Presentation: Program Overview

Presentation: Program Overview

AHRQ Safety Program for Mechanically Ventilated Patients Low Tidal Volume Ventilation: Introduction, Evidence, and Implementation AHRQ Safety Program for Mechanically Ventilated Patients AHRQ Pub. No. 16(17)-0018-54-EF January 2017 LTVV Intro, Evidence, Implementation 1 Learning Objectives After this session, you will be able to Explain why we should use low tidal volume ventilation (LTVV) Outline the historical background and scientific evidence supporting the use of LTVV Implement recommended standards for LTVV AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 2 What Is Low Tidal Volume Ventilation? Low tidal volume ventilation is a lung protective strategy that seeks to prevent ventilator-associated lung injury

LTVV is an approach that targets much lower tidal volume than what has been traditionally used LTVV also focuses on the avoidance of zero positive end-expiratory pressure (ZEEP) AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 3 What Are the Goals of LTVV? Target tidal volume of 68 mL/kg of predicted body weight (PBW) for patients without ARDS and 46 mL/kg PBW for patients with ARDS Predicted body weight based on height/gender Not ideal body weight Not actual body weight Avoid the use of ZEEP Use positive end-expiratory pressure (PEEP) settings 5 cm H20 AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 4 Why Should We Use LTVV? Significant benefit when outcomes are compared using lower volumes (6 cc/kg) versus traditional tidal volumes (12 cc/kg)1 Additional studies and meta-analysis showed

large tidal ventilation and the resulting high pressures were harmful 1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-8. PMID: 10793162. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 5 Why Should We Use LTVV? Low tidal volume ventilation protects lungs by Preventing volutrauma (overdistension of some alveoli areas and underdistension in other areas) Preventing barotrauma Preventing development of acute respiratory distress syndrome (ARDS) Suppressing activation of chemical inflammatory mediators Improving outcomes AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 6 AHRQ Safety Program for Mechanically Ventilated Patients HISTORY REVIEW

AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 7 Early History 1776: Dr. John Hunter developed a double bellows system that pushed and pulled air in and out of lung; used on dogs with tubes going into trachea 1837: Efforts like Hunters lost favor as chest compressions became preferred method for moving air (not same as CPR) Both positive and negative pressure systems continued to be developed 1850: French Academy of Sciences reported that positive pressure caused what we now know as barotrauma, which may result in pneumothorax, rupture of alveoli, and emphysema AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 8 The Iron Lung Negative pressure ventilation became the most common approach, ultimately resulting in the iron lung. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 9 Positive Pressure Vents Still Progressed

Johann Drger developed the portable Pulmotor in 1907. By 1909, the Pulmotor was a top seller for his company. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 10 Endotracheal Intubation Uncommon and considered inappropriate outside of the operating room (OR) Polio epidemics in the 1950s outstripped the supply of iron lungs, returning attention to the use of positive-pressure ventilation (PPV) in other settings Soon the transition to endotracheal tubes in conjunction with PPV outside the OR accelerated AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 11 1950s Despite progress, ventilators were still crude Difficult to precisely control volume and pressure Two primary modes were used Volume regulated Pressure limited

AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 12 Ventilator Progress 1960s though 1970s Ventilation was primarily volume controlled Ventilation was completely independent of patients pulmonary mechanics 1970s through 1980s Development of patient-triggered modes such as synchronized intermittent mandatory ventilation (SIMV) A great variety of modes became available AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 13 AHRQ Safety Program for Mechanically Ventilated Patients SUPPORTING RESEARCH AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 14 Common Ventilator Modes Volume Cycled Modes

Continuous mandatory ventilation (CMV) assist control (AC) Synchronized intermittent mandatory ventilation (SIMV) Volume support (VS) Pressure regulated volume controlled (PRVC) Pressure Cycled Modes Pressure support (PS) Continuous positive airway pressure (CPAP) Pressure control (PC) Airway pressure release ventilation (APRV) Bilevel ventilation Other Modes Proportional assist ventilation (PAV) Adaptive support ventilation (ASV) Inverse ratio ventilation (IRV) High-frequency oscillatory

