5th World Conference on Pediatric Critical Care

Geneva, Switzerland

The Bundles of Mecha nica l Ventila tion

Dr. Julio Farias
Dr. Ezequiel Monteverde
Servicio de Cuidados Intensivos Pediá tricos
Hospital de Niños “Dr R Gutié rrez”
Buenos Aires, Argentina
 The problem:

No clea r definition
Heterogeneity in informa tion
Low qua lity informa tion
Not much da ta a bout pedia trics
 The Bundle Concept

A "bundle" is a group of interventions rela ted to a

disea se process tha t, when executed together,
result in better outcomes tha n when implemented
individua lly.

Resar R et al. Using a bundle approach to improve ventilator

care processes and reduce ventilator associated pneumonia.
Jt Comm J Qual Patient Saf. 2005;31:243-248.
 The Bundle Concept

A "bundle" is a group of interventions rela ted to a

disea se process tha t, when executed together,
result in better outcomes tha n when implemented
individua lly.

Resar R et al. Using a bundle approach to improve ventilator

care processes and reduce ventilator associated pneumonia.
Jt Comm J Qual Patient Saf. 2005;31:243-248.
 The Bundle Concept

A group of evidence ba sed trea tments rela ted to a

disea se process, instituted together over a specific
time fra me a nd termed 'a ca re bundle ', is a nticipa ted
to result in better outcomes tha n when they a re
executed individua lly.

Gao F et al. The impact of compliance with 6-hour and 24-hour

sepsis bundles on hospital mortality in patients with severe sepsis:
a prospective observational study. Crit Care 2005;9(6):R764-70
 The problem with pedia tric bundles

Much of current clinica l pra ctice in the

pedia tric ICU is ba sed on a necdota l
experience combined with
extra pola tion from a dult da ta .
 The MV Bundle Contents
Prevent Lung Low TV/ low pla tea u pressure
Ventila tor protective
PEEP
Induced Lung ventila tion
Injury (VILI) stra tegies Daily “vacation” from sedation

Prevent Hea d over the bed

Ventila tor Ga stric ulcer prophyla xis
Associa ted
Pneumonia Deep venous thrombosis prophyla xis
(VAP) Da ily “va ca tion” from seda tion

Wea ning Sponta neous brea thing test

The Funda menta ls of Lung Protective Ventila tion

Low tida l volume ventila tion

Prevention of volutra uma
+ Injured lung is not homogeneous
+ A norma l TV would go prima rily
to healthier regions
+ Regional overinflation

Prevention of a telectra uma

+ Affects recruitable alveoli
+ Recruitment- derecruitment
+ Disruption of the surfa cta nt monola yer
+ Requirement of higher pressures
 The Funda menta ls of Lung Protective Ventila tion

Tidal volume Mortality % p - value

Low TV Control Low TV Control

Amato et al
N Engl J Med 1998 6.1± 0.2 11.9± 0.5 38 71 < 0.001
347- 54
Stewart et al
N Engl J Med 1998 7.2 ± 0.8 10.6± 0.2 50 47 0.38
355 – 61
Brochard et al
AJRCCM 1998 7.2 ± 0.2 10.4± 0.2 47 38 0.60
1831 – 38
ARDS Network
N Engl J Med 2000 6.3 ± 0.1 11.7± 0.1 31 40 0.007
1301- 8
Villar et al
Crit Care Med 2006 7.1 ± 0.1 10 ± 0.2 32 53 0.04
1311- 8
 The Funda menta ls of Lung Protective Ventila tion

Tidal volume Mortality % p - value

Low TV Control Low TV Control

Stewart et al
N Engl J Med 1998 7.2 ± 0.8 10.6± 0.2 50 47 0.38
355 – 61
Brochard et al
AJRCCM 1998 7.2 ± 0.2 10.4± 0.2 47 38 0.60
1831 – 38
Amato et al
6.1± 0.2 11.9± 0.5 38 71 < 0. 001
N Engl J Med 1998
347- 54
ARDS Network
N Engl J Med 2000 6.3 ± 0.1 11.7± 0.1 31 40 0.007
1301- 8
Villar et al
Crit Care Med 2006 7.1 ± 0.1 10 ± 0.2 32 53 0.04
1311- 8
The Funda menta ls of Lung Protective Ventila tion

