Evidence Base for Newer Modes of Mechanical Ventilation

Charles B. Spearman, MSEd, RRT, FAARC Assistant Professor Respiratory Care Programs Department of Cardiopulmonary Sciences Loma Linda University Loma Linda, California

Evidence Base for Newer Modes of Mechanical Ventilation: Overview

Background for evidence base levels Dual modes of ventilation Adaptive Support ventilation (ASV) Proportional Assist Ventilation (PAV) Airway Pressure Release Ventilation (APRV)

Evidence Base for Newer Modes of Mechanical Ventilation: Background

Evidence-based medicine: the integration of individual clinical expertise with the best available research evidence from systematic research and the patients values and expectations. D. R. Hess, RC,2004;49:7, 730-741.

Evidence Base for Newer Modes of Mechanical Ventilation: Background

New Horizons Symposium: Integrating Evidence-based Respiratory Care into Practice Published in: Respiratory Care, July 2004 (49:7) Topics covered: -What is EBM -EB of New Modes -RC Protocols -COPD Manag. -Asthma Manag. -ALI/ARDS Manag. -NIPPV -Weaning Also G. D. Rubenfelds article RCP role in EBM use

Evidence Base for Newer Modes of Mechanical Ventilation: Background

Other sources for evidence :based practice Clinical Practice Guidelines AARC, ACCP, ATS Evidence based guidelines Weaning, GOLD, Aerosol Task force, Asthma training, etc.

Evidence Base for Newer Modes of Mechanical Ventilation: Background

From: Branson & Johanningman, 2004:RC,49:7, 742-760.

New Modes of Mechanical Ventilation: Background

Introduction of the microprocessorcontrolled ventilator Better control of flow & exhalation valves Increased monitoring capabilities Increased pt-ventilator interaction Dual modes of ventilation introduced
From Mosbys R. C. Equip., 6th ed. 1999.

New Modes of Mechanical Ventilation: Examples of the first dual modes

Volume Assured Pressure Support (VAPS) & Pressure Augmentation Pressure Regulated Volume Control (PRVC) & similar modes Volume Support Ventilation (VS or VSV) & similar modes

Pressure vs. Volume Ventilation

(From Branson, R., Bird product literature)

Newer Methods of Ventilatory Support: dual modes

1st generation dual modes: VAPS, Press. Aug., PRVC & VS Allow variable flow delivery and pressure targeted ventilation approach Attempt to deliver a set tidal volume (TV) Allow peak airway pressure to vary breath to breath

VAPS: Volume Assured Pressure Support

Combines volume ventilation & pressure support

(for mech., vol. limited breaths only)

Uses TV, peak flow, and pressure sup./control settings Targets PS level with at least set peak flow first Continues until flow decreases to set peak flow, then:

If TV not delivered, peak flow maintained until vol. limit If TV or more delivered, breath ends

VAPS: Volume Assured Pressure Support

(From Branson, R., Bird product literature)

VAPS: (and Pressure Augmentation) Considerations The set TV is the minimum TV the patient will receive The set pressure support is the minimum the patient will receive The set peak flow is the minimum the patient will receive No ventilatory mechanics measured

Pressure Regulated Volume Control (Servo vents.)

Combines volume ventilation & pressure control (for mech., time-cycl. breaths only) Set TV is targeted Ventilator estimates vol./press. relationship each breath Ventilator adjusts level of pressure control breath by breath

Pressure Regulated Volume Control (Servo vents, example)

First breath = 5-10 cm H2O above PEEP V/P relationship measured Next 3 breaths, pressure increased to 75% needed for set TV Then up to +/- 3 cm H2O changes per breath Time ends inspiration

Pressure Regulated Volume Control (Siemens Servo 300)

From Siemens prod. literature

Pressure Regulated Volume Control - Considerations

Assist-control mode Like PC, flow varies automatically to varying patient demands Constant press. during each breath variable press. from breath to breath Time is cycling method; delivered TV can vary from set

First dual modes: VAPS, Press. Aug.

vs. PRVC & VS

VAPS (& Press.

