assessment of lung distending pressure.
A Sampling of What’s in the Journals
The use of airway Plateau Pressures to set ventilation may under-ventilate patients with intra-abdominal hypertension and overdistend the lungs of patients with atelectasis.
Thus PTP must be used to accurately set mechanical ventilation in the critically ill.
A Sampling of What’s in the Journals
Increases in peak airway pressure without a concomitant increase in alveolar distension are unlikely to cause damage. Critical variable is not PIP but PTP
In patients with a stiff chest wall from non-pulmonary ARDS that may have elevated pleural pressures airway Plateau Pressures may exceed 35 cmH2O without causing alveolar distension
A Sampling of What’s in the Journals
PES can be used to estimate transpulmonary pressures that are consistent with known physiology, and can provide meaningful information, otherwise unavailable, in critically ill patients.
A Sampling of What’s in the Journals
Pplat > 25 cmH2O
Static Lung Compliance < 40 ml/cmH2O
P/F Ratio < 300
PEEP > 10 cmH2O to maintain SaO2 > 90%
PaCO2 > 60 mmHg or pH < 7.2 attributable to respiratory acidosis
Wolfson Medical Center, Holon, Israel
One Hospital’s Protocol for Identification of Pes Candidates
Can utilize either a 5 or 7fr balloon-tipped catheter or a specialized NG/OG catheter that is inserted into the lower third of the esophagus, above the diaphragm.
Pressures that are exerted on the balloon are measured by a transducer either integral in the ventilator or in a separate box
An approximation of proper placement can be made by measuring the distance from the tip of the nose to the bottom of the earlobe and then from the earlobe to the distal tip of the xiphoid process of the sternum.
Esophageal Balloonary: The Catheter
Properly inserted the esophageal balloon will show simultaneous negative deflections in airway and esophageal pressures during an expiratory hold during a patient-initiated breath (Baydur Method). If balloon is inserted too far into the esophagus Pes will deflect
positively during a spontaneous inspiration.
PES tracing may show small cardiac oscillations reflective of cardiac activity.
PES should be similar (+ 10) to PGA (Bladder Pressure)
Measurements should match the patients clinical presentation.
Esophageal Balloonary: Catheter Placement
Increased abdominal pressure and/or decreased chest wall compliance is imposing a load on the lungs which is reflected in an increased pleural pressure during an inspiratory plateau. PAW PLAT = 39 cmH2O PTP PLAT = 9 cmH2O
Keep PTP PLAT < 20 cmH2O
Esophageal Numerology: PTP PLATTranspulmonary Pressure at End-Inspiratory Plateau
P AW = 15 cmH2OP ES = 10 cmH2OP TP PEEP = 5 cmH2O
10
15
5
10
10
Esophageal Numerology: PTP PEEPTranspulmonary Pressure at End-Expiratory Plateau
Esophageal Numerology: PTP PEEPTranspulmonary Pressure at End-Expiratory Plateau
Goal is to adjust PEEP to maintain PTP PEEP between 0 - +2 cmH2O
Negative PTP PEEP = pressure outside the lung is greater than pressure inside the lung.
Positive PTP PEEP = pressure inside the lung is greater than pressure outside the lung
May cause end-expiratory overdistension if too high
Good indicator of Work of Breathing Values <15 cmH2O may indicate patient is a good candidate for weaning.
The difference between PEAK esophageal pressure (PPEAK ES ) and BASELINE esophageal pressure (PEEPES)
PES = PPEAK ES – PPEEP ES
Adult Normal: 10 – 15 cm H2O Pediatric Normal: 7 – 19 cm H2O
Esophageal Numerology: PESDelta Esophageal Pressure
Analyzing the shape of the esophageal pressure tracing may provide information regarding lung compliance.
Stiff lung – airway pressures only partially transmitted to pleura Compliant lung – airway pressures readily transmitted to pleura Clear differences between end-expiratory and end-inspiratory
Interpretation of the Esophageal Pressure Tracing
Sorosky A, Crit Care Research and Practice
Case Study 1:Transpulmonary-Guided Ventilation
in Increased Abdominal Pressures
Transpulmonary-Guided Ventilation
HPX:
Morbidly Obese 24 yo Female with Pancreatitis
Settings:
PRVC-AC, RR-24, Vt-340, PEEP-7, FiO2-.45, Ti-.7
ABG:
pH-7.36, PaCO2-50,
PaO2-57, SaO2-93%
• CXR on current vent settings:• Any heart silhouette?• Any diaphragms?• Any aeration?
• Esophageal Balloon inserted • Initial PTP PEEP = -12.3 cmH2O• A negative PTP PEEP indicates the
lung is being derecruited from elevated external (pleural and/or abdominal) pressures.
Placed on PC/AC, RR-16, PIP-36, Ti-.70 & PEEP-20.
PTP PEEP now -3.7 cmH2O
Some Heart Border & Diaphragm now visible
Pump Up the PEEP
• PAW Plateau• 41 cmH2O
• PTP PLAT
• 21 cmH2O
Which Plateau Pressure is Correct?
• PEEP Increased to 25 cmH2O
• Ptp PEEP now +2.4 cmH2O• Lungs are remaining
open at end-exhalation
Further PEEP Pumpage
Hey, Let’s Try APRV!
