Precisamos de Bundles na ven1lação! Carlos Glória UCI- Centro hospitalar do Barlavento Algarvio

BUNDLE DA VENTILAÇÃO O conceito de bundle Visão crí1ca das estratégias incluídas na bundle da ven1lação A actual bundle reflecte o estado da arte da ven1lação mecânica? Que estratégias ven1latórias não podem estar excluídas numa bundle de ven1lação O futuro da ven1lação mecânica: the box or out of the box?

BUNDLES Tradução prá1ca do conceito filosófico de Gestalt O todo é mais do que a soma das partes Conjunto de prá1cas baseadas em evidência cienyfica que, quando implementadas em grupo e com consistência, conduzem a melhorias significa1vas de resultados A aplicação das medidas implica uma estratégia do tudo ou nada Os elementos da bundle são dicótomos e por isso a adesão é medida em termos de sim/não Exemplos: bundle da sépsis, bundle do cateter central, bundle da ven1lação

100,000 LIVES CAMPAIGN - 2005 The six interven,ons from the 100,000 Lives Campaign: Deploy Rapid Response Teams at the first sign of pa1ent decline Deliver Reliable, Evidence- Based Care for Acute Myocardial InfarcAon to prevent deaths from heart adack Prevent Adverse Drug Events (ADEs) by implemen1ng medica1on reconcilia1on Prevent Central Line InfecAons by implemen1ng a series of interdependent, scien1fically grounded steps Prevent Surgical Site InfecAons by reliably delivering the correct periopera1ve an1bio1cs at the proper 1me Prevent VenAlator- Associated Pneumonia by implemen1ng a series of interdependent, scien1fically grounded steps including the VenAlator Bundle IHI.org Ins0tute For Healthcare Improvement

BUNDLE DA VENTILAÇÃO Profilaxia da úlcera de stress Profilaxia da trombose venosa profunda Posição semi- recumbente Suspensão diária da sedação e tenta1va de ven1lação espontânea

VENTILATOR BUNDLE EFFECTIVENESS IN THE PREVENTION OF VAP 15 10 5 0 VAP incidence Before Aker Lack of methodologic rigor of the reported studies precludes any conclusive statements about the bundle s effec0veness or cost- effec0veness rigorous evalua0on of op0mal strategies for VAP preven0on is needed The ven0lator bundle is not a viable quality measure in the intensive care unit at this 0me. Crit Care Med 2009; 37:305-309

BUNDLE DA VENTILAÇÃO Profilaxia da úlcera de stress Profilaxia da trombose venosa profunda Posição semi- recumbente Suspensão diária da sedação e avaliação da possibilidade de desmame

RISK FACTORS FOR GI BLEEDING IN CRITICAL ILL PATIENTS N Engl J Med. 1994;330:377-381

SUCRALFATE VS RANITIDINE FOR THE PREVENTION OF UPPER GI BLEEDING IN PATIENTS REQUIRING MECHANICAL VENTILATION CLINICALLY IMPORTANT GI BLEEDING 1,7% rani1dine group vs 3.8% sucralfate group (RR 0.44, P=0.02) VENTILATOR ASSOCIATED PNEUMONIA N Engl J Med. 1998;338:791-797

BLEEDING AND PNEUMONIA IN INTENSIVE CARE PATIENTS GIVEN RANITIDINE AND SUCRALFATE FOR PREVENTION OF STRESS ULCER Rani1dine vs placebo Sucralfate vs placebo END- POINT ODDS RATIO EFFECT Clinically important GI bleeding Clinically important GI bleeding 0.72 None P=0.46 1.26 None P=0.70 Rani1dine vs placebo Pneumonia 0.98 None P=0.84 Sucralfate vs placebo Pneumonia 2.21 None P=0.14 Rani1dine vs sucralfate Pneumonia 1.35 Increased risk with rani1ne P=0.012 BMJ 2000; 321:1103 1106

BLEEDING IN CRITICALLY ILL PATIENTS WITH AND WITHOUT STRESS- ULCER PROPHYLAXIS Intensive Care Med 2003; 29:1306 13 STRESS ULCER PROPHYLAXIS IN CRITICALLY ILL PATIENTS: A RANDOMIZED CONTROLLED TRIAL Clinically significant GI bleeding Omeprazol n=72 Famo1dine n=71 Sucralfate n=69 Placebo n=75 1% 3% 4% 1% p>0.28 p VAP incidence 11% 10% 9% 7% p>0.36 Hepatogastroenterology 2004; 51(57):757-61