Tidal volume Mortality % p - value

Low TV Control Low TV Control

Stewart et al
N Engl J Med 1998 7.2 ± 0.8 10.6± 0.2 50 47 0.38
355 - 61
Brochard et al
AJ RCCM 1998 7.2 ± 0.2 10.4± 0.2 47 38 0.60
1831 - 38
Prevention of VILI: pressure or volume

Eichacker PQ. Am J Respir Crit Care Med. 2002;166:1510-4

Pressure or volume?

+ Ma ximum tra nsa lveola r pressure (a nd/ or tida l pressure

excursion) is the prima ry genera tor of da ma ging tissue
stra ins—not tida l volume per se .

+ Tra nsa lveola r pressure is a function of tida l volume in

rela tion to specific complia nce.

+ Although subject to chest wa ll complia nce, the

tra nsa lveola r pressure is strongly correla ted to end -
inspira tory pla tea u pressure

Marini JJ. Crit Care Med 2006;34:1540-2

Pressure or volume?

Age Range

0-2 yr 0-5 yr 0-18 yr

Crs, st 2.60 ± 0.6 2.02 ± 0.4 1.76 ± 0.2

Crs, dyn 3.06 ± 0.5 2.31 ± 0.3 2.06 ± 0.4

51 patients from 3 wk to 15 yr studied while under anesthesia –using

nitrous oxide and alcuronium– for urological surgery or repair of
inguinal hernias.

Lanteri CJ. J Appl Physiol 1993;74:369-378

Applica tion of PEEP

Day 1 Day 4 Day 6

Patients Overall ARDS Overall Overall ARDS
with PEEP
n 549 15 255 153 12

(%) 83% (95%) (75%) (80%) (91%)

Applied
PEEP 4 (2,5) 8 (5,10) 4 (3,5) 4 (3,5) 5 (4,9)

Farias JA a nd IGMVC; Intensive Ca re Med 2004 30:918–925

Applica tion of PEEP

How much PEEP is correct?

How much PEEP?
How much PEEP?
Da ily discontinua tion of seda tives

Protocol

+ Da ily interruption of the infusion of seda tives a nd a na lgesics

until the pa tients were a wa ke a nd could follow instructions
or until they beca me uncomforta ble or a gita ted a nd were
deemed to require the resumption of sedation.
+ Each day, the team assessed each patient's mental status
with respect to wakefulness.
+ The prima ry end points of the study were the dura tion of
mechanical ventilation, the length of stay in the intensive
ca re unit, a nd the length of sta y in the hospita l

Kress JP et al. Daily interruption of sedative infusions in

critically ill patients undergoing mechanical ventilation
NEJM 2000;342:1471-7
Da ily discontinua tion of seda tives

Results

+ The median duration of MV was

4.9 days in the intervention group,
as compared with 7.3 days in the
control group (p=0.004)
+ The median length of stay in the
intensive care unit was 6.4 days
as compared with 9.9 days,
respectively (p=0.02).
+ There were no differences in the rates of complications ( e.g.,
removal of the endotracheal tube by the patient) between both
groups m(p=0.88).

