Draegerwerk Ag & Co. Kgaa · XETR:DRW8
Draegerwerk Ag & Co. Kgaa — Dräger — Dräger Global Webinar Series June 2020
49 slides from Draegerwerk Ag & Co. Kgaa's conference presentation, June 2020
Slide 1: Different phenotypes and ventilation approaches in COVID-19 patients
Different phenotypes and ventilation approaches in COVID-19 patients Luigi Camporota Guy’s & St Thomas’ NHS Foundation Trust Hospital – London Centre of Human and Applied Physiology – KCL
Slide 2: COVID-19 respiratory failure: can ventilatory strategy contribute to outcome?
COVID-19 respiratory failure: can ventilatory strategy contribute to outcome? ~20% ~70% Hospitalised Patients Critically Ill patients “ARDS” (..-like) IMV 21% 89.9% ICU Mortality 16% 62%
Slide 3: Outcomes COVID-19 respiratory failure
Outcomes COVID-19 respiratory failure Study Ventilated PaO2/FiO2 Mortality Still in ICU (Completed Episodes) Schenck et al, Ann ATS 2020 267 103 mmHg 39% 141 (52.8%) Auld et al, CCM 2020 165 132 mmHg 37.6% 8 (4.8%) Grasselli et al, JAMA 2020 1581 160 mmHg 61.3% 920 (58.2%) Richardson, JAMA 2020 320
Slide 4: Effect of time of reporting on outcome
Effect of time of reporting on outcome In ICU Discharged Alive Died
Slide 5: Respiratory Support for COVID-19
Respiratory Support for COVID-19 Study IMV Prone Position ECMO China 42% 11.5% 11.5% Italy 99% 27% 1% China 29% 0% China 21% 0% China 37.6% 26% 6.4% USA 89% 47% 0% USA 90% USA 78% 39% -
Slide 6: ARDS: traditional model
ARDS: traditional model 1st Hit (Known Insult) Increased Permeability Lung Oedema 2nd Hit Increased Lung Weight VILI PEEP/ RM Amplification of forces Lung Collapse (Atelectasis) Increase Dynamic Strain Hypoxaemia Hypercapnia (Shunt) (Dead Space + Shunt) Smaller Ventilatable Lung “Low (decreased FRC)
Slide 7: COVID-19: atypical characteristics
COVID-19: atypical characteristics • Onset of respiratory failure 8-15 days from Insult • Dissociation between: • Radiology and symptoms – Radiological Injury can precede symptoms (i.e., diffuse CT abnormalities with mild clinical symptoms) • Degree of hypoxaemia and dyspnoea • Degree of hypoxaemia
Slide 8: n=81 (Wuhan – China)
n=81 (Wuhan – China) Group 1 Group 2 Group 3 Group 4 Subclinical (CT ≤1week (CT >1week (CT >2-3 weeks (CT – Pre symptoms) after symptoms onset) after symptoms onset) after symptoms onset) Unilateral Bilateral Multifocal Diffuse Consolidation Ground-Glass Shi et al Lancet Infect Dis 2020; 20: 425–34
Slide 9: Vascular Pulmonary abnormalities in COVID-19
Vascular Pulmonary abnormalities in COVID-19 sudden reduction calibre at the Vascular Dilatation centre of a new pulmonary lesion F. Albarello et al. / International Journal of Infectious Diseases 93 (2020) 192–197
Slide 10: Vascular Pulmonary abnormalities in COVID-19
Vascular Pulmonary abnormalities in COVID-19 T Min Lang et al he Lancet Infectious Diseases DOI: (10.1016/S1473-3099(20)30367-4)
Slide 11: Gas exchange and lung pathology: COVID-19 vs ARDS (H1N1)
Gas exchange an lung pathology: COVID-19 Vs ARDS (H1N1) There were three distinctive angiocentric features of COVID-19: 1. Severe endothelial injury associated with intracellular SARS-CoV-2 virus and disrupted endothelial cell membranes. 2. Widespread vascular thrombosis with microangiopathy and occ