NOSOCOMIAL PNEUMONIA RISK AND STRESS ULCER PROPHYLAXIS PANTOPRAZOLE VS RANITIDINE CHEST 2009; 136:440 447

Current Opinion in Cri1cal Care: April 2009 - Volume 15 - Issue 2 - p 139-143 When should stress ulcer prophylaxis be used in the ICU? Quenot, Jean- Pierre; Thiery, Nadiejda; Barbar, Saber Rou1ne prophylaxis against stress ulcers in the ICU is not well jus1fied by current evidence. Pa1ents at risk of stress ulcer- related bleeding are most likely to benefit from prophylaxis. Thus, healthcare professionals should con1nue to evaluate risk and assess the need for stress ulcer- related prophylaxis. Current Opinion in Cri1cal Care 2009; 15:139-143 Intensive Care Med 2010; 36:773 80

PROFILAXIA DA TROMBOSE VENOSA PROFUNDA We recommend, on admission to the intensive care unit, all pa0ents be assessed for their risk of VTE. Accordingly, most pa0ents should receive thromboprophylaxis (Grade 1A) CHEST 2004; 126:338S 400S

BUNDLE DE VENTILAÇÃO Profilaxia da úlcera de stress Profilaxia da trombose venosa profunda Posição semi- recumbente Suspensão diária da sedação e avaliação da possibilidade de desmame

POSIÇÃO SEMI- RECUMBENTE Supine body posi,on as a risk factor for nosocomial pneumonia in mechanically ven,lated pa,ents: a randomized trial Supine 0º Semirecumbent 45º? Clinically suspected VAP 16 of 47 (47%) 3 of 39 (8%) P=0.003 Microbiol. confirmed VAP 11 of 47 (23%) 2 of 39 (5%) P=0.018 Supine 10-14º Lancet 1999; 354:1851 1858 Feasibility and effects of the semirecumbent posi,on to prevent ven,lator- associated pneumonia: a randomized study Semirecumbent 23-30º Clinically suspected VAP 20 of 109 (18%) 16 of 112 (14%) ns Microbiol. confirmed VAP 8 of 109 (7%) 13 of 112 (12%) ns Crit Care Med 2006; 34:396 402

EFFECT ON THE DURATION OF MECHANICAL VENTILATION OF IDENTIFYING PATIENTS CAPABLE OF BREATHING SPONTANEOUSLY 1- Daily screening of respiratory func1on to iden1fy pa1ents capable of breathing spontaneously 2- successful tests were followed by two- hour trials of spontaneous breathing 149 pa1ents in the interven1on group received mechanical ven1la1on for a median of 4.5 days, as compared with 6 days in the 151 pa1ents in the control group (P=0.003). N Engl J Med 1996; 342:141-77

DAILY INTERRUPTION OF SEDATIVE INFUSIONS IN CRITICALLLY ILL PATIENTS UNDERGOING MECHANICAL VENTILATION Median dura1on of mechanical ven1la1on was 4.9 days in the interven1on group, as compared with 7.3 days in the control group (p=0.004), Median length of stay in the intensive care unit was 6.4 days in the interven1on group, as compared with 9.9 days in the control group (p=0.02). N Engl J Med 2000; 342:1471-7

PAIRED SEDATION AND VENTILATOR WEANING PROTOCOL FOR MECHANICALLY VENTILATED PATIENTS (AWAKENING AND BREATHING CONTROLLED TRIAL) Lancet 2008; 371:126 134

BUNDLE DA VENTILAÇÃO Estratégias genéricas no manejo do doente crí1co Profilaxia da úlcera de stress Profilaxia da trombose venosa profunda Estratégias específicas de prevenção da PAV Posição semi- recumbente Estratégias de diminuição do tempo de ven1lação Suspensão diária da sedação e avaliação da possibilidade de desmame Isto é suficiente?