Augmentation)

PRVC (& Vol. Support)

Use the set TV as the target for each breath Normal cycling may stop insp. below or above set TV

Use the set TV as a minimum Normal cycling occurs at or above the set TV Mechanics not measured

Pressure used based on mechanics

First dual modes: VAPS, Press. Aug.

vs. PRVC & VS

Peak airway pressure can reach high levels: Set appropriate high pressure limits

No settings for maximum tidal volume

Newer Ventilator Dual Modes:

AutoFlow: Drager ventilators Evita 4, Evita 2 dura

Adaptive Support Ventilation (ASV): Hamilton Galileo

Newer Ventilator Dual Modes:

Drager vents AutoFlow

First breath uses set TV & I-time Pplateau measured Pplateau then used V/P measured each breath Press. changed if needed (+/- 3) Then similar to PRVC
From Drager & Mosbys R. C. Equip., 6th ed. 1999.

Newer Ventilator Dual Modes:

Drager vents AutoFlow

Allows spont. breathing:

expiration and inspiration

Exp. efforts at peak insp. pressure open exh. valve; Ppeak maintained Active exhalation valve is a key feature
From Drager & Mosbys R. C. Equip., 6th ed. 1999.

Newer Ventilator Dual Modes:

Drager vents AutoFlow

Allows spont. breathing:

expiration and inspiration

From Drager

Newer Ventilator Dual Modes:

Drager vents AutoFlow - Considerations

Dual mode similar to PRVC

Targets vol., applies variable press. based on mechanics measurements Allows highly variable inspiratory flows Time ends mandatory breaths

Adds ability to freely exhale during mandatory inspiration (maintains pressure) Adds high TV alarm & limit Can be used in CMV, SIMV and MMV

Newer Ventilator Dual Modes:

Hamilton Galileos ASV (adapt. sup. vent.) Clinician enters pt. data & % support Vent. calculates needed min. vol. & best rate/TV to produces least work. Targeted TVs given as press. control or press. support breaths Breath is: PC if time triggered, PS if pt. triggered

Newer Ventilator Dual Modes:

Hamilton Galileos ASV (adapt. sup. vent.)

Vent. measures & analyzes data & mechanics each breath for:

compliance resistance inspiratory & expiratory time constants actual I-time, E-time, total f & min. vol. pressures

Press. adjusts in +/- 2 cm H2O to achieve TV

Newer Ventilator Dual Modes:

Hamilton Galileos ASV - Considerations

Mandatory breaths = PC, pt. triggered = PS both at same targeted TV and calculated press.

ASV: Principle mode of ventilation

Flow I Flow E Pinsp PEEP

+ * *

no patient activity: * machine triggered + time cycled

patient is active: * patient triggered + flow cycled

From Hamilton Medical

Newer Ventilator Dual Modes:

Hamilton Galileos ASV - Considerations

Mandatory breaths = PC, pt. triggered = PS both at same targeted TV and calculated press.

If pt.s f > set by vent., mode is PS If pt.s f < set by vent., mode is PC-SIMV/PS If patient is apneic, all breaths are PC

Newer Ventilator Dual Modes:

Hamilton Galileos ASV: Considerations Using least work as a criteria: calculation for needed rate may change, therefore calculated TV may change, and therefore calculated pressure needed for TV may change Both max. & min. TV limits are used As patient improves,support is decreased pressure can be reduced to PEEP + 5 cm

Newer Ventilator Dual Modes:

Summary:
Combined methods of press. & volume ventilation may replace standard volume ventilation. Prudent use of high pressure limits (and volume limits if available) and careful monitoring can decrease disadvantages of combined modes.

Newer Ventilator Dual Modes:

Evidence:

VAPS: No randomized controlled trials (RCT) 2 observational studies, 1 bench study with test lung Lower level outcomes: Reduced work Evid. levels III, B & level V, C

Newer Ventilator Dual Modes:

Evidence:

PRVC/VS (also referred to as adaptive PC):

2 small randomized controlled trials (RCT): post-op pts, no survival benefit, no diff or slightly shorter vent time, less interventions & blood gases 3 other randomized cross-over observational studies, & 5 other cross-over short term obs. studies: safe, small differences in lower PIP, some shorter to extubation Lower level outcomes: Small RCT trials: II, grade B evidence Small cross-over studies III, grade C