ventilation (HFOV) Extracorporeal membrane oxygenation (ECMO) Other AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 15 The Basis for Traditional Ventilation Strategies 1963 study in NEJM showed development of hypoxia in surgical patients when lower ventilation was provided. Perhaps the best course of action during controlled ventilation is to imitate nature quite closely in providing reasonably large tidal volumes at a respiratory rate not exceeding 14 to 16 per minute, and also in providing periodic passive hyperinflation of the lungs, thus replacing the lacking spontaneous deep breaths, or sighs. It might even be desirable if mechanical respirators were able to sigh automatically. Bendixen, NEJM, 19632 2. Bendixen HH, Hedley Whyte J, Laver MB. Impaired oxygenation in surgical patients

during general anesthesia with controlled ventilation. N Engl J Med. 1963 269:991-6. PMID: 14059732. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 16 Traditional Ventilation Strategies Since atelectasis is undesirable (shunt, hypoxia), a large tidal volume approach became the norm 1015 cc/kg Disseminated by most textbooks Evidence of oxygen toxicity also made physicians reluctant to use high fraction of inspired oxygen (FIO2) to overcome shunt and hypoxia AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 17 The Problem With Large Tidal Volumes (Vt) Acute lung injury (ALI) Involves a breakdown in lung architecture and capillary leak Leads to stiff lungs with areas of over- and underinflation Large Vt Results in overdistension of some areas resulting in

volutrauma, which is considered a major cause of ventilatorassociated lung injury Leads to inflammatory responses that further damage the lung(s) AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 18 The Problem With Large Tidal Volumes (Vt) Its clear that commonly used tidal volumes were injurious to the lung. Can also lead to barotrauma Rupture of alveoli Pneumothorax Some airspaces collapse, then reopen cyclically Shear stresses as alveoli close and pop open Researchers proposed using lower tidal volumes and allowing mild to moderate respiratory acidosis to improve outcomes. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 19 ARDSNet: Probability of Survival and Discharged Home1 Based on animal studies and some small clinical studies, the ARDSNet Trial (2000, NEJM) compared outcomes using traditional tidal volumes (>10 cc/kg) to lower volumes (46 cc/kg) in patients with ARDS and ALI and found significant benefit. 1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory

Distress Syndrome Network. N Engl J Med. 2000 342(18):1301-8. PMID: 10793162. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 20 Primary Findings1 VARIABLE GROUP RECEIVING LOWER TIDAL VOLUMES GROUP RECEIVING TRADITIONAL TIDAL VOLUMES P VALUE 31.0 39.8 0.007 65.7

55.0 <0.001 1211 1011 0.007 10 11 0.430 1511 1211 0.006 Death before discharge home and breathing without assistance (%) Breathing without assistance by day 28 (%) Number of ventilator-free days, days

1 to 28 Barotrauma, days 1 to 28 Number of days without failure of nonpulmonary organs or systems, days 1 to 28 Plusminus values are means SD. The number of ventilator-free days is the mean number of days from day 1 to day 28 on which the patient had been breathing without assistance for at least 48 consecutive hours. Barotrauma was defined as any new pneumothorax, pneumomediastinum, or subcutaneous emphysema, or a pneumatocele that was more than 2 cm in diameter. Organ and system failures were defined as described in the Methods section. 1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000 342(18):1301-8. PMID: 10793162. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 21 LTVV in ARDS Large Vt and the high pressures it generates were harmful3,4 LTVV became the mainstay of ARDS management Ventilate with Vt of 46 cc/kg PBW Plateau pressures should be measured, documented, and targeted to be no more then 30 cm H20 (too difficult to measure transpulmonary pressures clinically) PEEP/FIO2 escalation and de-escalation algorithm PBW = predicted body weight

It is based on weight and gender. 3. Putensen C, Theuerkauf N, Zinserling J, et al. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med. 2009 151(8):566-76. PMID: 19841457. 4. Girard TD, Bernard GR. Mechanical ventilation in ARDS: a state-of-the-art review. Chest. 2007 131(3):921-9. PMID: 17356115. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 22 Beyond ARDS? Emerging Evidence5 Multi-hit theory Priming: initial insult at risk for ARDS Pneumonia Sepsis Trauma Noncardiogenic shock Multiple transfusions Cardiopulmonary bypass Large Vt and large transpulmonary pressures leads to amplification of inflammation and ventilator induced lung injury (iatrogenic ARDS) 5. Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med. 2013 39(1):6-15. PMID: 23108608.

AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 23 Beyond ARDS? Emerging Evidence5 Direct lung insult* OR Indirect lung insult** *Direct lung insults Pneumonia Aspiration Toxic inhalation Pulmonary contusion Pulmonary vasculitis AHRQ Safety Program for Mechanically Ventilated Patients VentilatorInduced Lung Injury ARDS

**Indirect lung insults Sepsis Systemic inflammatory response syndrome Trauma Pancreatitis Post-circulatory arrest Multiple transfusions Severe burns Cardiopulmonary bypass 5. Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med. 2013 39(1):6-15. PMID: 23108608. LTVV Intro, Evidence, Implementation 24 ICU Patient Results5 (Qualitative Systematic Review) Control

Ventilatory Settings Experimental Ventilatory Settings Study Study Design ICU No. of Patients Tidal Volume (ml/kg) PEEP (cmH20) Tidal Volume (ml/kg) PEEP (cmH20)

Lee, et al. RCT Surgical 103 12 5 6 5 Trend for decreased pulmonary infections and decrease in MG duration Gajic, et al. (2004) COH Med/surg

332 OR for ALI = 1.3 with VT >6 ml/kg Gajic, et al. (2005) COH Med/surg 3,261

OR for ARDS = 2.6 with VT >700 ml Mascia, et al. (2007) OBS Neurocritical 86 9.5b 3.7b 10.4b 4.2b RR for ALI = 5.1 with high VT. Decreased inflammatory

cytokines with low VT Determann, et al. RCT Med/surg 150 10 a 6 a RR for ALI = 5.1 with high VT. Decreased inflammatory cytokines with low VT Pinheiro de Oliveira, et al.

RCT Med/surg 20 1012 5 57 5 Decreased BAL cytokines with low VT Mascia, et al. (2010) RCT Med/surg 118 1012

35 68 810 Increase in eligible and harvested lungs with low VT PEEP titrated based on a PEEP/FIO2 ladder Mean results Main findings with protective ventilation a b AHRQ Safety Program for Mechanically Ventilated Patients 5. Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med. 2013 39(1):6-15. PMID: 23108608.

LTVV Intro, Evidence, Implementation 25 Meta-analysis of LTVV in Patients Without Lung Injury6 ________________________________________________________________________________________________ Mean (SD) Protective Ventilation Conventional Ventilation P (n=1,416) (n=1,406) Value ________________________________________________________________________________________________ Age, y Weight, kg Tidal volume, mL/kg IBW PEEP, cm H2O Plateau pressure, cm H2O Respiratory rate, breaths/min Minute-volume, L/min PaO2/FIO2 PaCO2/ mm Hg pH 59.97 (7.92) 72.71 (12.34) 6.45 (1.09) 6.40 (2.39)

16.63 (2.58) 18.02 (4.14) 8.46 (2.90) 304.41 (65.74) 41.05 (3.79) 7.37 (0.03) 60.22 (7.36) 72.13 (12.16) 10.60 (1.14) 3.41 (2.79) 21.35 (3.61) 13.20 (4.43) 9.13 (2.70) 312.97 (68.13) 37.90 (4.19) 7.40 (0.03) .93 .93 .001 .01 .006 .01 .72 .51 .003

.11 6. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012 308(16):1651-9. PMID: 23093163. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 26 LTVV in Patients Without Lung Injury6 ____________________________________________________________________________________________________________ High VT, No. Low VT, No. Lung injury Events Total Events Total Weight, % RR (95% CI) ____________________________________________________________________________________________________________ Gajic et al., 2004 32 100 12

66 18.1 0.47 (0.22-1.00) Michelet et al., 2006 6 26 3 26 4.6 0.43 (0.10-1.97) Yilmaz et al., 2007 60 212 17 163 40.7 0.29 (0.16-0.53) Licker et al., 2009 20 533 5 558 17.7 0.23 (0.09-0.62) Determann et al., 2010 10 74

2 76 8.6 0.17 (0.04-0.82) Yang et al., 2011 4 50 1 50 3.4 0.23 (0.03-2.18) Fernandez-Bustamante et al., 2011 5 75 7 154 5.6 0.67 (0.20-2.17) Weingarten et al., 2012 1 20 0 20 1.3 0.32 (0.01-8.26) Subtotal (95% CI) Total events

1090 1113 138 100.0 47 FAVORS LOW VT FAVORS HIGH VT 0.33 (0.23-0.47) Heterogeneity: x=3.74; P =.81, I2 =0% Test for overall effect: z=6.06; P.001 LTVV significantly reduced development of lung injury For every 11 patients who received LTVV, 1 case of lung injury was prevented 6. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012 308(16):1651-9. PMID: 23093163.

AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 27 LTVV in Patients Without Lung Injury6 ____________________________________________________________________________________________________________ High VT, No. Low VT, No. Pulmonary infection Events Total Events Total Weight, % RR (95% CI) ____________________________________________________________________________________________________________ Lee et al., 1999 Michelet et al., 2006 Licker et al., 2009 Yang et al., 2011 Subtotal (95% CI) Total events 10 56 10 30

7 2 26 533 50 Heterogeneity: x=4.39; P =.22, I2 =32% Test for overall effect: z =2.79; P =.005 FAVORS LOW VT 6 23 1 665 57 FAVORS HIGH VT 47 681 16.6 26 558

50 100.0 14.6 55.8 13.0 0.20 (0.04-0.99) 0.48 (0.14-1.60) 0.72 (0.41-1.26) 0.13 (0.01-1.06) 0.52 (0.33-0.82) 32 LTVV significantly reduces the incidence of pulmonary infection For every 26 patients who received LTVV, 1 pulmonary infection was prevented 6. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012 308(16):1651-9. PMID: 23093163. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 28

LTVV in Patients Without Lung Injury6 ____________________________________________________________________________________________________________ High VT, No. Low VT, No. Atelectasis Events Total Events Total Weight, % RR (95% CI) ____________________________________________________________________________________________________________ Lin et al., 2008 Cai et al., 2007 Licker et al., 2009 Yang et al., 2011 Weingarten et al., 2012 2 5 47 3 5 Subtotal (95% CI) Total events

3 7 28 1 4 631 62 Heterogeneity: x=3.76; P=.44; I2=0% Test for overall effect: z=2.18; P=.03 FAVORS LOW VT 20 8 533 50 20 20 8 558 50 20

3.1 1.1 83.1 5.4 7.3 1.59 (0.24-10.70) 4.20 (0.33-53.12) 0.55 (0.34-0.89) 0.32 (0.03-3.18) 0.75 (0.17-3.33) 656 100.0 0.62 (0.41-0.95) 43 LTVV significantly reduced the incidence of atelectasis FAVORS HIGH VT 6. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012 308(16):1651-9. PMID: 23093163.

AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 29 LTVV in Patients Without Lung Injury6 ____________________________________________________________________________________________________________________ Mortality High VT, No. Low VT, No. Total Events Total Events Weight, % RR (95% CI) ____________________________________________________________________________________________________________________ Michelet et al., 2006 Wolthuis et al., 2007

Yilmaz et al., 2007 Licker et al., 2009 Determann et al., 2010 Fernandez-Bustamante et al., 2011 Sundar et al., 2011 Yang et al., 2011 Weingarten et al., 2012 1 2 69 15 23 26 13 212 533 74 75 1 2 1 1 Subtotal (95% CI)

Total events 2 3 27 13 24 3 74 50 20 1 0 1 1077 115 Heterogeneity: x=6.94; P=.54; I2=0% Test for overall effect: z=2.68; P=.007 FAVORS LOW VT 26 23 163

558 76 154 1.0 2.5 55.7 16.7 17.7 1.5 75 50 20 1145 2.08 (0.18-24.51) 0.82 (0.12-5.71) 0.41 (0.25-0.68) 0.82 (0.39-1.75) 1.02 (0.51-2.04) 1.47 (0.15-14.38) 2.2 0.49 (0.04-5.48) 1.7 0.33 (0.01-8.21) 1.1

1.00 (0.06-17.18) 0.64 (0.46-0.86) 74 LTVV significantly reduced mortality For every 23 patients who received LTVV, a life was saved FAVORS HIGH VT Hospital length of stay was also significantly reduced (6.91 days vs. 8.87 days) 6. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of lungprotective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a meta-analysis. JAMA. 2012 308(16):1651-9. PMID: 23093163. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 30 Focusing on ICU Patients Only Acute lung injury Three trials with 691 patients RR=0.33; 95% CI 0.21 to 0.51 p=0.001

