ISICEM 20, FLUID BALANCE, I like end expiratory occlusion test and tidal volume challenge,Jean Louis

i am gerry table from paris i am the owner to participate in this easycam 2020 virtual meeting and i will try the next minutes

to explain why i like the ant expert occasion test and title ruling challenge this slide presents my conflicts of interest as you know when we speak about full

responsiveness uh we speak about uh prediction of responsiveness and nowadays international societies recommend using

dynamic of static variables to predict full responsiveness when applicable but what is a dynamic variable it is something which can quantify the

slope of the frank stelling curve at the time you designed to give a treatment to your patients and we have in fact two categories of dynamic indices we have heart lung interaction indices

and we have pacifism tests and today i will not speak about pc legacy intakes i will concentrate on part-time interaction indices and namely anti-spread revision test and tidal challenge

but when we speak about heart lung interaction this is uh we know that the idea behind is that the more the stroke volume of the output changes with mechanical ventilation the more likely the

patient's heart is pretty responsive as you know the most popular indices are those related to respiratory variation of stroke volume during mechanical ventilation first pressurization ppv or

structural invasion svv as you know ppv high ppv uh earth pressure as you know is the difference between systemic and dynastic pressure

the high ppv is generally related to preload responsiveness and if the patient has a high ppv will respond to free demonstration and low ppv

is generally related to product and responsiveness and the patient will not respond to food administration unfortunately in patients hospitalizing

the icu there are many limitations to use first pressure vention or to struggle in directions at the bedside because we have some cases of force negative or false positive

in many situations this is why all the tests have been proposed and for example the and expert exploratory occlusion test the principle is that during

each mechanical insulation you have a decrease in in venous return and preload so if you interrupt the ventilator at the end of expiration for it in seconds for example

you should have a transient increase in its return and payload this increase in preload will result in increase in stock volume only in case

of pre-responsiveness and no increase in stroke volume in case of unresponsiveness therefore we can hypothesize that full responders

can be identified by an increase in the rack output during the anti-exploratory occlusion test what are the reasons are like the andex

protoculin test first because it works of course this is the first study we published two years ago with vmware and other in our institutions and we measure colorectal output using

the pulse contour method with the pico device and we gave volume to patients and we separated between responders and non-responders to food administration but before

giving fluids we perform the and expert recreation test and as you can observe patients who increase their caloric output during the test also increase their caloric output

after a free challenge and patients who did not increase gala carpool during the test were free non-responders so it is very easy to do and this was confirmed by many other

studies this is a meta-analysis recently published in annuals of intensive care with doctor francesco gavelli rishi and xavier monet and others we pulled all the studies that that

address the issue of free responseness using the unexpected equation test as you can observe there are 13 studies more than 500 tests and

the auroch curve the area under the rock curve was good 0.91 with a good sensitivity and good specificity and the average

cutoff value was around 5 so it works and also it works even in cases of inspiratory efforts during mechanical ventilation

in the study i already talked about we had the subgroup subgroup of patients of 23 patients with mechanical ventilation and spontaneous breathing activity as you can observe the area under the

rocker for the and export technology test was excellent 0.97 far larger than the aurora curve for ppv

which was only 0.68 so it works also in patients with mechanical ventilation and spontaneous building activity also it works even in cases of low lung

compliance ards for example and this is another study uh published eight years ago with the money and others

and we looked at patients with low respiratory system compliance lower than 30 ml per centimeters of water as you can observe the area under the

rocker for the prediction of responsiveness for ppv was not very good 0.69 but the area under the rock curve for

the end export occlusion test and the effects were assessed by galac output was excellent 0.97 so it works

also in patients with low compliance of the respiratory system also i like this test because it works even in cases of low tidal volume

and this is a additional analysis of the meta-analysis i spoke about before and we separated in a patient with low vt

less than 7 ml per kilogram and high vt higher than seven as you can observe the area under the rock curves for both

were excellent support 96 for low vt and 89 for ivt so it works in any case also because it works independently of

the level of peep this is another study we performed with dr silva the persevener and co-workers and in the same patients we applied two

levels of peep low peep five centers of water and a higher peep around fourteen thousand water and we looked at the effect of undex percolation tests and after we gave fluids to patients as

you can observe the area under the rock curves for low pip as well as for high pip were excellent so we can predict the responsiveness

independently of the level of pip using this and expert recreation test and finally i like this test simply because it is very easy to perform you have just to press a button for 50

seconds as exactly as you measure interesting peep but in this case you should press a button for longer time at least 15 seconds but it

is very very easy to do at the bedside of course as always we have limitations to this test and the patient should not interrupt the

test by triggering the ventilator due to violent inspiratory efforts and this may happen

in 22 percent of cases as we reported in this previous paper another limitation is that you should use a very precise and real-time

calculate measurement very important why because in the meta-analysis i already talked about the cut-off value found in these studies is around five percent five

percent is very low so you should use a very precise technique to measure caloric output and for example this threshold is not compatible with method having a poor precision for

example echocardiography since the least significant change for velocity time integral vti is around 10 so it's not possible

to use this test uh using this technique and this is why with meteorology money and others we propose to combine the effect of

anti-exploitation on collect output and the effect on an inspiratory occlusion on cardiac output using echocardiography and now when we added the results in absolute

values we found a cutoff value of 13 and 13 now is more compatible with the precision of echocardiography because as i said the least significant

change is around ten percent for velocity time integral so if you use echo you should combine the tests what about tidal volume challenge it is

another test to predict your responsiveness as you know first pressurization cannot be used in patients with low tidal volume

essentially because of the presence of false negative and this is well confirmed yesterday by lauren miller and co-workers they subdivided patients into groups

responders and non-responders according to the response of karaka put to food administration but before they measure pulse pressure variation and there are many situations where ppv is low

low why the patient is fully responder in terms of increasing caloric output zones there is a low sensitivity of ppv during low tidal volume ventilation

and this is why with sheila mayatra from mumbai and other colleagues from india we proposed a new test which is called the tidal volume challenge which consists

in increasing tidal volume transiently for one minute only from 6 ml to 8 ml per kilogram and now when you measure ppv the

area under the rocker for ppv8 is far better than for ppv6 but what was far better was the change

in ppv from six to eight ml per kilogram and we found a cut-off value of 3.5 for example if you have a ppv of seven percent you increase diagonal volume from six to

eight ml per kilogram and now if ppv is around 11 or 12 you can assume that the patient will respond to freedom expression if ppv increases from seven percent to

nine percent you can assume that the patient will not respond to freedom instruction so it is very easy very simple to do and our results were confirmed by

this study by antonio messina and the group of maurizio chiconi from italy but they performed this study in the operating room and they measure baseline ppv but also baseline

svvs for pulling variation and after they increase tidal volume from 6 ml per kilogram to 8 ml per kilogram and now as you can observe

the delta ppv and the delta svv were far better predictors of responsiveness than the baseline ppv and the baseline as i like the tidal volume challenge because

it seems to work well in cases of low tidal volume because it is very easy to perform and because it only requires an internal line there is no need of calico output

quadrant device and in my experience i have found that it is very useful during the curving 19 pandemic in patients with

severe elders which are who are ventilated with low tidal volume and we generally require high-dose sedative drugs

so my conclusion i like both the anti-spiritual tests and the tidal volume challenge because they're very helpful to overcome important limitations of ppv to predict

responsiveness and because they are very easy to perform in patients receiving mechanical ventilation thank you very much for your attention