AVANÇOS NA VENTILAÇÃO MECÂNICA Ven1lação não invasiva Manejo do ARDS e prevenção da VILI Descon1nuação do suporte ven1latório Prevenção da PAV

AVANÇOS NA VENTILAÇÃO MECÂNICA Ven1lação não invasiva

VNI EM DOENTES IMUNODEPRIMIDOS COM IRA Doentes subme1dos a transplante de orgãos Imunodeprimidos com infiltrados pulmonares, febre e insuficiência respiratória hipoxémica JAMA. 2000;283:235 241 N Engl J Med. 2001;344:481 487

VNI NA INSUFICIÊNCIA RESPIRATÓRIA HIPOXÉMICA Am J Respir Crit Care Med 2003;168:438 1444

VNI NO EDEMA AGUDO DO PULMÃO CPAP vs standard treatment CPAP vs standard treatment Bipap vs standard treatment Bipap vs standard treatment END- POINT RELATIVE RISK EFFECT Need for intuba1on 0.44 Favours CPAP Mortality 0.64 Favours CPAP Need for intuba1on 0.54 Favours bilevel Mortality - - - No effect Ann Intern Med. 2010;152:590-600

NIV NA DPOC END- POINT RELATIVE RISK EFFECT NIV vs usual medical care Need for intuba1on 0.42 Favours NIV NIV vs usual medical care Mortality 0.41 Favours NIV BMJ 2003;326:185-187

AVANÇOS NA VENTILAÇÃO MECÂNICA Manejo da ARDS e prevenção da VILI

MANEJO DA ARDS E PREVENÇÃO DA VILI VENTILAÇÃO DE BAIXO VOLUME / PRESSÃO LIMITADA Probabilidade de sobrevivência N Engl J Med 2000;342:1301-8

ARDS VENTILAÇÃO MECÂNICA IntervenAon group TV 6ml/Kg Pplat 30cm Higher PEEP HFOV Prone TV 5-8ml/kg PEEP 2cm>Pflex Control group TV 12ml/Kg Pplat 50cm LowerPEEP Conven1onal ven1la1on No prone TV 9-11ml/kg PEEP 5cm Chest 2007;131;921-929

INJURIOUS MECHANICAL VENTILATION IN THE NORMAL LUNG CAUSES A PROGRESSIVE PATHOLOGIC CHANGE IN DYNAMIC ALVEOLAR MECHANICS. Cri0cal Care 2007, 11:R64

HIGH TIDAL VOLUME INDUCES INFLAMMATION IN PATIENTS WITHOUT LUNG DISEASE Cri0cal Care 2010, 14:R39

AVANÇOS NA VENTILAÇÃO MECÂNICA Descon1nuação do suporte ven1latório

DISCONTINUAÇÃO DO SUPORTE VENTILATÓRIO QUAL A PRESSA? Lesão pulmonar induzida pela ven1lação (VILI) Pneumonia associada à ven1lação Lesão diafragmá1ca induzida pela ven1lação Aumento do tempo de internamento (UCI e hospital) Aumento dos custos

WHY WE FAIL TO LIBERATE A PATIENT FROM THE VENTILATOR Airways/lung Brain Cardiac Diaphragm Endocrin/Metabolic Abnormal respiratory mechanics Impaired gas exchange Delirium Psychological distress Other cogni1ve dysfunc1ons Ischemia Weaning induced pulmonary edema Muscle weakness Ven1lator induced diaphram injury Adrenal insufficiency, hypothyroidism Electrolytes Malnutri1on Cri0cal Care 2010, 14:245

DON T WEAN. LIBERATE! WAKE- UP AND BREATH! Lancet 2008; 371:126 134

PROTOCOLOS? Flexible and adap1ve to the needs of individual pa1ents Can lead to innova1ve changes in prac1ce Equivalent to weaning protocols in ICUs with high staffing levels Promotes educa1on and leads to highly skilled prac11oners Does not require the addi1onal resources needed to design, implement, and sustain weaning protocol use Less biased by human decision- making than physician directed weaning Developed based on best evidence Efficacy and safety supported by numerous clinical inves1ga1ons Can make up for limita1ons in local resources or staff availability Free physicians to perform other du1es in the ICU Facilitate quality monitoring and improvement Enhance communica1on Clin Chest Med 2008; 29:241 52

W AK E U P Spontaneous awakening safety screen Check No muscle relaxants No recent seizures No 24h MI No elevated ICP Spontaneous awakening trial Stop if RR 35 SpO2 < 88% Respiratory distress Spontaneous breathing trial Stop if RR 35 or 8 SpO2 < 88% Respiratory distress Spontaneous breathing safety screen Check No Dopa, no noradren Cough reflex present PaO2/fiO2 > 150 RSBI < 100-105 B R E A T H

