Driving Pressure value

Driving Pressure value ORDER NOW FOR CUSTOMIZED AND ORIGINAL ESSAY PAPERS ON Driving Pressure value Fully explain the step-by-step process of how to obtain an accurate Driving Pressure value on a mechanically ventilated patient? Driving Pressure value What ?P values should be targeted for ARDS patients and why? Fully explain the Open Lung Approach in regards to managing mechanically ventilated ARDS patients. Create your own question based upon the readings that you would like to pose to your fellow classmates which demonstrates you did more than simply skim the articles provided. attachment_1 attachment_2 Open Lung Approach for the Acute Respiratory Distress Syndrome: A Pilot, Randomized Controlled Trial* Robert M. Kacmarek, PhD, RRT, FCCM1,2; Jesús Villar, MD, PhD, FCCM3,4; Demet Sulemanji, MD1,2; Raquel Montiel, MD5; Carlos Ferrando, MD, PhD6; Jesús Blanco, MD, PhD3,7; Younsuck Koh, MD, PhD, FCCM8; Juan Alfonso Soler, MD, PhD9; Domingo Martínez, MD10; Marianela Hernández, MD11; Mauro Tucci, MD, PhD12; Joao Batista Borges, MD, PhD12; Santiago Lubillo, MD, PhD5; Arnoldo Santos, MD, PhD13; Juan B. Araujo, MD14; Marcelo B. P. Amato, MD, PhD12; Fernando Suárez-Sipmann, MD, PhD3,13; the Open Lung Approach Network *See also p. 237. ???1Department of Respiratory Care, Massachusetts General Hospital, Boston, MA. ????????2Department of Anesthesia, Critical Care and Pain Medicine, Harvard Medical School, Boston, MA. ????????3CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain. ????????4Multidisciplinary Organ Dysfunction Evaluation Research Network, Research Unit, Hospital Universitario Dr. Negrin, Las Palmas de Gran Canaria, Spain. ????????5Intensive Care Unit, Hospital Universitario NS de Candelaria, Santa Cruz de Tenerife, Spain. ????????6Department of Anesthesiology, Hospital Clinico de Valencia, Valencia, Spain. ????????7Intensive Care Unit, Hospital Universitario Río Hortega, Valladolid, Spain. ????????8Department of Pulmonary and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea. ????????9Intensive Care Unit, Hospital Universitario Morales Meseguer, Murcia, Spain. 10 Intensive Care Unit, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain. 11 Intensive Care Unit, Hospital Universitario de Txagorritxu, Vitoria, Spain. 12 Respiratory ICU, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil. 13 Intensive Care Unit, Hospital Universitario Fundacion Jiménez Díaz, Madrid, Spain. 14 Intensive Care Unit, Hospital Virgen de La Luz, Cuenca, Spain. Drs. Amato and Suárez-Sipmann contributed equally as senior authors. The complete list of investigators of the Open Lung Approach Network is provided in Appendix 1. Registered at ClinicalTrials.gov NCT00431158. Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal’s website (http://journals.lww.com/ccmjournal). Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. DOI: 10.1097/CCM.0000000000001383 32 www.ccmjournal.org Dr. Kacmarek is a consultant for Covidien and Orange Med, has received research grants from Covidien and Venner Medical, and had airfare and expenses to study meetings paid by the Research Unit, Hospital Dr. Negrin Las Palmas de Gran Canaria, Spain. Dr. Villar received funding from Maquet (grant for partially supporting the study), from the Instituto de Salud Carlos III, Spain (PI07/0113), and received support from Asociación Científica Pulmón y Ventilación Mecánica (Spain) for supporting traveling expenses and for coordinating study-related activities among Spanish centers. Driving Pressure value Dr. Amato received support for article research from São Paulo, State Research Foundation and Brazilian Council for Scientific and Technological Development (Brazil). He received support for travel from Maquet, consulted for Covidien (mechanical ventilation), and received grant support from Dixtal LTDA (electrical impedance tomography). Dr. Suarez-Sipmann consulted for Maquet Critical Care. The remaining authors have disclosed that they do not have any potential conflicts of interest. For information regarding this article, E-mail: [email protected] Objective: The open lung approach is a mechanical ventilation strategy involving lung recruitment and a decremental positive end-expiratory pressure trial. We compared the Acute Respiratory Distress Syndrome network protocol using low levels of positive end-expiratory pressure with open lung approach resulting in moderate to high levels of positive end-expiratory pressure for the management of established moderate/severe acute respiratory distress syndrome. Design: A prospective, multicenter, pilot, randomized controlled trial. Setting: A network of 20 multidisciplinary ICUs. Patients: Patients meeting the American-European Consensus Conference definition for acute respiratory distress syndrome were considered for the study. Interventions: At 12-36 hours after acute respiratory distress syndrome onset, patients were assessed under standardized ventilator