Presented by Dr.J.M.Arnal

1. Dr Jean-Michel Arnal Intensive Care Unit. Hôpital Font Pré Toulon France [email_address] Close loop ventilation in the ICU

5. Positive close loop control C ontroller  = i’ x i Valves Signal: Flow= i’ Gain = i P insp Unstable Add complexity Act as auxiliary respiratory muscle Intrabreath

6. Negative close loop control C ontroller  = i– i’ Valves Signal: V T actual = i’ V T Target = i P insp Target can be achieved Fast response Adapts to external modifications Interbreath

7. Determination of the target C ontroller  = i– i’ Valves Signal: V T actual = i’ V T Target = i P insp Operator set Automatically determined

12. Commercially available solutions Controlled mode Assisted mode Spont mode PAV NAVA SmartCare Adaptive Support Ventilation IntelliVent®

15. Improve patient ventilator synchrony Terzi. Crit Care Med 2010 n = 11

16. Increase variability of ventilation Coizel. Anesthesiology 2010 n = 12 n = 12 Schmidt. Anesthesiology 2010

18. Decreases weaning duration Lellouche. AJRCCM 2006 n = 144 patients, ventilation > 24 h

19. SmartCare n = 102 Rose. Intensive Care Med 2008 Weaning success: Control: 40 h (14 – 87) Smartcare: 43 h (6 – 169)

20. Adaptive Support Ventilation Ventilation Oxygenation Conventional ventilation ASV MV V T RR FiO 2 PEEP MV V T RR FiO 2 PEEP

21. Background The optimal respiratory rate 0.16 0.14 0.12 0.10 0.08 0.06 0.04 0.02 0 0 10 20 30 40 50 WOB res WOB el WOB tot 1+2a* RCe *( VM -f*( V‘D/VD )) - 1 f -target = a* RCe Respiratory rate (cycle/mn) WOB (Joule/sec) Otis AB.J Appl Physiol 1950

23. Ventilation delivered * p ≤ 0,05 versus normal Arnal. Intensive Care Med 2008 Normal COPD Chest wall stiffness ARDS n (d/patients) 706 / 140 217 / 40 54 / 13 136 / 36 RC exp (s) 0,78 ± 0,28 1,13  0,72* 0,41  0,16* 0,55 ± 0,21 * Vt/PBW (ml/Kg) 8,3  1,3 9,4  2,1* 7,1  1,1* 7,6  1,3 * RR (c/mn) 17  5 16  7 23  7* 20  6 * I/E 0,5  0,2 0,4  0,2* 0,5  0,2 0,63  0,27 *

24. Ventilation delivered Arnal. Intensive Care Med 2008

26. ASV and weaning Results: MV duration (h) n Control ASV p Sultzer Anesthesiology 2001 36 4,0 3,2 p < 0,02 Petter Anesth Analg 2003 34 3,2 2,7 NS Gruber Anesthesiology 2008 48 8,0 2,7 P < 0,05 Dongelmans Anesth Analg 2009 121 16,3 16,2 NS

27. ASV and weaning in COPD Kirakli. Eur Respir J 2011 n = 97

29. IntelliVent Ventilation Oxygenation Conventional ventilation ASV IntelliVent ® MV V T RR FiO 2 PEEP MV V T RR FiO 2 PEEP MV V T RR FiO 2 PEEP

30. IntelliVent

31. IntelliVent