AVANÇOS NA VENTILAÇÃO MECÂNICA Prevenção da PAV

PREVENÇÃO DA PAV ProtecAon of the paaent Semirecumbent posi1oning Avoid stress- ulcer prophylaxis Noninvasive ven1la1on Seda1on and weaning protocols Measures targeang microorganisms Hand washing Microbiological surveillance Clorhexidine oral rinse Selec1ve diges1ve decontamina1on IntervenAons targeang invasive devices Pressure endotracheal cuff at 20cmH2O Humidifica1on with head moisture exchangers Closed endotracheal suc1oning Drainage of condensate from ven1lator circuits SubgloŽc drainage No scheduled ven1lator changes Orotracheal and orogastric intuba1on 2008 CCCS 2008 BSAC 2008 SHEA IDSA 2009 ERTF BSAC Bri1sh Society for An1microbial Chemotherapy; CCCS Canadian Cri1cal Care Society; ERTF European Respiratory Task Force; SHEA/IDSA Society for Healthcare Epidemiology of America/Infec1ous Diseases ociety of AmericaS

A EUROPEAN CARE BUNDLE FOR PREVENTION OF VAP Semirecumbent pa1ent posi1oning Seda1on vaca1on and use of a weaning protocol Strict hand hygiene using alcohol Use of noninvasive ven1la1on Oral care with chlorhexidine No ven1latory circuit tube changes unless specifically indicated Appropriately educated and trained staff Cuff pressure control at least every 24 h Enteral feeding Use of heat moisture exchangers Avoidance of stress ulcer prophylaxis Use of sucralfate where stress ulcer prophylaxis is required Unit- specific microbiological surveillance Use of orotracheal tubes Restricted transfusion trigger policy Selec1ve diges1ve tract decontamina1on Intensive Care Med 2010; 36:773 780

A EUROPEAN CARE BUNDLE FOR PREVENTION OF VAP BASED ON MULTI- CRITERIA DECISION ANALYSIS (WEIGHTING AND SCORING MODEL) Ease of implementaaon within a care bundle package Clinical effecaveness against VAP and the likely benefit Strength of clinical evidence concerning the interven1on Consistency of findings from different studies Generalisability to different health care systems and sežngs Volume of clinical evidence suppor1ng the interven1on Coverage in all VAP pa1ents Impact on the health care system as a whole Weight (0-20) 18 16 15 9 9 8 5 3 The twelve mee1ng par1cipants individually scored each VAP interven1on on a 10- point scale Intensive Care Med 2010; 36:773 780

Intensive Care Med 2010; 36:773 780

PREVENÇÃO DA PAV ProtecAon of the paaent Semirecumbent posiaoning Avoid stress- ulcer prophylaxis Noninvasive venalaaon SedaAon and weaning protocols Measures targeang microorganisms Hand washing Microbiological surveillance Clorhexidine oral rinse Selec1ve diges1ve decontamina1on IntervenAons targeang invasive devices Pressure endotracheal cuff at 20cmH2O Humidifica1on with head moisture exchangers Closed endotracheal suc1oning Drainage of condensate from venalator circuits Subgloec drainage 2008 CCCS 2008 BSAC 2008 SHEA IDSA 2009 ERTF No scheduled venalator changes Orotracheal and orogastric intubaaon BSAC Bri1sh Society for An1microbial Chemotherapy; CCCS Canadian Cri1cal Care Society; ERTF European Respiratory Task Force; SHEA/IDSA Society for Healthcare Epidemiology of America/Infec1ous Diseases ociety of AmericaS

CONCLUSÕES É necessária uma verdadeira bundle da ven1lação que reflita o estado da arte na ven1lação mecânica Esta bundle da ven1lação deve incluir: Estratégias para diminuir a necessidade e a duração da ven1lação mecânica invasiva Tenta1va de VNI em doentes seleccionados Suspensão diária da sedação e tenta1va de ven1lação espontânea Estratégia adequada de ven1lação na ARDS e prevenção da VILI Ven1lação de baixo volume e pressão limitada Estratégia actualizada de prevenção da PAV

We do not need mechanical venalaaon any more Lorenzo Del Sorbo, MD; V. Marco Ranieri, MD Prevenção da ocorrência ou agravamento da insuficência respiratória através da iden1ficação e tratamento de mecanismos celulares e moleculares específicos Prevenção da necessidade de ven1lação mecânica invasiva adravés da ins1tuição precoce da VNI no tratamento da insuficiência respiratória Subs1tuição completa da ven1lação mecânica através do desenvolvimento de técnicas extracorporais de oxigenação e ven1lação Oxigenação por membrana extracorporal (ECMO) Remoção extracorporal de CO2 Crit Care Med 2010; 38 (Suppl):555-8

Sistemas minimamente invasivos de remoção extracorporal de dióxido de carbono Anesthesiology 2009; 111:826 835