Titration automatique de l'oxygène - en situation d'urgence Marseille, COPACAMU, March 2018
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From the white and cold Québec to Lyon …
Titration automatique de l’oxygène
en situation d’urgence
Erwan L’HER, MD, PhD,
Centre Hospitalier Universitaire de la Cavale Blanche
LATIM INSERM UMR 1101
Brest, France
Marseille, COPACAMU, March 2018
CONFLITS D’INTERET
• Research program on mechanical ventilation and
oxygen therapy automation : Canadian Fondation
for Innovation (Fonds des Leaders) / FRSQ
• Co-founder of a R&D company (OXYNOV’)
development of automated oxygen therapy
(FreeO2) and automated mechanical ventilation
• GE Healthcare, Sedana and Smiths Medical:
Fees for lectures and expertise
Eviter l’hypoxémie !
Oxygen is the metabolic fuel !
For all patients, adults, childs, pregnancy, …etc…
Current Opinion in Critical Care 2007 Journal of Internal medicine 2013
« Oxygen » Many studies on
541.731 publications since1867 physiopathology +++
« Hyperoxia »
7223 publications since 1945
Pubmed - "Hyperoxia"
Year of publications
400
350
300
250
200
150
100
50
0
1940 1960 1980 2000 2020
Hafner Ann Int Care 2015
RCT 434 patients ventilés
ICU Mortality = 11.6%
SpO2 target 94-98% PaO2 mediane
= 87 mmHg
SpO2 target 97-100% PaO2 mediane
= 102 mmHg
ICU Mortality = 20.2%
Girardis JAMA 2016
OXYDATIVE STRESS & VASOCONSTRICTION
Hyperoxia
ROS Membran lesions
DNA Fragmentation
Apoptosis
Decrease in [NO]
Inflammation
Lipid oxydation...
Vasoconstriction
↘ cardiac output (10-15%)
Hyperoxia
↘ coronary flow (20-30%)
Ganz Circulation 1972, Frobert CU 2004, Bak AP 2007,
↗ coronary resistances, vasoconstriction
McNulthy Am J Physiol Heart Circ Physiol 2005, ↗ cardiac enzymes
Farquhar AHJ 2009, Cabello Cochrane 2013, Stub ↗ infarctus size (+35%)
Circulation 2015, Fonnes Int J Cardiol 2016
↗ peri-operative infarctus (2.2 vs.0.9%)
18 patients Room Air 100%
(stable coronary disease)
Johnson 15’ 15’ Journal of
BJA 2003, Floyd JAP 2003, Floyd,
Coronary Blood Anesthesia
Cardiothoracic Flow 2007, Ronning Stroke 1999, ↘ cerebral blood flow (20-30%)
45 32
Rincon Crit (cm3/min)
Care Med 2014, Rincon J Neurol ↗ mortality (stroke, TBI)
Neurosurg
Coronary vascular Psy 2014, Brenner Arch Surgery 2012
resistances
(mmHg/(min/cm3))
2.2 3.1
PaO2
(mmHg)
73 273
Kilgannon JAMA 2010, Bellomo Crit Care 2011, ↗ mortality (post cardiac arrest)
Janz Crit Care SaO
Med 22012, 93
Ihle Crit Care
100Rescus
(%)
2013, Nelskyla Scan J Trauma Resusc Emerg Med
2013, Lee Am J Emerg Med 2014
McNulthy Am J Physiol Heart Circ Physiol 2005
CBF was measured
7 healthy men
by using noninvasive
continuous arterial
spinlabeled-perfusion MRI
à 30% CBF reduction
with hyperoxia
(for similar PaCO2)
HYPEROXIA IN PATIENTS WITH STROKE
Outcome Total Hypoxia Normoxia Hyperoxia
% Death (n=2894) (n=1316) (n=1084) (n=450)
Overall 52 53 47 60*
Minor or moderate strokes
Ischemic 48 46 47 57*
stroke
Subarachnoid 44 45 38 60*
without O2
n=259 hemorrhage
Intracerebral 59 61 54 61
with O2 hemorrhage
(3L/min 24h)
n=292
Ronning Stroke 1999 Rincon Crit Care Med 2014Guidelines: Summary
Minimal SpO2
à 92 % (ICU) or 88% (ARDS) Jubran Crit Care 2015
à 94 % (all patients except COPD) O’Driscoll Thorax 2008
à 88% (COPD) O’Driscoll Thorax 2008
Maximal SpO2 (under additional oxygen)
à 96-98 % (ICU) or 92% (ARDS)
à 98 % (all patients except COPD) O’Driscoll Thorax 2008
à 92% (COPD) O’Driscoll Thorax 20082017
UK review of the quality of care provided to
patients receiving noninvasive ventilation
Initial management
Oxygen therapy is the #1 treatment in the acute care
www.ncepod.org.ukInitial management
Oxygen
88-92 in 28.6%
Below 88 in 24.4%
Above 92 in 47%
www.ncepod.org.ukOBJECTIVES OF OXYGEN THERAPY
Treating hypoxemia (Spo2 > 88 ou 94%)
Avoiding hyperoxia (Spo2 < 92 ou 98%)
Oxygen weaning
Apparently simple objectives
…but are not achieved
51%
17%
Cousins Int Journal COPD 2016INTERVENTION
September 2009
Présentations
Working groups
Protocols
Stickers….
