Presentation on theme: "Carl Hinkson, MS, RRT-ACCS, NPS, FAARC Respiratory Care Department"— Presentation transcript:
1 Contemporary Ventilator Management in Patients with and at risk of ALI/ARDS Carl Hinkson, MS, RRT-ACCS, NPS, FAARCRespiratory Care DepartmentHarborview Medical CenterSeattle, WA
2 Program Objectives Identify the research question of the study. Identify the study design.Discuss the main results of the study.Discuss the implication of the study on patient care.
3 April 2013 RESPIRATORY CARE Journal Webcast This webcast and any accompanying materials are copyrighted by the American Association for Respiratory Care (AARC). Any public display, sale, copy or distribution of the video or materials may only be undertaken with the prior written consent of the AARC. Copyright 2013
4 BackgroundPatients with ALI/ARDS benefit from low tidal volume ventilation with limitation of plateau pressuresDespite several studies, the strategy to best manage PEEP in ALI/ARDS remains elusiveIt is unclear if there is any benefit to ventilating patients without ALI/ARDS with low tidal volume ventilation
5 Background What is the research question? Any concerns about COI? What variables impact administered tidal volumeWhat is the impact of ALI/ARDS on outcomesWhether or not clinicians are consistently using low tidal volume ventilation after the 2000 ARDS Network studyThe authors hypothesized ventilating with a low tidal volume would be associated with less post intubation ALI/ARDSAny concerns about COI?This research was not directly funded. Nor did any authors have any direct conflict of interests. Some authors reported receiving research funds or consulting fee not related to this topic
6 MethodsSecondary analysis of the Lung Injury Prevention Score (LIPS) studyObservational, 22 center cohortConducted between March to August 200919 centers prospectively collected data3 centers retrospectively collected data
7 Methods Inclusion criteria > 18 years of age 1 or more risk factor for ALI/ARDSSepsisShockPancreatitisPneumoniaAspirationHigh-risk traumaHigh-risk surgeryAdmitted through ED or operating rooms
8 Methods Exclusion criteria Excluded if they developed ALI/ARDS within six hours of assessmentTransferred from an outside institutionDied in the EDAdmitted for palliation (comfort care)Re-admitted during the study periodPatients who never received mechanical ventilation or received mechanical ventilation for < 1 day
9 Methods Data collected Baseline characteristicsSociodemographicsComorbiditiesData was collected within first 6 hours of evaluationInitial ventilator settings, parameters, volumes, and pressuresFor subjects that developed post intubation ALI/ARDS the first set of ventilator data was collected after the diagnosis was made.
10 Methods Outcomes Primary Secondary Initial tidal volume & PEEP in: Patients who never developed ALI/ARDS,Patients intubated because of ALI/ARDSPatients who developed ALI/ARDS after intubationResearchers used the American-European Consensus Conference definitionSecondaryDevelopment of ALI/ARDS after initial intubationHospital outcomes: ventilator free days & mortality
11 Methods Statistical Analysis Kolmogorov-Sminov test for normal distributionStudent’s t-test or Mann-Whitney for continuous variablesCategorical variables compared using Chi-squared or Fischer’s exact testOne-way ANOVA for variation in tidal volume settingsMultivariate analysis was done with logistic regression (one for tidal volume, one for PEEP)Significance (alpha/α) was 0.05, all test were two-sidedData was expressed as median with interquartile ranges
15 ResultsInitial ventilator settings and inspiratory pressures
16 ResultsComparison of Subjects Without ALI/ARDS at Onset of Mechanical Ventilation, Initially Treated with tidal Volume of <8 mL/kg PBW versus ≥ 8 mL/kg PBW
17 ResultsComparison of Subjects Without ALI/ARDS at Onset of Mechanical Ventilation, Initially Treated with tidal Volume of <8 mL/kg PBW versus ≥ 8 mL/kg PBW
18 ResultsFactors Associated with Greater Odds of Receiving ≥ mL/kg PBW on Initial Ventilation in the subjects Without ALI/ARDS at Onset of Mechanical Ventilation; after adjusting for center.About Odds Ratios
19 ResultsClinical Outcomes of Subjects Without ALI/ARDS at Onset of Ventilation (Based on Tidal Volume)
20 ResultsInitial Ventilator Settings and Pressures Among the 722 Subjects Without ALI/ARDS at Onset of Mechanical Ventilation
21 ResultsVentilator Settings and Parameters Before and After Development of ALI/ARDS in the 161 Subjects who Developed ALI/ARDS After the Onset of Mechanical Ventilation
23 Results – Inter-center variation in VT among all MV pts ARDSnet target VTInter-center variation in initial tidal volume settings among all intubated and mechanically ventilated patients (n=829)
24 Results – Inter-center variation in VT among MV pts that did not develop ALI/ARDS ARDSnet target VT
25 Results – Inter-center variation in VT among MV pts intubated for ALI/ARDS ARDSnet target VT
26 Results – Inter-center variation in VT among MV pts with post-intubation ALI/ARDS ARDSnet target VT
27 Discussion What do these finding mean? Application of low tidal volume is variable, but clinicians are getting better about using low tidal volume ventilation for ALI/ARDSSicker patients were more likely to receive low VT ventilationVentilator settings and delivering VT < 8mL/kg PBW is not associated with development of post-intubation ALI/ARDS or outcomesDevelopment of post-intubation ALI/ARDS was associated with more resource utliziationSubjects were more likely to receive low VT if they were male, taller, and less obese.Shorter & heavier subjects tended to receive VT ≥8mL/kg PBW
28 Discussion What are the study limitations? Analysis is based from initial ventilator checkThe study was under-powered to detect outcome differencesStudy limited by observational natureWhat additional work is needed in this area?Why patients who develop ARDS post intubation consume more resourcesProspective research the role of ventilator settings on post-intubation ARDS
29 Editorial From Robert P Dickson, MD Main limitation of this study “snapshot” nature of the ventilator dataDifficult to ascertain if subjects received low VT ventilation based only on ventilator dataThe absolute difference between the “at intubation” and “post-intubation” ALI/ARDS was smallMessage of lower tidal volume from ARDSnet trial seems to have gotten outDifficult to measure patient initially?
30 Conclusions What are the authors’ conclusions? Improved, but not ideal adherence to lower VT ventilationVariation in ventilator management did not affect outcomesPost-intubation ARDS was associated with greater resource utilizationWhat is the take-home message?You should still use low VT ventilation for ARDS ptsAssure that VT is calculated from PBW not ABW
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