settings (Fio2?0.5, positive end-expiratory pressure ?10 cm H2O). If Pao2/Fio2 ratio remained less than or equal to 200 mm Hg, patients were randomized to open lung approach or Acute Respiratory Distress Syndrome network protocol. All January 2016 • Volume 44 • Number 1 Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Feature Articles patients were ventilated with a tidal volume of 4 to 8 ml/kg predicted body weight. Measurements and Main Results: From 1,874 screened patients with acute respiratory distress syndrome, 200 were randomized: 99 to open lung approach and 101 to Acute Respiratory Distress Syndrome network protocol. Main outcome measures were 60-day and ICU mortalities, and ventilator-free days. Mortality at day-60 (29% open lung approach vs. 33% Acute Respiratory Distress Syndrome Network protocol, p = 0.18, log rank test), ICU mortality (25% open lung approach vs. 30% Acute Respiratory Distress Syndrome network protocol, p = 0.53 Fisher’s exact test), and ventilator-free days (8 [0-20] open lung approach vs. 7 [0-20] d Acute Respiratory Distress Syndrome network protocol, p = 0.53 Wilcoxon rank test) were not significantly different. Airway driving pressure (plateau pressure – positive end-expiratory pressure) and Pao2/Fio2 improved significantly at 24, 48 and 72 hours in patients in open lung approach compared with patients in Acute Respiratory Distress Syndrome network protocol. Barotrauma rate was similar in both groups. Conclusions: In patients with established acute respiratory distress syndrome, open lung approach improved oxygenation and driving pressure, without detrimental effects on mortality, ventilator-free days, or barotrauma. Driving Pressure value This pilot study supports the need for a large, multicenter trial using recruitment maneuvers and a decremental positive end-expiratory pressure trial in persistent acute respiratory distress syndrome. (Crit Care Med 2016; 44:32–42) Key Words: acute respiratory distress syndrome; barotrauma; decremental positive end-expiratory pressure trial; mechanical ventilation; positive end-expiratory pressure; recruitment maneuver; ventilator-free days T he approach to ventilatory support affects outcome in the acute respiratory distress syndrome (ARDS) (1–5). The ARDS network (ARDSnet) (1) established the benefit on mortality of using small tidal volume (VT) in patients with ARDS. However, substantial controversy still exists over the application of positive end-expiratory pressure (PEEP) (3–9) and the use of lung recruitment (10, 11). There are 6 randomized controlled trials examining the effects of PEEP in patients with ARDS (3–8). However, the results of these trials vary greatly. In the majority of these studies, patients did not have established ARDS, defined as patients who on standard ventilator settings 24 hours after ARDS diagnosis still had a Pao2/Fio2 less than or equal to 200 mm Hg. Patients meeting the American-European Consensus Conference (AECC) criteria for ARDS whose Pao2/Fio2 is more than 200 mm Hg on standardized ventilator settings have an ICU mortality of about 12–23%, whereas those with a Pao2/ Fio2 up to 200 mm Hg on standardized ventilator settings have a mortality of about 45–55% (12–14). These figures are consistent with recent epidemiologic data (15–17). All of the studies with a positive effect on outcome also established a VT and plateau and driving pressure difference Critical Care Medicine between groups (3, 5, 9), applied PEEP based on the patient’s lung mechanics, and enrolled patients meeting the AECC criteria for ARDS (18). Speculation regarding the lack of benefit from higher PEEP in the Assessment of Low tidal Volume and elevated End-expiratory volume to Obviate Lung Injury (4), Lung Open Ventilation (6), and Express (7) trials is that it is not known how many of these patients had established ARDS and if those without established ARDS were harmed by inadvertently high PEEP levels. Appropriate patient selection is a critical aspect of enrollment criteria since it has been demonstrated that response to standardized ventilator settings identifies patients with established ARDS and predicts mortality (12–15). Several authors (19–24) have argued that the most appropriate method for setting PEEP is to recruit the lung and then to determine the least PEEP necessary to maintain the lung open by a decremental PEEP trial (open lung approach, OLA). Theoretically, this temporal sequence insures ventilation on the deflation curve of the respiratory system’s pressure-volume curve, improves lung mechanics, and decreases cyclic lung stress by avoiding derecruitment (20–24). Driving Pressure value Since hypoxemia in ARDS is primarily a result of intrapulmonary shunt, failure to recruit lung not only allows shunting to persist but may also result in overdistension of open alveoli (20). Recent data indicate that lung recruitment maneuvers are capable of safely recruiting lung volume and improving gas