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Clinical Decision Support in Mechanical Ventilation- Egyptian Critical Care Summit

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Dr.Mahmoud Abbas
Dr.Mahmoud Abbas

Clinical Decision Support in Mechanical Ventilation- Egyptian Critical Care Summit. Presented by Dr Lluis Blanch Egyptian Critical care Summit is the leading medical event and exhibition in Egypt

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Dr. Lluís Blanch Senior Critical Care Director of Research and Innovation Corporació Sanitària Parc Taulí Cairo, 13th of January 2015 Clinical Decision Support in Mechanical Ventilation D r.Lluís Blanch
L.Blanch is inventor of one Corporació Sanitaria Parc Taulí owned US patent: “Method and system for managed related patient parameters provided by a monitoring device,” US Patent No. 12/538,940. L.Blanch owns 10% of BetterCare S.L. which is a research and development company, spin off of Corporació Sanitària Parc Taulí. Financial Disclosures Lluis Blanch MD, PhDD r.Lluís Blanch
tachycardiatachycardia intercostalintercostal recessionrecession supresternal &supresternal & supraclavicularsupraclavicular recessionrecession sternomastoidsternomastoid activityactivity diaphoresis &diaphoresis & nasal flaringnasal flaring cyanosiscyanosis tachypneatachypnea abdominalabdominal paradoxparadox Tobin MJ. Principles and Practice of MV. 1994.Tobin MJ. Principles and Practice of MV. 1994. Dissynchrony between Patient & Ventilator D r.Lluís Blanch
Clinical Decisions to: Improve synchrony Decrease workload Safety Decrease burnout Data utilization D r.Lluís Blanch
Synchrony D r.Lluís Blanch
Types of asynchrony Flow delivery flow starvation insuficient pressurization Triggering trigger delay autotrigger inefective inspitarory effort double trigger reverse triggering Timing premature cycling Tip > Tiv prolonged cycling Tiv > Tip D r.Lluís Blanch
VCV PCV Double triggering occurs when the ventilator inspiratory time is shorter than the patient’s inspiratory time Double triggering Corretger E, Murias G,… Blanch L. Med Intensiva ((2011 Oct 17) D r.Lluís Blanch
Crit Care Med 2013;41:2177-87 30 pts with breath stacking: No Intervention Increase Sedation/Analgesia Ventilator Adjustment D r.Lluís Blanch
Crit Care Med 2013;41:2177-87 Change in Ventilator: Increase Ti or Use PSV D r.Lluís Blanch
Crit Care Med 2013;41:2177-87 Increase Ti from 0.4 s to 1 s IEE D r.Lluís Blanch
D r.Lluís Blanch
Descriptive tracings ALI Patient Paw Q V Ineffective Inspiratory Efforts During Expiration Corretger E, Murias G,… Blanch L. Med Intensiva (2011 Oct 17) D r.Lluís Blanch
Intensive Care Med. 2006 Oct;32(10):1515-22. D r.Lluís Blanch
Crit Care Med 2009; 37:2740–2745 D r.Lluís Blanch
Patient & Waveforms & Intelligence D r.Lluís Blanch
Validation of the Better Care® system to detect ineffective efforts during expiration (IEE) in MV patients: A Pilot Study. Blanch L et al. Intensive Care Med 2012 (DOI 10.1007/s00134-012-2493-4) 8 patients; 1024 breaths Experts Opinion EAdi Validation 8 patients; 9600 breaths D r.Lluís Blanch