Slide 12: Vascular Thrombosis
Vascular Thrombosis Small sized arterioles intra-septal micro vessel Medium sized arteries Marini JJ, Gattinoni L. JAMA.doi:10.1001/jama.2020.6825
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Slide 14: Thrombosis Bleeding GSTT
Thrombosis Bleeding GSTT COVID-19 Non- COVID-19 PRE-ECMO • DVT 33% 6.7% • PE 29% 10% • PE and/or Infarction 45% - • SAH 25.8% 14.2%
Slide 15: CT scan Patterns
CT scan Patterns
Slide 16: Lung weight and shunt in ARDS and COVID-19
Lung weight and shunt in ARDS and COVID- 19 2000 - 45 1828 40% 3000 - COVID-19 2404 H1N1 1556 Lung Weight (g) Controls Lung Weight (g) 1371 29% 2000 - Shunt (%) 30 1681 1000 - 21% 1045 1000 - 15 500 - 500 - 0 - 0 0 - Mild Moderate Severe ARDS Task Force – JAMA , 2012 Ackermann et al – NEJM 2020,
Slide 17: Phenotype L / Phenotype H
Phenotype L Phenotype H L. Gattinoni, D. Chiumello, P. Caironi, M. Busana, F. Romitti, L. Brazzi, L. Camporota – ICM 2020
Slide 18: Phenotype L / Phenotype H
Hypoxaemia Dysregulation of Pulmonary Oedema Pulmonary perfusion Collapse – “ARDS-like” • Low Elastance • High lung compliance • Low V/Q Pulmonary • Higher Recruitability • Low recruitability Micro-Thrombosis • High RàL shunt/Deadspace • Low “PEEP response” • Higher “PEEP response” Phenotype L Time
Slide 19: “Phenotypes” in COVID-19: “Time x Treatment”
“Phenotypes” in COVID-19: “Time x Treatment” 45% 75% Consolidated tissue 55% <25% Consolidated tissue Lieuwe D.J. Bos et al Annals ATS 2020
Slide 20: Phenotype screening and definition
Assessment of “shunt fraction” Severity of hypoxaemia Assessment of “Risk of P-SILI” Phenotype Screening “Strain” Phenotype Definition: Differential Treatment Phenotype L and H Failure & Escalation
Slide 21: HFNC, NIV, CPAP...intubate?
HFNC, NIV, CPAP...intubate?
Slide 22: Considerations – Infection Control, Support Required, Duration, Resources
Considerations 1 – Infection Control 2 - Support Required 3- Duration of Disease WOB Failure rate Hypoxaemia Tolerance Control of TPP 4- Resources ICU beds Staffing Ventilators Oxygen
Slide 23: NIV in ARDS
NIV in ARDS 1.0 Intubation 0.8 OR 2.60 (1.36 – 4.96) Survival Probability 0.6 NIV vs 0.4 Invasive Invasive HFNC NIV NIV Mortality OR 2.33 0.2 PaO2/FiO2 < 20 kPa PaO2/FiO2 > 20 > kPa (1.22 – 4.47) 0.0 0 5 10 15 20 25 0 5 10 15 20 25 Bellani et al ; AJRCCM, 2017 Frat et al, NEJM, 2015
Slide 24: “De novo” respiratory failure has greater risk of NIV failure
“de novo” respiratory failure has greater risk of NIV failure P=0.014 250 200 Hours 150 P=0.68 100 50 46% 26% NIV Failure NIV Failure 0 Alive Dead Alive Dead De Novo Previous Cardiac respiratory Failure or respiratory Failure Carrillo et al ICM - 2002
Slide 25: High tidal volumes during NIV might lead to VILI
High tidal volumes during NIV might lead to VILI Carteaux et al ; Crit Care Med 2016 Frat et al ; Lancet Resp Med 2016
Slide 26: Association of hospital NIV for Strong Evidence Conditions and NIV failure rates
