1. Epidemiology of Mechanical Ventilation Antonio Anzueto MD Professor of Medicine University of Texas Health Science Center, San Antonio, Texas

2. 1952: Copenhagen polio epidemic First month 31 patients with respiratory paralysis 27 patients died (87%)

3. Bjørn Ibsen The tank respirator (negative-pressure) did not provide adequate ventilation An elevated CO 2 -content was indicative of CO 2 retention, and not, as the epidemiologists considered, of metabolic alkalosis. Early application of positive-pressure ventilation

4. Hand ventilator used in the Copenhagen polio epidemic of 1952 by hundreds of “ventilators”

5. Mortality July 1952  March 1953 Months

6. “Anesthesiologic period” Before 1970 1970 – mid ’90s New modes of Ventilation PEEP Respiratory mechanics late’90s - Nowadays Protective ventilatory strategy

7. How many patients admitted to an ICU receive mechanical ventilation? What are the characterisitics of these patients? How is mechanical ventilation applied? What are the factors associated with outcome ?

8. How many patients admitted to an ICU receive mechanical ventilation? What are the characterisitics of these patients? How is mechanical ventilation applied? What are the factors associated with outcome ?

9. USA/CAN SPA ARG BRA CHI POR URU COPD 16 11109 10235 Coma 7203221151043 Neuromus. 348413192 ARF 74645066624750 ARDS 79972037 Pneumonia 9’6118’51912911 TOTAL 1315566810 REASON FOR MV (%) A. Esteban, A. Anzueto, I. Alía et al Am J Respir Crit Care Med 2000;161:1450

10. LATIN AMERICA ACSIMVSIMV-PSVPSVPCV 85 % 3 % 6 % 2 % ACSIMVSIMV-PSVPSVPCV 74 % 5 % 9 % 2 % 7 % AC-----SIMV-PSV-----PCV 71 % 14 % 7% DAY 1 DAY 4 DAY 7 USACANADAACSIMVSIMV-PSVPSVPCV 46 % 6 % 15 % 2 % 20 % ACSIMVSIMV-PSVPSVPCV52% 4 % 10 % 4 % 22 % ACSIMVSIMV-PSVPSVPCV 39 % 3 % 21 % 6 % 24 % EUROPEACSIMVSIMV-PSVPSVPCV 62 % 3 % 9 % 1 % 15 % ACSIMVSIMV-PSVPSVPCV 57 % 2 % 6 % 2 % 23 % AC----SIMV-PSVPSVPCV 57 % 5 % 4 % 23 % MODES OF VENTILATION

11. J.F. Num, et al.BMJ 1972 1 ICU 426 100 23.5% Mech. Vent. D.L. Gillespie, et al.Chest 1986 1 ICU ---327 Resp. failure A. Esteban, et alChest 1994 42 ICU 630 290 46% Mech. Vent. A.F. Connors, et al. AJRCCM 1996 5 ICU ---1.016COPD A. Esteban, et al. AJRCCM 2000 412 ICU 4.153 1.638 39% Mech. Vent. M.L. Nevins, et al.Chest 2001 --- 166COPD A. Esteban, et al.JAMA 2002 361 ICU 15.757 5.183 33% Mech. Vent. S. Karason, et al Acta Anaes. Scand. 2002 27 ICU ---108 Mech. Vent. Place Patients admitted Patients with MV Type of patients

12. How many patients admitted to an ICU receive mechanical ventilation? What are the characterisitics of these patients? How is mechanical ventilation applied? What are the factors associated with outcome ?

13. Are we changing the way we use mechanical ventilation ? 1998 vrs 2004

14. 17575 PATIENTS WERE ADMITTED FROM 1 TO 31 MARCH 1998 FROM 1 TO 31 MARCH 1998 5183 RECEIVED M.V. > 12 h. (33 %) 5183 RECEIVED M.V. > 12 h. (33 %) 361 ICUs 20 COUNTRIES 20 COUNTRIES MONITORING WAS PERFORMED DAILY DURING THE COURSE OF MV UNTIL DAY 28 FOLLOW-UP WAS PERFORMED UNTIL HOSPITAL DISCHARGE A.Esteban, A. Anzueto, F. Frutos, I. Alía et al. JAMA 2002;287:345-355

15. 19982004 Age61 (46, 72) % Women37%40% SAPS II44 (34,54)41 (30, 55) Demographic Characteristics A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

16. 2004 1998 Reason for Mechanical Ventilation A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

17. 2004 1998 Etiology of Acute Respiratory Failure A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

18. How many patients admitted to an ICU receive mechanical ventilation? What are the characterisitics of these patients? How is mechanical ventilation applied? What are the factors associated with outcome ?

19. 0 10 20 30 40 50 60 70 CMV SIMV-PSV PCV PSV SIMV 1998 13579111315171921232527

20. 0 10 20 30 40 50 60 70 CMV SIMV-PSV PCV PSV SIMV 1998 13579111315171921232527 0 60 10 20 30 40 50 CMV PSV SIMV-PSV SIMV PCV CVRP 2004

21. Ventilator Parameters 19982004 Tidal Volume (ml/kg) 9 (8, 10)7 (6, 8) RR16 (14, 19)17 (14, 20) PEEP4 (2,5)5 (5, 7) Plateau Pressure 23 (21, 26)20 (16, 25) >353%2% A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

22. Ventilator Settings & ARDS What are the usual ventilator settings? What are the usual ventilator settings? What are the outcomes associated with small vs. moderate or large tidal volumes? What are the outcomes associated with small vs. moderate or large tidal volumes?