Compared with the EAdi, the IEE algorithm had a SS of 65.2%, SP 99.3%, PPV 90.8%, NPV 96.5%, and Kappa index 73.9% Validation of the Better Care® system to detect ineffective efforts during expiration (IEE) in MV patients: A Pilot Study. Blanch L et al. Intensive Care Med 2012 (DOI 10.1007/s00134-012-2493-4) D r.Lluís Blanch
Asynchrony Index & Sedation Scale Representative Patient 0 100 200 300 400 500 600 700 800 900 1000 1100 0 10 20 30 40 50 AI SAS Hour Hours AI SAS D r.Lluís Blanch
Mechanical Ventilation-Induced Reverse-Triggered Breaths Stretch receptors & vagal C fibers are responsible for the Hering-Breuer reflexes Reverse triggering & Respiratory Entrainment Akoumianaki E et al. Chest 2013;143:927-38. D r.Lluís Blanch
D r.Lluís Blanch
Automation D r.Lluís Blanch
D r.Lluís Blanch
Adaptive pressure to a target VT PCV Breaths VCV Breath Adaptative PCV until target VT is reached Crs Increases and VT exceeds the target, Paw is reduced until VT reaches the target Flow (L/s) Paw (cmH2O) VT (mL) D r.Lluís Blanch
Working principles of Adaptive Support Ventilation (ASV) to maintain the target minute ventilation: - minimum work - expiratory time = 3 TCD r.Lluís Blanch
ASV generates a PS support breath with an automatically adjusted PS level in order to achieve the target combination of VT and RR Based on ETCO2 information, MV is automatically adjusted to keep ETCO2 within expert- based acceptable ranges Basic principles of IntelliVent-ASV Ventilation Modified from Claverias N et al Poster at ASA 2011 D r.Lluís Blanch
Based on SpO2 information, PEEP and FiO2 are automatically adjusted to keep SpO2 within expert-based acceptable ranges according a PEEP- FiO2 table derived from the ARDS Network Basic principles of IntelliVent-ASV Oxygenation Modified from Claverias N et al Poster at ASA 2011 D r.Lluís Blanch
Arnal JM et al ICM 2012 D r.Lluís Blanch
Pressure support ventilation Ti/Ttot during MV Pes CO2 V . Paw 1 s 0.7s1s D r.Lluís Blanch
Terminal Dyssynchrony Parthasarathy S et al. Am J Respir Crit Care Med 1998;158:1471-78. COPD & PSV Expiratory muscle activation Ti vent > Ti patient D r.Lluís Blanch
Edi VT Health Disease Neuro-muscular coupling µV µV µV ml ml ml D r.Lluís Blanch
D r.Lluís Blanch
Proportional assistance D r.Lluís Blanch
Courtesy of Rafael Fernandez MD, PhD D r.Lluís Blanch
Am J Respir Crit Care Med Vol 174. pp 894–900, 2006 RCT 144 ICU pts. Mean MV duration 3.5 to 4 days 74 computer-driven weaning; 70 physician-controlled weaning CDW Evita 4 Usual Weaning CDW Evita 4 Usual WeaningComplications during MV Outcome D r.Lluís Blanch
Days to successful extubation Proportion Successfully Extubated Automated Weaning Protocolized Weaning AJRCCM 2013;187:1203-11 Fewer tracheostomies & well accepted D r.Lluís Blanch
RCT 102 ICU pts. Mean MV duration 119 to129 hours 51 SmartCare/PS; 51 control (clinician PS & PEEP reduction) SmartCare/PS Control pOutcomes Reductions in weaning time were not confirmed when SmartCare/PS was compared to weaning managed by critical care nurses, using a 1:1 nurse/patient ratio. D r.Lluís Blanch
Proyecto Multicentrico Alarmas Inteligentes durante la VM. Sabadell 5 Julio 2012 D r.Lluís Blanch

