proportional assist ventilation (pav+) and neurally ... · psv, pav, nava trigger control cycling...
TRANSCRIPT
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Proportional Assist Ventilation (PAV+) and Neurally Adjusted Ventilatory
Assist (NAVA)
L. Brochard
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Laurent Brochard Toronto
Laurent Brochard Toronto
PAV et NAVA
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Conflicts of interest
• Our clinical research laboratory has received research grants for clinical trials from the following companies – Covidien (PAV+)
– Dräger (SmartCare)
– General Electric (FRC)
– Maquet (NAVA)
– Fisher Paykel (Optiflow)
– Vygon (CPAP)
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Proportional Assist Ventilation (PAV+) and Neurally Adjusted
Ventilatory Assist (NAVA)
• Two (Canadian) proportional modes
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Proportional Modes: what for?
• Better Patient-Ventilator Synchrony
• Better adaptation to changes in demand
• Optimal tidal volume (and frequency) for lung protection
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ABC of ventilation PSV, PAV, NAVA
Trigger Control Cycling end
expiration
PSV Flow or
Pressure
Constant
Pressure
% Peak-
Flow
PEEP
NAVA patient
EMG
Pressure
proportion-
nal to
EMGdi
End of
EMGdi
PEEP and
EMGdi
PAV Flow or
Pressure
Pressure
proportion-
nal to flow
and volume
End of
Patient
Flow
PEEP
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RESPIRATORY SYSTEM MODEL
Compliance and Resistance = CONSTANT
Pressure, Volume, Flow= VARIABLES
Equation of Motion
muscle + ventilator
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G: gains for volume (VA) and flow (FA) VA is a fraction (percentage) of Ers, and FA is a fraction of Rrs
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Equation of motion
Pappl = (VxE) + (V'xR)
Pappl = Paw + Pmus
Pappl = (VxE) + (V'xR) = Pel + Pres
Gain
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huge
Paw proportional
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Gianouli et al AJRCCM 1999
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Estimation of Elastance
300 ms end inspiratory pause manoeuvre at a random intervals of 4 to 10 breaths : PplatPAV
EPAV = (PplatPAV - PEEPtot) / Vt
Younes M, et al. AJRCCM 2001;164:50-60
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FLOW
Pes
Paw
GAIN = 40%
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Settings in PAV+
FiO2 PEEP Gain
How to adjust it?
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understand « Gain »
K = 1
1 - Gain
(P0 = 0) Ptot = K . |Pmus| For a Gain of 75% support
K = 1
0.25
K = 1
1 - 0.75
K = 4
Paw
25% 75%
100%
Ptot
Pmus
Carteaux et al CCM 2013
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Adaptation of the Gain every 8h if needed
Clinical data collected daily
A computer was connected to the
ventilator for continuous recording
of ventilator’s data (sampling frequency =
1 min)
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19 switch to ACV
52 PAV+
33 until Extubation
27 settings according to
protocol (82%)
4 needed additional
settings 2 out of the
rules
1 Intolerance 18 Aggravation
Carteaux et al CCM 2013
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Each box-plot represents a patient
PTPmus median values all over PAV+ ventilation per patient P
TP
mu
s (c
mH
20.s
.min
-1)
Carteaux et al CCM 2013
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Conclusions
• Many patients tolerate PAV+ ventilation over several days
• Setting PAV+ to target a « normal » level of effort seems feasible
• The target is reached in 85% of the cases
• Refinement of the Paw criteria may be necessary
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Elec
tro
des
+ -
+ -
+ -
+ -
+ -
+ -
+ -
+ -
+ -
Filtrage
Ventilateur
Amplification
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Catheter Edi
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J. Appl.Physiol. 1998, 85: 2146–2158,
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NAVA catheter: position
NA
VA
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NA
VA
NAVA uses Eadi for…
Triggering
Cycle
Deliver proportional assist
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NA
VA
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Courtesy of H Roze
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Courtesy of H Roze
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Courtesy of H Roze
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Double – trigg NAVA
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Paw = Edi x Gain de NAVA
Titration?