Association of hospital NIV for Strong Evidence Conditions (SEC) and NIV failure rates Use of NIV outside SEC = More NIV failures A.B. Mehta et al Ann Am Thorac Soc Vol 14, No 11, pp 1667–1673, Nov 2017
Slide 27: Late intubations have worse outcome
Late intubations have worse outcome intubated intubated < 48h of HFNC > 48h of HFNC (74.3%) (25.7%) ICU Mortality 39.2% 66.7% OR 0.34 (0.13 – 0.98) In-ICU Cardiac 31.1% P< 0.001 Dysfunction 10.8% OR 0.6 Ventilator (0.43 – 0.94) Free days Kang et al; Intensive Care Med (2015) 41:623–632
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Slide 29: Awake prone-position in COVID-19
Awake prone-position in COVID-19 • N=24 • 63% able to tolerate PP > 3 hours • Oxygenation increased during PP in only 25% of patients • Not sustained in 50% post supination Elharrar et al JAMA 2020
Slide 30: Using NIV in Prone Position Outside the ICU
Using NIV in Prone Position Outside the ICU N=15 • Later application • Patients were not included if NIV failed while in the prone position • Unclear effect on intubation Sartini et al – JAMA 2020
Slide 31: Pleural Pressure swings and spontaneous breathing
Pleural Pressure swings and spontaneous breathing > 15 cmH2O = excessive WOB Poes Poes
Slide 32: Inspiratory effort NIV failure and radiological changes
Inspiratory effort NIV failure and radiological changes Tonelli eta al AJRCCM 2020 10.1164/rccm.201912-2512OC DPoes DPoes DPoes 34 cmH2O 31.5 cmH2O 11 cmH2O 1 2 3 4
Slide 33: Spontaneous Breathing: Lung injury Phenotype transitioning
Spontaneous Breathing: Lung injury Phenotype transitioning Lung Oedema Impaired Gas Exchange (fibrin) Lung Elastance Lung Injury Increased Capillary Leak Respiratory Drive P-SILI Increased Poes Swings Increased PTr VT during NIV Modified from Brochard Pesenti AJRCCM
Slide 34: Spontaneous Breathing – Severity and VILI
Spontaneous Breathing – Severity and VILI Takeshi Yoshida, et al – CCM 2013 Mild Injury - SB Mild Injury + SB Severe Injury - SB Severe Injury + SB
Slide 35: Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure
Mechanical Ventilation to Minimize Progression of Lung Injury in Acute Respiratory Failure Laurent Brochard", Arthur Slutsky’, and Antonio Pesenti?:* ‘Keenan Research Centre for Biomedical Science of St. Michael’s Hospital, Toronto, Ontario, Canada; “Interdepartmental Division of Critical Care Medic
Slide 36: Intubation and Ventilation amid the COVID-19 Outbreak: Wuhan’s Experience
ANESTHESIOLOGY Intubation and Ventilation amid the COVID-19 Outbreak Wuhan’s Experience ingzhong Meng, M.D., Haibo Qiu, M.D., Li Wan, M.D. Yuhang Ai anggal D. Qulian Guo, M.D. shpande, M.D. Lina Zhang, M.D., Ph.D., Jie Meng, M.O., Ph.O. Chuanyao Tong, M.D., Hong Liu, M.D. ize Xiong, M.D., Ph.D. Awes
Slide 37: Management of critically ill patients with COVID-19 in ICU
tpsrssrgto nase axbo09t Annals of Intensive Care REVIEW ‘Open Access Management of critically ill patients 2 with COVID-19 in ICU: statement from front-line intensive care experts in Wuhan, China 3nghona Yang?, Min Xia Zheng!” Ling Sang _—— PiO,/FiO, < 150 mmHg Endotracheal intubation Lung protectiv
Slide 38: Management of Respiratory Failure (COVID-19): Intubation
