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Intensive Care Medicine

, Volume 39, Issue 3, pp 463–471 | Cite as

Evaluation of fully automated ventilation: a randomized controlled study in post-cardiac surgery patients

  • François Lellouche
  • Pierre-Alexandre Bouchard
  • Serge Simard
  • Erwan L’Her
  • Marc Wysocki
Original

Abstract

Purpose

Discrepancies between the demand and availability of clinicians to care for mechanically ventilated patients can be anticipated due to an aging population and to increasing severity of illness. The use of closed-loop ventilation provides a potential solution. The aim of the study was to evaluate the safety of a fully automated ventilator.

Methods

We conducted a randomized controlled trial comparing automated ventilation (AV) and protocolized ventilation (PV) in 60 ICU patients after cardiac surgery. In the PV group, tidal volume, respiratory rate, FiO2 and positive end-expiratory pressure (PEEP) were set according to the local hospital protocol based on currently available guidelines. In the AV group, only sex, patient height and a maximum PEEP level of 10 cmH2O were set. The primary endpoint was the duration of ventilation within a “not acceptable” range of tidal volume. Zones of optimal, acceptable and not acceptable ventilation were based on several respiratory parameters and defined a priori.

Results

The patients were assigned equally to each group, 30 to PV and 30 to AV. The percentage of time within the predefined zones of optimal, acceptable and not acceptable ventilation were 12 %, 81 %, and 7 % respectively with PV, and 89.5 %, 10 % and 0.5 % with AV (P < 0.001). There were 148 interventions required during PV compared to only 5 interventions with AV (P < 0.001).

Conclusion

Fully AV was safe in hemodynamically stable patients immediately following cardiac surgery. In addition to a reduction in the number of interventions, the AV system maintained patients within a predefined target range of optimal ventilation.

Keywords

Positive-pressure respiration Randomized trial Closed-loop Thoracic surgery Cardiac surgery Mechanical ventilation 

Notes

Acknowledgments

Dr. Lellouche holds a clinical research scholarship from FRSQ (Fonds de Recherche en Santé du Québec). Hamilton Medical provided a restricted grant of 60,000 Can$ to conduct the study and provided ventilators for the study. The funding agencies had no role in the conduct of the study, in the collection, analysis or interpretation of the data, or in the preparation, review or approval of the manuscript. Marc Wysocki participated to the study design, but data were analyzed independently from Hamilton Medical at IUCPQ Research Center (Serge Simard, biostatistician), and manuscript draft was prepared mainly by François Lellouche.

Conflicts of interest

Dr. Wysocki was head of medical research at Hamilton Medical Company when the study was performed; he is now Medical Director of GE Healthcare.

Supplementary material

134_2012_2799_MOESM1_ESM.docx (136 kb)
Supplementary material 1 (DOCX 135 kb)