23. 10 ml/kg Measured Body Weight (= 12 ml/kg Predicted) is the 75 th percentile and is within one standard deviation of the mean of the average tidal volume used in the 1st week of ARDS Tidal Volume Distribution Mean = 8.81 Std Deviation = 2.05 Median = 8.66 P 25 -P 75 = 7.50-10.00 Mean Tidal Volume (ml/kg) (1st week of ARDS) P 75 Fergusson et al CCM 2005; 33:21-30

24. Observed and Corrected ICU Mortality by Tidal Volume Category 496 ARDS Patients Fergusson et al CCM 2005; 33:21-30

25. – These data suggest that the using tidal volumes of 6-7 ml/kg may be beneficial compared with 8-10 ml/kg Corrected Mortality – P PLAT % Mortality Plateau Pressure Category (cm H 2 O) * *p=0.37 for slope=0 Tidal Volume Category (ml/kg ABW) Corrected Mortality - V T % Mortality *p=0.03 for slope=0 * < 6 ml/kg group excluded Fergusson et al CCM 2005; 33:21-30

26. ARDS: Ventilator Parameters 19982004 Tidal Volume (ml/kg)8 (7, 10)7 (6, 9) RR18 (16, 21)18 (16, 24) PEEP7 (5, 9)9 (7, 11) Plateau Pressure27 (24, 30)26 (22, 29) >356%3%

27. Weaning Modes A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

28. Outcome: Duration 19982004 Mechanical Ventilation (days) 3 (2, 7)4 (2, 9) Weaning (days) 2 (1, 4)2 (1,3) A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

29. Reintubation/Tracheostomy 19982004 Reintubation 14% Tracheostomy 11%13% Time 12 (7, 17)11 (8, 16) A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

30. How many patients admitted to an ICU receive mechanical ventilation? What are the characterisitics of these patients? How is mechanical ventilation applied? What are the factors associated with outcome ?

31. DURATION OF M. VENTILATION - days 5  5 DURATION OF WEANING - days 3  3 LENGTH OF STAY AT THE ICU - days 11  14 LENGTH OF STAY AT THE HOSP - days 22  24 OVERALL IN - ICU MORTALITY 31 % IN - HOSPITAL MORTALITY 36 % IN - HOSPITAL MORTALITY 36 % A.Esteban, A. Anzueto, F. Frutos, I. Alía et al. JAMA 2002;287:345-355

32. SURVIVAL CURVES ACCORDING TO REASON FOR M.V.

33. PaO 2 / FiO 2 n=7736.8%DEAD n=209  50 SAPS II n=449100%TOTAL n=25957.6%DEAD ICU MORTALITY n=13544.7%DEAD n=302 NO ACUTE RENAL FAILURE n=5147.2%DEAD n=108 < 100 OR = 2.58 n=2625.7%DEAD n=101 100 - 200 OR = 1

34. AGE n=449100%TOTAL n=25957.6%DEAD ICU MORTALITY n=13544.7%DEAD n=302 NO ACUTE RENAL FAILURE n=5862.3%DEAD n=93 > 50 SAPS II n=1136.6%DEAD n=30  48 OR = 1.67 OR = 8.47 n=4774.6%DEAD n=63 > 48

35. n=449100%TOTAL n=25957.6%DEAD ICU MORTALITY n=12484.3%DEAD n=147 YES ACUTE RENAL FAILURE PaO 2 / FiO 2 n=9790.6%DEAD n=107 < 100 OR = 25.98 n=2767.5%DEAD n=40 100 - 200 OR = 5.99

36. 10 No shock, SAPS II between 51 and 35, P a O 2 /F i O 2 >150, coma, age  45 103 16 % 1.73 (1.00 - 3.01) 11 No shock, SAPS II between 51 and 35, P a O 2 /F i O 2 >150, no coma, no sepsis 1084 16 % 1.64 (1.28 - 2.08) 12 No shock, P a O 2 /F i O 2 >150, SAPS II 150, SAPS II <35133210%1 Nº Failure (%) ODDS RATIO (CI 95%) 1 Shock, non acute renal failure, P a O 2 /F i O 2 <150 104 81 % 36.93 (21.98 - 62.05) 2 Shock, acute renal failure 533 77 % 30.26 (23.11 - 39.64) 3 Shock, non acute renal failure, P a O 2 /F i O 2 >150, SAPS II >52 176 58 % 12.04 (8.76 - 17.57 4 No shock, SAPS II >51, coma 247 52 % 9.61 (7.08 - 13.06) 5 No shock,SAPS II  51, P a O 2 /F i O 2 <150 273 39 % 5.67 (4.19 - 7.66) 6 No shock, SAPS II between 51 and 35, P a O 2 /F i O 2 >150, coma, age >45 160 36 % 4.87 (3.36 - 7.04) 7 No shock, SAPS II between 51 and 35, P a O 2 /F i O 2 >150, no coma, sepsis 76 34 % 4.57 (2.76 - 7.58) 8 No shock, SAPS II >51, no coma 763 33 % 4.28 (3.39 - 5.41) 9 Shock, non acute renal failure, P a O 2 /F i O 2 >150, SAPS II  52 332 29 % 3.68 (2.74 - 4.95)

37. Outcome: Length of Stay - Mortality 19982004 ICU – LOS (days) 7 (4, 14) ICU – Mortality (%) 31%35% Hospital – LOS (days) 16 (9, 29)16 (8, 30) Hospital – Mortality (%) 40% A.Esteban, A. Anzueto, et al. JAMA 2002;287:345-355 A. Esteban et al AJRCCM 2008; 177:170-177

38. Mechanical Ventilation: Conclusions Mechanical ventilation is use in a significant number of patients in the ICU. Outcome is related to both factors at baseline and complications of critical illness during the course of mechanical ventilation. There have being significant changes in the implementation of mechanical ventilation over the last 5 years.

39. Obrigado