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Clinical Decision Support in Mechanical Ventilation- Egyptian Critical Care Summit

  • 1. Dr. Lluís Blanch Senior Critical Care Director of Research and Innovation Corporació Sanitària Parc Taulí Cairo, 13th of January 2015 Clinical Decision Support in Mechanical Ventilation D r.Lluís Blanch
  • 2. L.Blanch is inventor of one Corporació Sanitaria Parc Taulí owned US patent: “Method and system for managed related patient parameters provided by a monitoring device,” US Patent No. 12/538,940. L.Blanch owns 10% of BetterCare S.L. which is a research and development company, spin off of Corporació Sanitària Parc Taulí. Financial Disclosures Lluis Blanch MD, PhDD r.Lluís Blanch
  • 3. tachycardiatachycardia intercostalintercostal recessionrecession supresternal &supresternal & supraclavicularsupraclavicular recessionrecession sternomastoidsternomastoid activityactivity diaphoresis &diaphoresis & nasal flaringnasal flaring cyanosiscyanosis tachypneatachypnea abdominalabdominal paradoxparadox Tobin MJ. Principles and Practice of MV. 1994.Tobin MJ. Principles and Practice of MV. 1994. Dissynchrony between Patient & Ventilator D r.Lluís Blanch
  • 4. Clinical Decisions to: Improve synchrony Decrease workload Safety Decrease burnout Data utilization D r.Lluís Blanch
  • 6. Types of asynchrony Flow delivery flow starvation insuficient pressurization Triggering trigger delay autotrigger inefective inspitarory effort double trigger reverse triggering Timing premature cycling Tip > Tiv prolonged cycling Tiv > Tip D r.Lluís Blanch
  • 7. VCV PCV Double triggering occurs when the ventilator inspiratory time is shorter than the patient’s inspiratory time Double triggering Corretger E, Murias G,… Blanch L. Med Intensiva ((2011 Oct 17) D r.Lluís Blanch
  • 8. Crit Care Med 2013;41:2177-87 30 pts with breath stacking: No Intervention Increase Sedation/Analgesia Ventilator Adjustment D r.Lluís Blanch
  • 9. Crit Care Med 2013;41:2177-87 Change in Ventilator: Increase Ti or Use PSV D r.Lluís Blanch
  • 10. Crit Care Med 2013;41:2177-87 Increase Ti from 0.4 s to 1 s IEE D r.Lluís Blanch
  • 12. Descriptive tracings ALI Patient Paw Q V Ineffective Inspiratory Efforts During Expiration Corretger E, Murias G,… Blanch L. Med Intensiva (2011 Oct 17) D r.Lluís Blanch
  • 13. Intensive Care Med. 2006 Oct;32(10):1515-22. D r.Lluís Blanch
  • 14. Crit Care Med 2009; 37:2740–2745 D r.Lluís Blanch
  • 15. Patient & Waveforms & Intelligence D r.Lluís Blanch
  • 16. Validation of the Better Care® system to detect ineffective efforts during expiration (IEE) in MV patients: A Pilot Study. Blanch L et al. Intensive Care Med 2012 (DOI 10.1007/s00134-012-2493-4) 8 patients; 1024 breaths Experts Opinion EAdi Validation 8 patients; 9600 breaths D r.Lluís Blanch
  • 17. Compared with the EAdi, the IEE algorithm had a SS of 65.2%, SP 99.3%, PPV 90.8%, NPV 96.5%, and Kappa index 73.9% Validation of the Better Care® system to detect ineffective efforts during expiration (IEE) in MV patients: A Pilot Study. Blanch L et al. Intensive Care Med 2012 (DOI 10.1007/s00134-012-2493-4) D r.Lluís Blanch
  • 18. Asynchrony Index & Sedation Scale Representative Patient 0 100 200 300 400 500 600 700 800 900 1000 1100 0 10 20 30 40 50 AI SAS Hour Hours AI SAS D r.Lluís Blanch
  • 19. Mechanical Ventilation-Induced Reverse-Triggered Breaths Stretch receptors & vagal C fibers are responsible for the Hering-Breuer reflexes Reverse triggering & Respiratory Entrainment Akoumianaki E et al. Chest 2013;143:927-38. D r.Lluís Blanch
  • 23. Adaptive pressure to a target VT PCV Breaths VCV Breath Adaptative PCV until target VT is reached Crs Increases and VT exceeds the target, Paw is reduced until VT reaches the target Flow (L/s) Paw (cmH2O) VT (mL) D r.Lluís Blanch
  • 24. Working principles of Adaptive Support Ventilation (ASV) to maintain the target minute ventilation: - minimum work - expiratory time = 3 TCD r.Lluís Blanch
  • 25. ASV generates a PS support breath with an automatically adjusted PS level in order to achieve the target combination of VT and RR Based on ETCO2 information, MV is automatically adjusted to keep ETCO2 within expert- based acceptable ranges Basic principles of IntelliVent-ASV Ventilation Modified from Claverias N et al Poster at ASA 2011 D r.Lluís Blanch
  • 26. Based on SpO2 information, PEEP and FiO2 are automatically adjusted to keep SpO2 within expert-based acceptable ranges according a PEEP- FiO2 table derived from the ARDS Network Basic principles of IntelliVent-ASV Oxygenation Modified from Claverias N et al Poster at ASA 2011 D r.Lluís Blanch
  • 27. Arnal JM et al ICM 2012 D r.Lluís Blanch
  • 28. Pressure support ventilation Ti/Ttot during MV Pes CO2 V . Paw 1 s 0.7s1s D r.Lluís Blanch
  • 29. Terminal Dyssynchrony Parthasarathy S et al. Am J Respir Crit Care Med 1998;158:1471-78. COPD & PSV Expiratory muscle activation Ti vent > Ti patient D r.Lluís Blanch
  • 30. Edi VT Health Disease Neuro-muscular coupling µV µV µV ml ml ml D r.Lluís Blanch
  • 33. Courtesy of Rafael Fernandez MD, PhD D r.Lluís Blanch
  • 34. Am J Respir Crit Care Med Vol 174. pp 894–900, 2006 RCT 144 ICU pts. Mean MV duration 3.5 to 4 days 74 computer-driven weaning; 70 physician-controlled weaning CDW Evita 4 Usual Weaning CDW Evita 4 Usual WeaningComplications during MV Outcome D r.Lluís Blanch
  • 35. Days to successful extubation Proportion Successfully Extubated Automated Weaning Protocolized Weaning AJRCCM 2013;187:1203-11 Fewer tracheostomies & well accepted D r.Lluís Blanch
  • 36. RCT 102 ICU pts. Mean MV duration 119 to129 hours 51 SmartCare/PS; 51 control (clinician PS & PEEP reduction) SmartCare/PS Control pOutcomes Reductions in weaning time were not confirmed when SmartCare/PS was compared to weaning managed by critical care nurses, using a 1:1 nurse/patient ratio. D r.Lluís Blanch
  • 37. Proyecto Multicentrico Alarmas Inteligentes durante la VM. Sabadell 5 Julio 2012 D r.Lluís Blanch