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Brander L, et al. Chest 2009; 135:695-703
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NA
VA
14 patients
Intensive care Med 2012; 38(2):230-9
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NA
VA
15 patients
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NA
VA
Patient 1
Patient 2
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G Carteaux 2010
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% of total pressure supported by NAVA
% P
tot
NAVA G Carteaux 2010
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Colombo et al. ICM 2008
Physiologic response to varying levels of pressure support and neurally
adjusted ventilatory assist in patients with acute respiratory failure
Control?
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Neurally adjusted ventilatory assist decreases ventilator-induced lung injury
and non –pulmonary organ dysfunction in rabbits with acute lung injury
Brander et al. ICM 2008
Control?
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Pmus,Peak = (Paw,Peak – PEEP) . 1 – Gain
Gain
Delta Paw (cm H20) = Paw,Peak - PEEP
1 2 3 4 5 6 7 8 9 10 12 15 17 20 25 30 35 40
% assist
20 4 8 12 16 20 24 28 32 36 40 48 60 68 80 100 120 140 160
25 3 6 9 12 15 18 21 24 27 30 36 45 51 60 75 90 105 120
30 2 5 7 9 12 14 16 19 21 23 28 35 40 47 58 70 82 93
35 2 4 6 7 9 11 13 15 17 19 22 28 32 37 46 56 65 74
40 2 3 5 6 8 9 11 12 14 15 18 23 26 30 38 45 53 60
45 1 2 4 5 6 7 9 10 11 12 15 18 21 24 31 37 43 49
50 1 2 3 4 5 6 7 8 9 10 12 15 17 20 25 30 35 40
55 1 2 2 3 4 5 6 7 7 8 10 12 14 16 20 25 29 33
60 1 1 2 3 3 4 5 5 6 7 8 10 11 13 17 20 23 27
65 1 1 2 2 3 3 4 4 5 5 6 8 9 11 13 16 19 22
70 0 1 1 2 2 3 3 3 4 4 5 6 7 9 11 13 15 17
75 0 1 1 1 2 2 2 3 3 3 4 5 6 7 8 10 12 13
80 0 1 1 1 1 2 2 2 2 3 3 4 4 5 6 8 9 10
85 0 0 1 1 1 1 1 1 2 2 2 3 3 4 4 5 6 7
90 0 0 0 0 1 1 1 1 1 1 1 2 2 2 3 3 4 4
Pmus,Peak
Gain
( )
Carteaux et al CCM 2013
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Pmus
RR
Ti Te
Pmus,Peak
PTPmus
Pmus,Peak x Ti
2 PTPmus = x RR
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CRITERIA FOR WEANING TRIAL -Resolution of the pathologie requiring intubation -No sign of ARD -Fi02 50% -SaO2 ≥ 90% -Conscious patient -No vasopressor, haemodynamic stability
Adjust FiO2 and PEEP
According to: -Oxygenation (SpO2, PaO2) - Underlying respiratory disease
How to adjust the Gain 1
Standard settings
Assess Pmus
Pmus < 5 cmH2O 5 Pmus 10 cmH2O Pmus > 10 cmH2O
Decrease Gain in steps of 10%
Optimal WOB area. Decrease Gain in steps of 5% while Pmus remains in this area.
Increase Gain in steps of 10%
Initiating PAV+
INITIAL SETTINGS -Gain: 50% -Inspiratory trigger: 1 l/min -Expiratory trigger: 1% -FiO2 et PEEP: no specific rule
ALARMS -Paw max: 40 cmH2O -RR: 40/min -Vte max: 10 ml/kg -Vte min: 0 ml
If appears, while Pmus is in the optimal area
-Signs of ARD -Vte < 5 ml/kg -Respiratory acidosis
Increase Gain in steps of 10%
-Vte > 10 ml/kg -Respiratory alcalosis
Decrease Gain in steps of 10%
FiO2 & PEEP optimisation
2 Aditional settings
Search another hypertotilation’s cause
Persistance Lack
Regardless of the Gain
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