exchange and lung mechanics (11, 20–24). Based on these data, we hypothesized that the use of lung recruitment maneuvers and a decremental PEEP trial (individualized moderate to high PEEP) would result in a lower mortality than the original ARDSnet protocol (lower levels of PEEP) (1). Our goal was to compare 60-day all-cause mortality (patients were followed for 60 d following randomization) in patients with established ARDS managed with the OLA lung protective ventilation strategy compared with the ARDSnet protocol. METHODS This multicenter, pilot, randomized, controlled trial was performed in 20 ICUs (Appendix 1). The study was approved by the institutional review boards of all participating hospitals. All patients and/ or family members provided written informed consent. Patients All adult patients (> 18 yr) admitted to participating ICUs and meeting AECC criteria for ARDS (12) who were on mechanical ventilation for less than 96 hours were considered for enrollment. Inclusion criteria were Pao2/Fio2 up to 200 mm Hg, acute onset, bilateral infiltrates on anterior-posterior chest radiograph, no (clinical, echocardiographic, or hemodynamic) evidence of left heart failure, recruited into the trial within 48 hours of meeting above criteria. Exclusion criteria were age less than 18 years; weight less than 35 kg predicted body weight (PBW); body mass index greater than 50; intubation as a result of an acute exacerbation of chronic pulmonary disease: chronic obstructive pulmonary disease, asthma, cystic fibrosis, etc; acute brain injury or elevated intracranial pressure (> 18 mm Hg); immunosuppressed patients receiving chemotherapy or radiation therapy (< 2 mo after chemotherapy or www.ccmjournal.org Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. 33 Kacmarek et al radiation therapy); and severe cardiac disease: New York Heart Association class 3 or 4 or acute coronary syndrome or persistent ventricular tachyarrhythmias. See online data supplement (Supplemental Digital Content 1, http://links.lww.com/CCM/ B466) for additional details. During the subsequent 12–36 hours after enrollment, patients were ventilated according to the ARDSnet protocol (Table 1) (1) and then reassessed (qualifying blood gas) on specific ventilator settings for established moderate/severe ARDS (25). Baseline arterial blood gases were then obtained on 100% oxygen. Subsequently, patients’ were randomized to ARDSnet or OLA. Table 1. Protocol ARDSnet. ARDSnet patients were managed throughout the entire study by the original ARDSnet protocol (1) (Table 1) (online data supplement, Supplemental Digital Content 1, http://links.lww.com/CCM/B466). In both groups, permissive hypercapnia was allowed and target VT referred to a volume calculated based on the patients’ PBW (26). All patients were managed in the supine position, although head of bed elevation was not specified. OLA. A lung recruitment maneuver followed by a decremental PEEP trial was performed before establishing initial Mechanical Ventilation Protocol Standard ventilation settings All enrolled patients ?Ventilator mode VC ?VT range 4–8 mL/kg PBW ?Respiratory rate Adjusted to maintain Paco2 between 35 and 60 mm Hg ?PEEP Set using Fio2-PEEP table ?Driving Pressure value Fio2 Set using Fio2-PEEP table ?Recruitment maneuvers No ?Inspiratory time ?1s ?Plateau pressure goal ? 30 cm H2O Specific ventilation settings All enrolled patients ?Ventilator mode VC ?VT ? 6 mL/kg PBW ?Respiratory rate Adjusted to maintain Paco2 between 35 and 60 mm Hg ?PEEP ? 10 cm H2O ?Fio2 ? 0.5 ?Recruitment maneuvers No ?Inspiratory time ?1s ?Plateau pressure goal ? 30 cm H2O After randomization settings Open lung approach Acute Respiratory Distress Syndrome network protocol ?Ventilator mode PC VC ?VT target 6 mL/kg PBW 6 mL/kg PBW ?VT range 4–8 mL/kg PBW 4–8 mL/kg PBW ?Respiratory rate ? 35 breaths/min ? 35 breaths/min ?PEEP Set using decremental PEEP trial Set using Fio2-PEEP table ?Recruitment maneuvers Yes No ?Inspiration: expiration ratio 1:1–1:3 1:1–1:3 ?Arterial pH goal ? 7.30 and ? 7.45 ? 7.30 and ? 7.45 ?Plateau pressure goal ? 30 cm H2O ? 30 cm H2O ?Partial pressure of arterial oxygen goal 55–80 mm Hg 55–80 mm Hg ?Oxygen saturation by pulse oximetry 88–95% 88–95% VC = volume control, VT = tidal volume, PBW = predicted body weight, PEEP = positive end-expiratory pressure, PC = pressure control. 