References

  1. 1.
    Angus DC, Kelley MA, Schmitz RJ, White A, Popovich J Jr (2000) Caring for the critically ill patient. Current and projected workforce requirements for care of the critically ill and patients with pulmonary disease: can we meet the requirements of an aging population? JAMA 284:2762–2770PubMedCrossRefGoogle Scholar
  2. 2.
    Zilberberg MD, de Wit M, Pirone JR, Shorr AF (2008) Growth in adult prolonged acute mechanical ventilation: implications for healthcare delivery. Crit Care Med 36:1451–1455PubMedCrossRefGoogle Scholar
  3. 3.
    Moerer O, Plock E, Mgbor U, Schmid A, Schneider H, Wischnewsky MB, Burchardi H (2007) A German national prevalence study on the cost of intensive care: an evaluation from 51 intensive care units. Crit Care 11:R69PubMedCrossRefGoogle Scholar
  4. 4.
    Zilberberg MD, Shorr AF (2008) Prolonged acute mechanical ventilation and hospital bed utilization in 2020 in the United States: implications for budgets, plant and personnel planning. BMC Health Serv Res 8:242PubMedCrossRefGoogle Scholar
  5. 5.
    Dasta JF, McLaughlin TP, Mody SH, Piech CT (2005) Daily cost of an intensive care unit day: the contribution of mechanical ventilation. Crit Care Med 33:1266–1271PubMedCrossRefGoogle Scholar
  6. 6.
    Ely EW, Bennett PA, Bowton DL, Murphy SM, Florance AM, Haponik EF (1999) Large scale implementation of a respiratory therapist-driven protocol for ventilator weaning. Am J Respir Crit Care Med 159:439–446PubMedGoogle Scholar
  7. 7.
    Scales DC, Adhikari NK (2008) Lost in (knowledge) translation: “All breakthrough, no follow through”? Crit Care Med 36:1654–1655PubMedCrossRefGoogle Scholar
  8. 8.
    Villar J, Kacmarek RM, Hedenstierna G (2004) From ventilator-induced lung injury to physician-induced lung injury: why the reluctance to use small tidal volumes? Acta Anaesthesiol Scand 48:267–271PubMedCrossRefGoogle Scholar
  9. 9.
    Lellouche F, Bojmehrani A, Burns K (2012) Mechanical ventilation with advanced closed-loop systems: automating knowledge transfer and reducing the supply demand. Eur Respir Mon 55:217–228Google Scholar
  10. 10.
    Laubscher TP, Heinrichs W, Weiler N, Hartmann G, Brunner JX (1994) An adaptive lung ventilation controller. IEEE Trans Biomed Eng 41:51–59PubMedCrossRefGoogle Scholar
  11. 11.
    Otis AB, Fenn WO, Rahn H (1950) Mechanics of breathing in man. J Appl Physiol 2:592–607PubMedGoogle Scholar
  12. 12.
    Lellouche F, Bouchard PA, Wysocki M, Laubscher T, Novotni D, Lopez R, Bruehschwein F, Durish G, L’Her E (2010) Prospective randomized controlled study comparing conventional ventilation versus a fully closed-loop ventilation (Intellivent) in post cardiac surgery ICU patients. Am J Respir Crit Care Med 181:A6035Google Scholar
  13. 13.
    Arnal JM, Wysocki M, Novotni D, Demory D, Lopez R, Donati S, Granier I, Corno G, Durand-Gasselin J (2012) Safety and efficacy of a fully closed-loop control ventilation (IntelliVent-ASV(R)) in sedated ICU patients with acute respiratory failure: a prospective randomized crossover study. Intensive Care Med 38:781–787PubMedCrossRefGoogle Scholar
  14. 14.
    Shapiro BA, Peruzzi WT (2000) Respiratory care. In: Miller RD (ed) Anesthesia. Churchill Livingstone, Philadelphia, pp 2403–2443Google Scholar
  15. 15.
    Wilson WC, Benumof JL (2005) Anesthesia for thoracic surgery. In: Miller RD (ed) Miller’s anesthesia. Churchill Livingstone, Philadelphia, pp 1847–1939Google Scholar
  16. 16.
    Cheng DC, Karski J, Peniston C, Asokumar B, Raveendran G, Carroll J, Nierenberg H, Roger S, Mickle D, Tong J, Zelovitsky J, David T, Sandler A (1996) Morbidity outcome in early versus conventional tracheal extubation after coronary artery bypass grafting: a prospective randomized controlled trial. J Thorac Cardiovasc Surg 112:755–764PubMedCrossRefGoogle Scholar
  17. 17.
    Wysocki M, Arnal JM, Feissel M, L’Her E, Roesler J, Bialais E, Lellouche F (2010) What ventilation and blood gases are “desirable” in adult mechanically ventilated patients. Intensive Care Med 35:S106Google Scholar
  18. 18.
    Lellouche F, Dionne S, Simard S, Bussieres J, Dagenais F (2012) High tidal volumes in mechanically ventilated patients increase organ dysfunction after cardiac surgery. Anesthesiology 116:1072–1082PubMedCrossRefGoogle Scholar
  19. 19.
    Sulemanji D, Marchese A, Garbarini P, Wysocki M, Kacmarek RM (2009) Adaptive support ventilation: an appropriate mechanical ventilation strategy for acute respiratory distress syndrome? Anesthesiology 111:863–870PubMedCrossRefGoogle Scholar
  20. 20.
    Arnal JM, Wysocki M, Nafati C, Donati S, Granier I, Corno G, Durand-Gasselin J (2008) Automatic selection of breathing pattern using adaptive support ventilation. Intensive Care Med 34:75–81PubMedCrossRefGoogle Scholar