Newer Ventilator Dual Modes:

Evidence:

ASV:

2 small randomized controlled trials (RCT): no survival benefit, sub-group (10 infants) shorter vent time, less BPD; adult study showed only less PIP in PRVC 3 other cross-over observational studies, lower PIP, (better gas exchange in animal study only) Lower level outcomes: Small RCT trials: II, grade B evidence Small cross-over studies III for humans, V for animal study, all grade C

New Modes of Mechanical Ventilation: Bi-level ventilation methods

Ventilation methods that allow spontaneous breathing at two airway pressures: BiPAP (Drager E-4 & E-2 dura) BiLevel (NPB 840) APRV (NPB 840, Drager E-4 & E-2 dura) Pressure targeted strategy & spont. Breathing can fit lung protective criteria

BiLevel Ventilation: NPB 840

Uses two levels of pressure for two time periods Mandatory breaths at the higher pressure are time cycled Spontaneous breaths can be pressure supported
Spontaneous Breaths

Spontaneous Breaths

T
From PB product lit.

BiLevel Ventilation: NPB 840

Uses 2 pressure levels for 2 time periods PEEPlow & PEEPhigh, Thigh and Tlow Patient triggering & cycling can change phases
PEEPHIGH
Synchronized Transitions

PEEPLOW TLOW

THIGH
Synchronized Transitions

T
From PB product lit.

BiLevel Ventilation: NPB 840

Pressure support may be applied at both pressures during a spont. breath

If PS is set higher than PEEPH, the PS pressure is applied to a spontaneous effort at upper pressure
PEEPH PEEPHigh + PS Pressure Support

P
PEEPL

From PB product lit.

BiLevel Ventilation: NPB 840

If PS is set lower than PEEPH, PS is applied to patient efforts at the lower pressure, PEEPL
Spontaneous Breaths

Pressure Support

T
From PB product lit.

APRV (Drager ventilators)

Airway Pressure Release Ventilation Like BiPAP/BiLevel but time at the lower pressure (release time) is usually short, 1-1.5 seconds Spontaneous breathing still allowed throughout low & high pressures

APRV (Drager ventilators)

Airway Pressure Release Ventilation

From Mosbys R. C. Equip. 6th ed. 1999.

Newer Methods of Ventilatory Support: Proportional Assist Ventilation

PAV - currently on PB 840 in US prototype/research ventilators, Drager Evita 4 & Respironics BiPAP Vision Allows free flow based on patient effort Targets portion of patients work during spontaneous breaths Automatically adjusts flow, volume and pressure needed each breath

Methods of Ventilatory Support: PAV

continued Vol. assist % reduces work of elastance Flow assist% reduces work of resistance's Pressure adjusts during each breath to control work level Increased patient effort causes increased applied pressure (and flow & volume)

Methods of Ventilatory Support: PAV

continued

From Younes, M: Ch.15, in Tobin, MJ Prin. & Pract. Of Mech. Vent. 1994 McGaw-Hill, Inc.

Methods of Ventilatory Support: PAV

continued

Other controls useful for PAV: High pressure limit High volume limit Back-up ventilation mode Typical alarms etc.

Methods of Ventilatory Support: PAV

- Considerations Consistent level of support per breath Patient controls breathing pattern Patient triggered mode (Unless back-up mode present) Reduced support with Auto-PEEP Cannot compensate for leaks (prototypes)

Methods of Ventilatory Support: PAV

-Evidence
Huge number of studies since 1992.

BUT, almost no large RCTs. Most were small, short term observational comparing PAV to pressure support. Largest trial in NIPPV for ARF: showed no difference for intubation, stay, mortality. Better comfort for PAV Most all other trials rated level III, grades or C.

New Modes of Mechanical Ventilation: Other neat stuff

New Modes of Mechanical Ventilation: Other neat stuff

Automatic tube compensation: Drager Evita 4

From Drager prod. lit.

New Modes of Mechanical Ventilation: Summary

Older modes & ventilators: passive, operator-dependant tools New modes on new generation ventilators: adaptively interactive goal oriented patient centered

Adapted from John J. Marini, MD; AARC congress, 11/98