Mortality Three trials with 561 patients RR=0.57; 95% CI 0.38 to 0.84 p=0.005 Pulmonary infection One trial with 103 patients RR=0.20; 95% CI 0.04 to 0.99 p=0.05 RR = Relative risk CI = Confidence interval AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 31 Quality Gap Large Vt still commonly used in ICUs5 Up to 18 cc/kg PBW Pulmonary damage shown to occur within a few hours of mechanical ventilation7 Clinicians often miss early or mild ARDS or fail to appreciate the at-risk patient quality gap8 5. Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for

all critically ill patients? Intensive Care Med. 2013 39(1):6-15. PMID: 23108608. 7. Zupancich E, Paparella D, Turani F, et al. Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial. J Thorac Cardiovasc Surg. 2005 130(2):378-83. PMID: 16077402. 8. Herasevich V, Tsapenko M, Kojicic M, et al. Limiting ventilator-induced lung injury through individual electronic medical record surveillance. Crit Care Med. 2011 39(1):34-9. PMID: 20959788. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 32 AHRQ Safety Program for Mechanically Ventilated Patients LOW TIDAL VOLUME IMPLEMENTATION AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 33 Preemption Why wait? Why not initiate LTVV on all patients to minimize risk? Too late once ARDS/ALI criteria are met A few hours of mechanical

ventilation with large Vt may start the cascade AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 34 Low Tidal Volume Implementation9 A 2013 study reviewed patients undergoing relatively major abdominal surgery and receiving mechanical ventilation for between 4 and 5 hours Patients who received a low tidal volume strategy using PEEP settings had statistically significant improvements in a variety of parameters when compared to standard tidal ventilations Postoperative complications Pulmonary complications Length of stay 9. Furtier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Eng J Med. 2013 Aug 1;369(5):428-37. PMID: 23902482. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 35 Low Tidal Volume Implementation Patients at risk of ARDS should be ventilated with a Vt of 68 ml/kg PBW

Tidal volumes of this size eliminate most hypercarbia AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 36 Use PBW Rather Than ABW Predicted body weight (PBW) is based on gender and height For BMI > 25, actual body weight (ABW) will lead to incorrect Vt and is associated with increased organ failure5 5. Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med. 2013 39(1):6-15. PMID: 23108608. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 37 What About Positive End-Expiratory Pressure? Low Vt does cause atelectasis, as correctly suggested by Bendixens research in 1963 But only when it is used in isolationwithout PEEP PEEP counteracts this tendency, especially in obesity Prevents one form of atelectrauma (alveoli snapping open and closed) 812 cm H2O PEEP is used in many studies of pre-emptive low

Vt, but many also use 58 cm H2O Use ARDSNet protocol if ARDS is diagnosed AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 38 What About PEEP? Unclear optimal level in nonacute lung injury (non-ALI) patients Clear that we should not use zero endexpiratory pressure ZEEP is considered any PEEP < 5 Associated with negative outcomes10,11 Hypoxia Ventilator-associated pneumonia Increased mortality 10. Metnitz PG, Metnitz B, Moreno RP, et al. SAPS 3 Investigators. Epidemiology of mechanical ventilation: analysis of the SAPS 3 database. Intensive Care Med. 2009 35(5):816-25. PMID: 19288079. 11. Manzano F, Fernndez-Mondjar E, Colmenero M, et al. Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med. 2008 36(8):222531. PMID: 18664777. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 39 Respiratory Rate Using Low Vt may require increased respiratory rates

to prevent excessive hypercarbia Permissive hypercapnia (partial pressure of carbon dioxide [pCO2] in the 50s) may be needed Usually tolerated well unless there is also a severe metabolic acidosis Maintain minute ventilation as best as possible May need to increase to 30 breaths per minute or more Potential downsides with these high rates include breathstacking and high auto-PEEP AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 40 Plateau Pressure Need to keep <30 cm H2O To achieve this, Vt may need to be dropped further depending on compliance Bronchodilators, sedation, or very rarely paralysis may be necessary Sedation and paralysis should be used very sparingly, especially paralytics, unless severe ARDS is present AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 41 Barriers to Low Vt Implementation Translation of evidence into practice is difficult Only 46% of eligible ARDS patients received LTVV 8 years after ARDSNet trial12

