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3. Important Notice  Every member who wants to earn CRCE for their participation today must complete the evaluation at the end of today’s program. This includes not only those who registered for this webcast; but those members who did not have an opportunity to register for this webcast and are participating with other registered members. Additionally, those who did not register must have their participation verified by a registered member in their group when completing their evaluation. Instructions to facilitate this are provided in the evaluation instrument.  To accommodate sites where multiple participants will need to use the same computer to complete their evaluation, the evaluation will remain accessible for one hour following the completion of the webcast.  Remember, to earn CRCE your name, AARC member number and the participant name you or your group used to access the webcast must be provided on the evaluation.

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5. Important Notice  Every member who wants to earn CRCE for their participation today must complete the evaluation at the end of today’s program. This includes not only those who registered for this webcast; but those members who did not have an opportunity to register for this webcast and are participating with other registered members. Additionally, those who did not register must have their participation verified by a registered member in their group when completing their evaluation. Instructions to facilitate this are provided in the evaluation instrument.  To accommodate sites where multiple participants will need to use the same computer to complete their evaluation, the evaluation will remain accessible for one hour following the completion of the webcast.  Remember, to earn CRCE your name, AARC member number and the participant name you or your group used to access the webcast must be provided on the evaluation.

7. Important Notice  Every member who wants to earn CRCE for their participation today must complete the evaluation at the end of today’s program. This includes not only those who registered for this webcast; but those members who did not have an opportunity to register for this webcast and are participating with other registered members. Additionally, those who did not register must have their participation verified by a registered member in their group when completing their evaluation. Instructions to facilitate this are provided in the evaluation instrument.  To accommodate sites where multiple participants will need to use the same computer to complete their evaluation, the evaluation will remain accessible for one hour following the completion of the webcast.  Remember, to earn CRCE your name, AARC member number and the participant name you or your group used to access the webcast must be provided on the evaluation.

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9. Important Notice  Every member who wants to earn CRCE for their participation today must complete the evaluation at the end of today’s program. This includes not only those who registered for this webcast; but those members who did not have an opportunity to register for this webcast and are participating with other registered members. Additionally, those who did not register must have their participation verified by a registered member in their group when completing their evaluation. Instructions to facilitate this are provided in the evaluation instrument.  To accommodate sites where multiple participants will need to use the same computer to complete their evaluation, the evaluation will remain accessible for one hour following the completion of the webcast.  Remember, to earn CRCE your name, AARC member number and the participant name you or your group used to access the webcast must be provided on the evaluation.

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11. Important Notice  Every member who wants to earn CRCE for their participation today must complete the evaluation at the end of today’s program. This includes not only those who registered for this webcast; but those members who did not have an opportunity to register for this webcast and are participating with other registered members. Additionally, those who did not register must have their participation verified by a registered member in their group when completing their evaluation. Instructions to facilitate this are provided in the evaluation instrument.  To accommodate sites where multiple participants will need to use the same computer to complete their evaluation, the evaluation will remain accessible for one hour following the completion of the webcast.  Remember, to earn CRCE your name, AARC member number and the participant name you or your group used to access the webcast must be provided on the evaluation.

12. The NEW AARC Exam Prep course provides you with: Free access to NBRC CRT and RRT practice exams Your personalized study prescription Over 28 hours of video instruction from top educators, respiratory therapists and physicians Tips for developing excellent test-taking skills Opportunities to earn continuing education credit

13. 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 September 2013 RESPIRATORY CARE Journal Webcast

14. Moderator Shawna Strickland, PhD, RRT-NPS, AE-C, FAARC AARC Associate Executive Director-Education

15. 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.