Management of Respiratory Failure (COVID-19): Intubation Phenotype Screening “Strain”
Slide 39: Problem 2: Benefit only for large differences in Vt
Problem 2: Benefit only for large differences in Vt N=116; 7.1 vs 10.3 ml/Kg PBW Brochard Mortality Stewart 46.6% (LTV) vs 37.9% (TTV) 0.25 - Brower Sun Log OR Death East 0.00 - PReVENT N=120; 7.2 vs 10.8 ml/Kg PBW Mortality -0.25 – 50% (LTV) vs 47%(TTV) ARDSNet More Hypercapnia (52% vs 28%) N=961;
Slide 40: Driving pressure but not VT was associated to Outcomes in ARDS
Driving pressure but not VT was associated to Outcomes in ARDS N= 1745 Pplat < 30 cmH2O Vt < 7 mL/Kg PBW M. Amato; N Engl J Med 2015; 372:747-755
Slide 41: Management of Respiratory Failure (COVID-19)
Management of Respiratory Failure (COVID-19): Phenotypes Identification More liberal tidal volumes Lower tidal Lower tidal volumes are unnecessary As per “ARDS” strategies. Higher PEEP is ineffective, creates dead space, PEEP response variable affects blood flow (think vascular dilation/ thrombi) PE
Slide 42: Potential for Lung recruitment and ventilation/Perfusion mismatch in COVID-19
Potential for Lung recruitment and ventilation/Perfusion mismatch in COVID-19 Mauri et al., Crit Care Med 2020 Shunt Fraction (%Pixel) 13% (7-14) Dead Space Fraction (%Pixel) 22% (19-31) Recruitment/Inflation Ratio 0.79 (0.16 – 1.4) AJRCCM 2020 Dead Space to Shunt Ratio AJRCCM - October 1, 2019 2.3
Slide 43: Low recruitability: effect of proning
Low recruitability : effect of proning 83% poorly recruitable R/I 0.21 ±0.14 Not-Proned Proned C. Pan et al AJRRCM 2020
Slide 44: Intraluminal connective tissue, organising pneumonia
Intraluminal connective tissue Bronchiolitis obliterans • Acute fibrinous organising pneumonia (AFOP) Organising • Microthrombi Pneumonia • Intra-alveolar fibrin Fibrin Balls • Fibrin-rich pneumonitis
Slide 45: Prevalent Mechanism Of Hypoxaemia
PaO2/FiO2 ≤ 20 kPa Compliance ≥ 40 ml/cmH2O Prevalent Mechanism Of Hypoxaemia Excessive Pulmonary Vasodilation Excessive Pulmonary Vaso-constriction (shunt) (dead space) Hypoxaemia with: Hypoxaemia with: • Lower Dead space indices • Higher Dead space indices Improvement after iNO test (20 ppm for 1-
Slide 46: Management of Respiratory Failure (COVID-19): Failure & Escalation
Management of Respiratory Failure (COVID-19): Failure & Escalation
Slide 47: Summary
Summary Prone Position Low PEEP Higher PEEP Low PEEP More Liberal VT Low VT Low VT “Fixed” Dead-Space Heparin (Immuno-Thrombosis) Dynamic Vaso-Contriction (Dead-Space) iNO/Iloprost Vasodilation (Shunt) Normal Lung Reduced Lung Volumes Volumes Low oedema Higher oedema Low oedema (OP / Fibrosis) (non
Slide 48: Points
Points 1. Patients with COVID-19 acute hypoxemic respiratory failure (AHRF) often present with: • Profound hypoxemia • Unusually good compliance • Preserved lung gas volume on CT chest imaging • Substantial increases of respiratory drive. 2. The excessive drive may amplify the risk of lung damage th
Slide 49: Luigi.Camporota@gstt.nhs.uk
The role of high-flow oxygen therapy in acute respiratory failure Luigi.Camporota@gstt.nhs.uk