Application to non-ALI patients is not well known, but likely much lower nationally 12. Umoh NJ, Fan E, Mendez-Tellez PA, et al. Patient and intensive care unit organizational factors associated with low tidal volume ventilation in acute lung injury. Crit Care Med. 2008 36(5):1463-8. PMID: 18434907. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 42 Address Variability in Practice Do you have a standardized protocol? If a provider orders settings outside of LTVV strategy parameters, is a change to the order required? How is the order modified? Do your providers comply with protocols? AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 43 Steps to Implementing a LTVV Strategy Educate staff on LTVV strategy Identify inconsistencies in prescriber engagement or agreement Garner buy-in from all providers

Address and work with dissenters Develop standard protocol Employ default strategy that encourages LTVV AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 44 Protocol Standardize protocol Electronic health record Paper Assign custodian of process Respiratory therapist Physician Include tools to support or reinforce expectation Add system redundancies AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 45 Closing Gaps in Quality Audit your intervention practices Review LTVV data LTVV Data Collection tool

Tip: The LTVV Data Collection tool can be found at https://www.ahrq.gov/professionals/quality-patient-safety/hais/tools/mvp/modules/technical/ daily-ltvv-tool.html . AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 46 Summary Low tidal volume ventilation Beneficial for patients with ALI/ARDS Data also suggest it is beneficial in non-ALI/ARDS ICU patients Current recommendations Target Vt 68 mL/Kg (or less if ARDS) PEEP 5 cm H2O AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 47 LTVV Quick Reference for Tidal Volume AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 48

Questions? AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 49 References 1. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-8. PMID: 10793162. 2. Bendixen HH, Hedley Whyte J, Laver MB. Impaired oxygenation in surgical patients during general anesthesia with controlled ventilation. N Engl J Med. 1963;269:991-6. PMID: 14059732. 3. Putensen C, Theuerkauf N, Zinserling J, et al. Meta-analysis: ventilation strategies and outcomes of the acute respiratory distress syndrome and acute lung injury. Ann Intern Med. 2009;151(8):566-76. PMID: 19841457. 4. Girard TD, Bernard GR. Mechanical ventilation in ARDS: a state-of-the-art review. Chest. 2007;131(3):921-9. PMID: 17356115. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 50 References 5. Lellouche F, Lipes J. Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med. 2013;39(1):6-15. PMID: 23108608. 6. Serpa Neto A, Cardoso SO, Manetta JA, et al. Association between use of

lung-protective ventilation with lower tidal volumes and clinical outcomes among patients without acute respiratory distress syndrome: a metaanalysis. JAMA. 2012;308(16):1651-9. PMID: 23093163. 7. Zupancich E, Paparella D, Turani F, et al. Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial. J Thorac Cardiovasc Surg. 2005;130(2):378-83. PMID: 16077402. 8. Herasevich V, Tsapenko M, Kojicic M, et al. Limiting ventilator-induced lung injury through individual electronic medical record surveillance. Crit Care Med. 2011;39(1):34-9. PMID: 20959788. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 51 References 9. Furtier E, Constantin JM, Paugam-Burtz C, et al. A trial of intraoperative low-tidal-volume ventilation in abdominal surgery. N Eng J Med. 2013 Aug 1;369(5):428-37. PMID: 23902482. 10. Metnitz PG, Metnitz B, Moreno RP, et al. SAPS 3 Investigators. Epidemiology of mechanical ventilation: analysis of the SAPS 3 database. Intensive Care Med. 2009;35(5):816-25. PMID: 19288079. 11. Manzano F, Fernndez-Mondjar E, Colmenero M, et al. Positive-end expiratory pressure reduces incidence of ventilator-associated pneumonia in nonhypoxemic patients. Crit Care Med. 2008;36(8):2225 31. PMID: 18664777. 12. Umoh NJ, Fan E, Mendez-Tellez PA, et al. Patient and intensive care unit organizational factors associated with low tidal volume ventilation in

acute lung injury. Crit Care Med. 2008;36(5):1463-8. PMID: 18434907. AHRQ Safety Program for Mechanically Ventilated Patients LTVV Intro, Evidence, Implementation 52

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