  21. 21.
    Sulzer CF, Chiolero R, Chassot PG, Mueller XM, Revelly JP (2001) Adaptive support ventilation for fast tracheal extubation after cardiac surgery: a randomized controlled study. Anesthesiology 95:1339–1345PubMedCrossRefGoogle Scholar
  22. 22.
    Chatburn RL, Mireles-Cabodevila E (2011) Closed-loop control of mechanical ventilation: description and classification of targeting schemes. Respir Care 56:85–102PubMedCrossRefGoogle Scholar
  23. 23.
    Dojat M, Brochard L, Lemaire F, Harf A (1992) A knowledge-based system for assisted ventilation of patients in intensive care units. Int J Clin Monit Comput 9:239–250PubMedCrossRefGoogle Scholar
  24. 24.
    Mireles-Cabodevila E, Hatipoglu U, Chatburn RL (2013) A rational framework for selecting modes of ventilation. Respir Care 58(2):348–366Google Scholar
  25. 25.
    Lellouche F, Mancebo J, Jolliet P, Roeseler J, Schortgen F, Dojat M, Cabello B, Bouadma L, Rodriguez P, Maggiore S, Reynaert M, Mersmann S, Brochard L (2006) A multicenter randomized trial of computer-driven protocolized weaning from mechanical ventilation. Am J Respir Crit Care Med 174:894–900PubMedCrossRefGoogle Scholar
  26. 26.
    Burns KEA, Lellouche F, Lessard M, Hand L, Zhou Q, Keenan SP, Meade M (2011) Wean earlier and automatically with new technology: preliminary results of the wean study. Am J Respir Crit Care Med 183:A6248Google Scholar
  27. 27.
    Rose L, Presneill JJ, Johnston L, Cade JF (2008) A randomised, controlled trial of conventional versus automated weaning from mechanical ventilation using SmartCare/PS. Intensive Care Med 34:1788–1795PubMedCrossRefGoogle Scholar
  28. 28.
    Schädler D, Elke G, Pulletz S, Haake N, Frerichs I, Scholz J, Zick G, Weiler N (2009) The effect of automatic weaning with SmartCare/PS on ventilation time in postsurgical patients – a randomized controlled trial. Am J Respir Crit Care Med 179:A3646Google Scholar
  29. 29.
    Embriaco N, Azoulay E, Barrau K, Kentish N, Pochard F, Loundou A, Papazian L (2007) High level of burnout in intensivists: prevalence and associated factors. Am J Respir Crit Care Med 175:686–692PubMedCrossRefGoogle Scholar
  30. 30.
    Poncet MC, Toullic P, Papazian L, Kentish-Barnes N, Timsit JF, Pochard F, Chevret S, Schlemmer B, Azoulay E (2007) Burnout syndrome in critical care nursing staff. Am J Respir Crit Care Med 175:698–704PubMedCrossRefGoogle Scholar
  31. 31.
    Schultz MJ, Haitsma JJ, Slutsky AS, Gajic O (2007) What tidal volumes should be used in patients without acute lung injury? Anesthesiology 106:1226–1231PubMedCrossRefGoogle Scholar
  32. 32.
    Lellouche F, Lipes J (2013) Prophylactic protective ventilation: lower tidal volumes for all critically ill patients? Intensive Care Med 39(1):6–15. doi: 10.1007/s00134-012-2728-4 PubMedCrossRefGoogle Scholar
  33. 33.
    Wrigge H, Uhlig U, Baumgarten G, Menzenbach J, Zinserling J, Ernst M, Dromann D, Welz A, Uhlig S, Putensen C (2005) Mechanical ventilation strategies and inflammatory responses to cardiac surgery: a prospective randomized clinical trial. Intensive Care Med 31:1379–1387PubMedCrossRefGoogle Scholar
  34. 34.
    Zupancich E, Paparella D, Turani F, Munch C, Rossi A, Massaccesi S, Ranieri VM (2005) Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial. J Thorac Cardiovasc Surg 130:378–383PubMedCrossRefGoogle Scholar
  35. 35.
    Esteban A, Ferguson ND, Meade MO, Frutos-Vivar F, Apezteguia C, Brochard L, Raymondos K, Nin N, Hurtado J, Tomicic V, Gonzalez M, Elizalde J, Nightingale P, Abroug F, Pelosi P, Arabi Y, Moreno R, Jibaja M, D’Empaire G, Sandi F, Matamis D, Montanez AM, Anzueto A (2008) Evolution of mechanical ventilation in response to clinical research. Am J Respir Crit Care Med 177:170–177PubMedCrossRefGoogle Scholar
  36. 36.
    Hubmayr RD (2011) Point: is low tidal volume mechanical ventilation preferred for all patients on ventilation? Yes. Chest 140:9–11PubMedCrossRefGoogle Scholar
  37. 37.
    Dongelmans DA, Veelo DP, Bindels A, Binnekade JM, Koppenol K, Koopmans M, Korevaar JC, Kuiper MA, Schultz MJ (2008) Determinants of tidal volumes with adaptive support ventilation: a multicenter observational study. Anesth Analg 107:932–937PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg and ESICM 2013

Authors and Affiliations

  • François Lellouche
    • 1
  • Pierre-Alexandre Bouchard
    • 1
  • Serge Simard
    • 1
  • Erwan L’Her
    • 2
    • 3
  • Marc Wysocki
    • 4
  1. 1.Centre de recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecUniversité LavalQuebec CityCanada
  2. 2.Hôtel Dieu de LévisQuebec CityCanada
  3. 3.Centre Hospitalier Universitaire La Cavale BlancheBrestFrance
  4. 4.GE Healthcare, Life Care Solution EuropeBucFrance

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