34 www.ccmjournal.org January 2016 • Volume 44 • Number 1 Copyright © 2015 by the Society of Critical Care Medicine and Wolters Kluwer Health, Inc. All Rights Reserved. Feature Articles ventilator settings (19–24). After ensuring hemodynamic stability, a lung recruitment maneuver was performed using pressure control ventilation to a peak pressure between 50 and 60 cm H2O and PEEP 35–45 cm H2O depending on patient’s response (22). Patients were sedated to apnea before the recruitment maneuver and neuromuscular-blocking agents were used if necessary to insure patient safety during the maneuver by avoiding large increases in transpulmonary pressure. For details, see online data supplement (Supplemental Digital Content 1, http://links.lww.com/CCM/B466). For the decremental PEEP trial, mechanical ventilation mode was volume assist/control, VT 4–6 mL/kg, PEEP 25 cm H2O, and ventilatory rate set at the level prior to the recruitment maneuver. After a 3-minute stabilization period, dynamic compliance (VT divided by peak pressure – PEEP) was recorded. PEEP was then decreased in 2 cm H2O steps and compliance recorded after stabilization. Dynamic compliance was automatically calculated and displayed on the Servo-i ventilator with each breath (on a daily basis, static compliance was determined: VT divided by plateau pressure – PEEP). This process was continued until the PEEP level corresponding to the maximum compliance was identified. Once the maximum compliance PEEP was identified, the lung was again recruited and PEEP set at the maximum compliance PEEP + 3 cm H2O. Following the second recruitment maneuver, the mode was changed to pressure assist/control, maximum compliance PEEP + 3 cm H2O, pressure assist/control level set to establish a peak inspiratory pressure less than 30 cm H2O, VT 4–8 mL/kg. If VT was set less than 5 mL/kg PBW, plateau pressure was allowed to exceed 30 cm H2O. Finally, the Fio2 was reduced to the lowest level maintaining the target Pao2. For details, see online data supplement (Supplemental Digital Content 1, http://links.lww. com/CCM/B466). In addition, after PEEP was set, PEEP was not to be modified for 24 hours and then only when the Fio2 decreased to 0.40. When PEEP was decreased, it was decreased at a rate not to exceed 2 cm H2O every 8 hours; if the decrease in PEEP resulted in a loss of oxygenation or lung mechanics, PEEP was to be reestablished. Driving Pressure value of ventilation for OLA throughout the study followed the ARDSnet protocol. In both groups, patients were assessed daily for readiness for a spontaneous breathing trial based on the ARDSnet criteria (1) (for details, see online data supplement, Supplemental Digital Content 1, http://links.lww.com/CCM/B466). Those meeting criteria received a 30- to 60-minute spontaneous breathing trial. If the patients passed the trial, they were extubated, unless there was a specific reason not to extubate. Patients older than 65 years, hypercapnic (> 45 mm Hg after extubation), with an ineffective cough and excessive secretions, with more than one weaning failure, with more than one comorbid condition (any chronic organ failure), upper airway obstruction, or Acute Physiology and Chronic Health Evaluation (APACHE) II score greater than 12 on the day of extubation received noninvasive ventilation (bilevel positive airway pressure) for 24–48 hours until stable or requiring reintubation (for details, see online data supplement, Supplemental Digital Content 1, http://links. lww.com/CCM/B466). Critical Care Medicine Data Gathering Data were collected on day 0 (enrollment), day 1 (randomization), and days 2, 3, 4, 5, 6, 7, 10, 14, 21, 28, and every 7 days after randomization until extubation, including APACHE II (27), lung injury score, Simplified Acute Physiology Score (28), and Sequential Organ Failure Assessment (29) scores, and organ failures (30, 31). Data gathering after randomization included the highest and lowest value for each parameter within the specific 24-hour period. For details, see online data supplement (Supplemental Digital Content 1, http://links.lww.com/CCM/B466). The primary outcome was all-cause death at 60 days after randomization (patients were followed for 60 d). Secondary outcomes included ventilator-free days at day 28 (32), incidence of barotrauma, development of extrapulmonary organ failures, length of ICU and hospital stay, and ICU and hospital mortality. In addition, we compared PEEP, Fio2, driving pressure (plateau pressure minus PEEP), VT, respiratory rate, plateau pressure, gas exchange, number of organs failures, and APACHE II score between groups. Power Analysis/Study Design The power analysis was based on an expected 45% mortality in the ARDSnet group. This mortality was determined from the recent data on effect of standard ventilator setting trial conducted by the Spanish Hospitales Españoles para el estudio de la Lesión Pulmonar aguda network (5). In that study, patients with severe and persistent ARDS managed with a VT of 6–8 mL/kg PBW had a mortality of 45.5%. In the OLA group, a mortality of 33% was expected. This was based on the findings of the Spanish Acute Respiratory Insufficiency: España Study (14) Pflex trial in which the mortality in the Pflex group was 33%. Based on these data, it was expected that approximately 600 patients would need to be randomized into the 2 groups, ARDSnet protocol and OLA, with an ? of less than 0.05 and a ? of greater than 80%. Statistical Analysis … Get a 10 % discount on an order above $ 100 Use the following coupon code : NURSING10