Kress JP et al. Daily interruption of sedative infusions in

critically ill patients undergoing mechanical ventilation
NEJM 2000;342:1471-7
Ventila tor bundle

The key components of the Ventila tor Bundle a re:

+ Eleva tion of the Hea d of the Bed

+ Da ily "Seda tion Va ca tions" a nd Assessment of
Rea diness to Extuba te
+ Peptic Ulcer Disea se Prophyla xis
+ Deep Venous Thrombosis Prophyla xis

Resar R et al. Using a bundle approach to improve ventilator care

processes and reduce ventilator associated pneumonia. Jt Comm
J Qual Patient Saf. 2005;31:243-248.
Ventila tor bundle
Semirecumbent Supine p
group group value
Rate of clinically 3/39 [8%] 16/47 [34%] 0.003
suspected NP
The key components
Rate of microbiologically
of the Ventila
2/39 [5%]
tor Bundle a re:
11/47 [23%] 0.018
confirmed NP
+ body
Supine Eleva tion
position andof thenutrition
enteral Hea dwere ofindependent
the Bedrisk
factors for nosocomial pneumonia and the frequency was
+ for
highest Da ily "Seda
patients tion
receiving Va
enteral ca tions"
nutrition a ndbody
in the supine Assessment of
Rea diness
position (14/28, 50%). to Extuba te
Drakulovic MB. Lancet 1999;354:1851-8
+ Peptic Ulcer Disea se Prophyla xis
+ Deep Venous Thrombosis Prophyla xis

Resar R et al. Using a bundle approach to improve ventilator care

processes and reduce ventilator associated pneumonia. Jt Comm
J Qual Patient Saf. 2005;31:243-248.
Ventila tor bundle Intervention p
Control group
group value
Semirecumbent Supine p
Duration
group of MV group 4.9 (2.5-8.6)
value 7.3 (3.4-16.1) 0.004
Rate of clinically Length
3/39 [8%]
of stay (days)
16/47 [34%] 0.003
suspected NP ICU 6.4 [3.9-12.0] 9.9 [4.7-17.9] 0.02
The key components
Rate of microbiologically 2/39
of
[5%]
the Ventila
Hospital tor
11/47 [23%]13.3
Bundle16.9
[7.3-20.0]
0.018
a re:
[8.5-26.6] 0.19
confirmed NP Kress JP et al. N Eng J Med 2000;342:1471-7
+ body
Supine Eleva tion
position andof thenutrition
enteral Hea dwere ofindependent
the Bedrisk
factors for nosocomial pneumonia and the frequency was
+ for
highest Da ily "Seda
patients tion
receiving Va
enteral ca tions"
nutrition a ndbody
in the supine Assessment of
Rea diness
position (14/28, 50%). to Extuba te
Drakulovic MB. Lancet 1999;354:1851-8
+ Peptic Ulcer Disea se Prophyla xis
+ Deep Venous Thrombosis Prophyla xis