• PLOW of 0
• PTP PEEP of -15 cmH2O
• IMMEDIATE Derecruitment!
Now What?
Returned to PC/AC with PEEP of 25 cmH20
PTP PEEP now +2.4 cmH2ONo derecruitment!
PAW PEAK of 46 cmH2OPTP PEAK of 27 cmH2O
Physicians were hesitant to maintain PEEP of 25
CXR six day post PEEP adjustment using PES monitoring PEEP 16cmH2O with FiO2 of .40 Heart border and diaphragms visible
Now What?
Case Study 2:Transpulmonary-Guided Ventilation
Identifying Post-Code Derecruitment
PTP Pre & Post Instillation of Oleic Acid
• Pre-Instillation• PTP PEEP = +2 cmH2O• No Derecruitment
• Post-Instillation• PTP PEEP = -2 cmH2O• Derecruitment on
PEEP of 4
PEEP Increased to 8
• PEEP increased to 8 cmH2O
• PTP PEEP increased to +1.2 cmH2O
Changes Following Resuscitative-Fluid Bolus
• Following multiple fluid boluses during resuscitation it was noticed that PES increased from 8 cmH2O to 12 cmH2O
• PTP PLAT increased to 27 cmH2O
• PEEP immediately increased to 10 cmH2O
• This kept PTP PEEP from dropping into negative• No “Post-Code
Derecruitment”
One Last Point
Quality Requires Standardization
The most meaningful cost reduction strategies will involve standardization of clinical care and elimination of variation in patient procedures.
May 9, 2012
We Need to Define Quality
Q = A x (O + S) W
Q – QualityA – AppropriatenessO – OutcomesS – ServiceW – Waste
Questions?
Email: [email protected]
References
Mechanical Ventilation Guided by Esophageal Pressure in Acute Lung Injury, Talmor D, NEJM 2008
Should Mechanical Ventilation be Guided by Esophageal Pressure Measurements?, Plataki M, Curr Op in Crit Care 2011
Are Esophageal Pressure Measurements Important in Clinical Decision-Making in Mechanically Ventilated Patients?. Talmor D, Resp Care 2010
Transpulmonary Pressure as a Surrogate of Plateau Pressure for Lung Protective Strategy: Not Perfect but more Physiologic, Richard JC, Int Care Med 2012
Abdominal Compartment Syndrome in Patients with Isolated Extraperitoneal Injuries, Kopelman T, J Trauma 2000
78
References
Esophageal and Gastric Pressure Measurement, Benditt J, Resp Care 2005
Esophageal Pressure in Acute Lung Injury: do they Represent Artifact of Useful Informatinon about Transpulmonary Pressure, Chest Wall Mechanics and Lung Stress, Loring S, J Appl Physiol 2010
Maintaining End-Expiratory Transpulmonary Pressure Prevents Worsening of Ventilator-Induced Lung Injury Caused by Chest Wall Constriction in Surfactant-Depleted Rate, Loring S, Crit Care Med 2010
Medical Effectiveness of Esophageal Balloon Pressure Manometry in Weaning Patients from Mechanical Ventilation, Gluck E, Crit Care Med 1991
Optimal PEEP Guided by Esophageal Balloon, Piraino T, AARC Open Forum Abstract
Plateau and Transpulmonary Pressure with Elevated Intra-Abdominal Pressure or Atelectasis, Kubiak B, J Surg Res 2009
79
References
Esophageal and Transpulmonary Pressures in Acute Respiratory Failure, Talmor D, Crit Care Med 2000
Effect of Intra-Abdominal Pressure on Respiratory Mechanics, Pelois P, Acta Clinica Belgica 2007
What is Normal Intra-Abdomial Pressure and how is it Affected by Positioning, Body Mass and Positive End-Expiratory Pressure?, DeKeulenaer B, Int Care Med 2009
Targeting Tranpsulmonhary Pressure to Prevent Ventilator Induced Lung Injury, Talmor D, Min Anest 2009
BiCor Directed Weaning Reduces Ventilator Days, ICU Stay, Length of Hospitalization, and Cost of Care, Rouben L, Chest 1996
Effects of Positive End-Expiratory Pressure on Respiratory Function and Hemodynamics in patients with Acute Respiratory Failre with and without Intra-Abdominal Hypertension: a Pilot Study, Krebs J, Crit Care 2009
80
References
Refocusing on Transpulmonary Pressure, Marini, Focus Journal 2010
Respiratory Restriction and Elevated Pleural and Esophageal Pressures in Morbid Obesity, Behazin N, J Appl Physiol 2010
Weaning Prediction: Esophageal Pressure Monitoring Compliments Readiness Testing, Jubran A, Am J Respir Crit Care Med 2005
The use of Transpulmonary Pressure to Set Optimal Positive End-Expiratory Pressure: A Case Report, Piraino T, Can J Resp Ther 2010
Goal-Directed Mechanical Ventilation: Are We Aiming at the Right Goals? A Proposal for an Alternative Approach Aiming at Optimal Lung Compliance, Guided by Esophageal Pressure in ARDS, Sorosky A, Critical Care Research and Practice 2012
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