16. INDIVIDUALIZED POSTIVE END-EXPIRATORY PRESSURE SETTING IN PATIENTS WITH ACUTE RESPIRATORY DISTRESS SYNDROME. A RANDOMIZED CONTROLLED PILOT STUDY RESPIRATORY CARE SEPTEMBER 2013 VOL 58 NO 9 Brian K. Walsh, RRT-NPS, ACCS, RPFT, FAARC Harvard Medical School Boston Children’s Hospital

17. Background Volume ventilation if not properly used can create repetitive lung injury (Stress / Strain) PEEP is utilized to maintain the recruited alveoli No method of choosing optimal PEEP has been found to be superior. Would you agree with the background?

18. Research Question Does individualizing PEEP settings based on the highest compliance improve oxygenation, reduce multiple organ dysfunction, and improve survival in patients with ARDS? Hypothesis – Individualized level of PEEP, set at highest compliance, improves oxygenation when compared to a fixed PEEP level based on FIO 2 Why do you suspect that we abandoned chasing compliance in the past?

19. Lung Mechanics vs. Gas Exchange Round 1 Lung Mechanics 1.PEEP improves FRC 2.PEEP improves compliance 3.PEEP does not open the lung – it keeps it open 4.PEEP can worsen compliance by over distension 5.Best compliance titration favors pulmonary mechanics at the expense of gas exchange. Gas Exchange 1.PEEP improves gas exchange 2.Large tidal volumes and lower PEEP can improve gas exchange 3.PEEP can increase deadspace, increase PVR, and worsen gas exchange 4.FIO 2 PEEP titration grid favors gas exchange outcomes

20. Conflicts of Interest None disclosed Frame of Reference – this study was conducted in Spain

21. Methods Open, randomized control pilot study Included patients diagnosed with ARDS by the ATS/ERS Consensus Definition – Maintained criteria for 24 hours Excluded patients who: – < 18 years of age – Pregnant – Neuromuscular disease – Intracranial hypertension / head trauma – LV dysfunction – > 72 hours of mechanical ventilation – Evidence of barotrauma

22. Methods First 24 hours – ventilated with 6-8 mL/Kg PBW – Plateau < 30, RR 30 bpm (max 35), pH 7.30-7.45, SPO2 88-95% Block randomization Control - ARDSNet protocol PEEP titration, 6-8 ml/Kg Vt No power analysis disclosed – pilot study Why block randomize study patients?

23. Methods - Protocol

24. Methods / Results

25. Results

30. Conclusions Did not improve oxygenation Associated with significant increase in organ dysfunction free days Strong trend in lower mortality

31. Discussion No difference in MAP nor oxygenation – There is that relationship again – 80% of the compliance guided ventilation group would have had different levels of PEEP First study to set PEEP based on compliance – Others have utilized the lower inflection points. Shorted duration of MOD Why does this protocol lower MOD?

32. Discussion How is this study and others related? – Limiting plateau pressure – Transpulmonary pressure Are you satisfied with their explanation of barotrauma in the study group? – 17% - higher than the norm Limitations – Pilot study, unblinded, enrolled < 45% of subject who met inclusion criteria, determining best compliance

33. Why is determining best compliance difficult? Suter, PM 1978 What if you don’t get a change? How long do you wait between changes? What if they cannot tolerate the higher PEEP? What if escalation in PEEP produce the same compliance? What do you do if you have to suction during titration? Does tidal volume change compliance?

35. Editorial + BKW Multiple factors influence the outcomes of PEEP titration studies. New procedures based on the ARDSNet Protocol may needed to be revisited – Prone position / Nitric Oxide / Surfactant Individualized PEEP management based on lung mechanics shows promise – Potentially more helpful in select patient populations (intrinsic vs. extrinsic)

36. Quick Look Current knowledge – Lung protective ventilation (low tidal volume and limited plateau pressure) improves outcomes in ARDS (now known as moderate ARDS), but the best method of selecting the PEEP is controversial, and clinical trails have had conflicting results. What this paper contributes to our knowledge – In ARDS patients, low-tidal-volume ventilation coupled with PEEP set according to the highest pulmonary compliance was associated with more organ dysfunction- free days and a trend toward lower mortality.