Resar R et al. Using a bundle approach to improve ventilator care

processes and reduce ventilator associated pneumonia. Jt Comm
J Qual Patient Saf. 2005;31:243-248.
Ventila tor bundle Intervention p
Control group
group value
Semirecumbent Supine p
Duration
group of MV group 4.9 (2.5-8.6)
value 7.3 (3.4-16.1) 0.004
Rate of clinically Length
3/39 [8%]
of stay (days)
16/47 [34%] 0.003
suspected NP ICU 6.4 [3.9-12.0] 9.9 [4.7-17.9] 0.02
The key components
Rate of microbiologically
of
Hospital
2/39 [5%]
the Ventila tor
11/47 [23%]13.3
Bundle16.9
[7.3-20.0]
0.018
a re:
[8.5-26.6] 0.19
confirmed NP Kress JP et al. N Eng J Med 2000;342:1471-7
+ body
Eleva tion Borrero
theE,nutrition
Bank S, MargolistheI, etBed
al: Comparison of antacid and
Supine position andof
enteral Hea dwere
ofindependent risk
sucralfate in the prevention of gastrointestinal bleeding in patients
factors for nosocomial pneumonia and the frequency was
+ for
highest Da ily "Seda
patients
whotion
receiving Va caill.tions"
are critically
enteral nutrition
Am J Med a 1985;79:62–64
ndbody
in the supine Assessment of
Rea diness
position (14/28, 50%). to Extuba te
Bresalier RS, Grendell JH, Cello JP, et al: Sucralfate versus titrated
Drakulovic MB. Lancet 1999;354:1851-8
antacid for the prevention of acute stress-related gastrointestinal
+ Peptic Ulcer Disea se Prophyla xis
hemorrhage in critically ill patients. Am J Med 1987; 83:110–116
+ Deep Venous Thrombosis Prophyla xis
Cook D, Guyatt G, Marshall J, et al: A comparison of sucralfate and
ranitidine for the prevention of upper gastrointestinal bleeding in
patients requiring mechanical ventilation. Canadian Critical Care
Trials Group. N Engl J Med 1998; 338:791–797
Resar R et al. Using a bundle approach to improve ventilator care
processes and reduce ventilator associated pneumonia. Jt Comm
J Qual Patient Saf. 2005;31:243-248.
Ventila tor bundle Intervention p
Control group
group value
Semirecumbent Supine p
Duration
group of MV group 4.9 (2.5-8.6)
value 7.3 (3.4-16.1) 0.004
Rate of clinically Length
3/39 [8%]
of stay (days)
16/47 [34%] 0.003
suspected NP ICU 6.4 [3.9-12.0] 9.9 [4.7-17.9] 0.02
The key components
Rate of microbiologically
of
Hospital
2/39 [5%]
the Ventila tor
11/47 [23%]13.3
Bundle16.9
[7.3-20.0]
0.018
a re:
[8.5-26.6] 0.19
confirmed NP Kress JP et al. N Eng J Med 2000;342:1471-7
+ body
Eleva tion Borrero
theE,nutrition
Bank S, MargolistheI, etBed
al: Comparison of antacid and
Supine position andof
enteral Hea dwere
ofindependent risk
sucralfate in the prevention of gastrointestinal bleeding in patients
factors for nosocomial pneumonia and the frequency was
+ for
highest Da ily "Seda
patients
whotion
receiving Va caill.tions"
are critically
enteral nutrition
Am J Med a 1985;79:62–64
ndbody
in the supine Assessment of
Rea diness
position (14/28, 50%). to Extuba te
Bresalier RS, Grendell JH, Cello JP, et al: Sucralfate versus titrated
Drakulovic MB. Lancet 1999;354:1851-8
antacid for the prevention of acute stress-related gastrointestinal
+ Peptic Ulcer Disea se Prophyla xis
hemorrhage in critically ill patients. Am J Med 1987; 83:110–116
+ Deep Venous Thrombosis Prophyla xis
Cook D, Guyatt G, Marshall J, et al: A comparison of sucralfate and
ranitidine for the prevention of upper gastrointestinal bleeding in
patients requiring mechanical ventilation. Canadian Critical Care
Trials Group. N Engl J Med 1998; 338:791–797
Resar R et al. Using a bundle approach to improve ventilator care
processes and reduce ventilator associated pneumonia. Jt Comm
J Qual Patient Saf. 2005;31:243-248.
Other bundles

1 Eleva tion of the hea d of the bed (HOB) to 30º

to 45º unless medica lly contra indica ted,

2 Continuous remova l of subglottic secretions,

3 Cha nge of ventila tor circuit no more often tha n

every 48 hours, a nd

4 Wa shing of ha nds before a nd a fter conta ct

with ea ch pa tient.

Arlene F et al. Am J Crit Care. 2007;16(1):20-7

Other bundles

1 Eleva tion of the hea d of the bed (HOB) to 30º

to 45º unless medica lly contra indica ted,

2 Continuous remova l of subglottic secretions,

3 Cha nge of ventila tor circuit no more often tha n

every 48 hours, a nd

4 Wa shing of ha nds before a nd a fter conta ct

with ea ch pa tient.

Arlene F et al. Am J Crit Care. 2007;16(1):20-7

Other bundles

1 Eleva tion of the hea d of the bed (HOB) to 30º

to 45º unless medica lly contra indica ted,

2 Continuous remova l of subglottic secretions,

3 Cha nge of ventila tor circuit no more often tha n

every 48 hours, a nd

4 Wa shing of ha nds before a nd a fter conta ct

with ea ch pa tient.

Arlene F et al. Am J Crit Care. 2007;16(1):20-7

Other bundles

1 Eleva tion of the hea d of the bed (HOB) to 30º

to 45º unless medica lly contra indica ted,

2 Continuous remova l of subglottic secretions,

3 Cha nge of ventila tor circuit no more often tha n

every 48 hours, a nd

4 Wa shing of ha nds before a nd a fter conta ct

with ea ch pa tient.

Arlene F et al. Am J Crit Care. 2007;16(1):20-7

In Pedia trics …

+ Change ventilator circuits only when soiled

+ Drain circuit condensate every 2-4 hours
+ Store oral suction devices in non-sealed
plastic bags at bedside
+ Mouth care every 4 hours
+ Elevate head of bed
+ Drain ventilator circuit before moving patient

Chest 2006; 130: 138S-139S

In Pedia trics …

Pre-bundle Post-bundle p

Mean VAP rate 6.6/1000 vent days 0.5/1000 vent days <0.05

VAP incidence 39/1076 (3.6%) 1/409 (2.4%)

Chest 2006; 130: 138S-139S

Libera tion from mecha nica l ventila tion

When to initia te?

MacIntyre NR. Chest 2001;120:375S-396S

Libera tion from mecha nica l ventila tion
Ca n the pa tient susta in sponta neous brea thing?

n SE EF TF
Farias JA; et al.
84 89 % 16 % 10 %
Int Care Med 1998:1070- 5
Farias JA; et al.
418 77 % 14 % 23 %
Int Care Med 2002:752- 7

Randolph; A et al.
313 42 % 11% 58 %
JAMA 2002: 2561- 8

Noizet O; et al. 54
80 % 20 % 3%
Crit Care Med 2005, 798- 7 (57)
Chavez A; et al.
70 91 % 7.8 % 9%
PCCM 2006. 324- 328
Libera tion from mecha nica l ventila tion
Sponta neous brea thing tria l in children

+ Multicenter, prospective, RCT

including 257 infa nts a nd
children who received MV a t
lea st for 48h a nd were
considered a ble to undergo a
SBT by their prima ry physicia n

+ Pa tients were ra ndomly a ssigned

to perform a SBT in one of two
wa ys: PSV of 10 cmH2O or T-
piece.

Farias JA et al. Intensive Care Med 2001; 27:1649- 54

Libera tion from mecha nica l ventila tion
Sponta neous brea thing tria l in children
Reintubated
Reconnected Extubated
within 48h
Pressure
26 (21%) 99 (79%) 15 (15%)
support (n=125)

T-piece (n=132) 30 (23%) 102 (77%) 13 (13%)

Pressure support T-piece

p
(n=125) (n=132)
Patients that remain
67.2 67.4 0.97
extubated 48 h after SBT
Reintubation rate 15.1 12.7 0.62

Trial failure rate 20.8 22.7 0.81

Farias JA et al. Intensive Care Med 2001; 27:1649-54

Libera tion from mecha nica l ventila tion
Sponta neous brea thing tria l in children

As in a dults , successful extuba tion ca n be

a chieved in most children a fter the first
brea thing tria l, performed either with pressure
support of 10 cmH2O or a T- piece.

Farias JA et al. Intensive Care Med 2001; 27:1649-54

 The Bundles of Mecha nica l Ventila tion

Prevent Lung Low TV/low plateau pressure

Ventila tor protective PEEP
Induced Lung ventila tion
Injury (VILI) stra tegies Daily “vacation” from sedation

Prevent Hea d over the bed

Ventila tor Ga stric ulcer prophyla xis
Associa ted +
+
Change ventilator circuits only when soiled
Drain circuit condensate every 2- 4 hours
Pneumonia Deep venous thrombosis prophyla xis
+ Store oral suction devices in non-
non- sealed
plastic bags at bedside
(VAP) +
Da
+
Mouth care every 4 hours
ily “va ca tion” from seda tion
Elevate head of bed
+ Drain ventilator circuit before moving patient

Wea ning Sponta neous brea thing test