Audit #1 Audit #2 Audit #3
June-August 2009 October 2009-February 2010 February-May 2014
102 patients 102 patients 72 patientsFlowmeter (rotameter) is a technology from
the end of XIXth century
No innovation
in the field of
oxygen
administration
…..
Utilization in the medical field for 100 years !
Maximillien Neu: 1st publication on rotameter use = 1910Oxygen flowmeter Oxymeter
Currently:
+
Oxygen flowrate
setting
Constant Variable SpO2
Oxygen flowrate
Manual adjustements
Future:
with FreeO2 Monitoring:
SpO2 O2 flowrate
The clinician set
the SpO2 target + RR HR
Trends
Variable oxygen Constant SpO2
Automated titration and weaning
Every second to maintain the target SpO2Inclusion criteria: ED admission for acute respiratory distress requiring O2≥3L/min
Exclusion criteria : O2≥15 L/min, urgent mechanical ventilation support(invasive or NIV)
Randomisation: FreeO2 or manual adjustment of O2 during 3 hours
In both groups, SpO2 was continuously recorded by the same oximeter (Nonin technology)
Primary outcome:
% of time in the SpO2 target:
88-92% (hypercapnic patients)
92-96% (hypoxemic patients)
Grants: PHRC National FreeO2 Hypox (France), MDEIE (Québec) L’Her et al. ERJ 2017RESULTS % of time in the SpO2 target
Oxygenation 120
% PRESULTS: Oxygen weaning
Partial or complete oxygen weaning
during the 3 hours study Impact on outcomes after study
45 20 FreeO2 Total
FreeO2 Total
PRESULTS FreeO2
Impact on patients outcome
ICUoftransfert
Rate ICU transfer
(%) 20
PManual Titration
(n=25)
During the whole
duration of oxygen
therapy
Automated Titration
FreeO2
(n=25)
Continuous recording Remote monitoring at nursing station
of SpO2, RR and HR (FreeO2 arm)
(both groups)
Primary outcome: Secondary outcomes:
Nurses and Physicians evaluation Oxygenation parameters (target, hypoxemia,
of oxygen and oxygen monitoring hyperoxia), duration of oxygen therapy, hospital
in both study arms length of stay
(0 to 10 scales)
Lellouche et al. International Journal of COPD 2016Lellouche et al. International Journal of COPD 2016
Economic analysis, cost/efficiency analysis
à FreeO2 æ 20.7% cost per patient after180 days
(i.e. -2959,71 Can$) (p=0,39)
à ICER (incremental cost-effectiveness ratio)
FreeO2 is cost effective:
(1) -96,91$ per % of time in the SpO2 target
(2) -411,09$ per % less with hyperoxia
(3) -2250,04$ per % less with hypoxemiaCONCLUSIONS
O2 flowrate should be titrated to achieve NORMOXIA
à Treating hypoxemia
à Avoiding hyperoxia
(COPD, coronaropathy, stroke, cardiac arrest, pediatry/neonatalogy….)
Automated O2 TITRATION with FreeO2 provides the
optimal dosage based on patient’s needs
Automated O2 WEANING may reduce hospital
length of stay and costs associated with acute
exacerbation of COPDClinical Cases
Typical indications
Publications under processEarly postoperative monitoring
Continuous adjustment and rapid weaning, less hyperoxia
In the recovery roomLate postoperative monitoring
Rapid response to adverse events and less hypoxemia
In the ward, following high-risk surgeryFreeO2 for oxygen adjustment under NIV Rapid response to oxygenation requirements
FreeO2 during acute coronary syndrome
Oxygenation following myocardial infarction in the CICU
Mean inclusion duration = 11.5 ± 2.8 hours
60 25%
Manual O2 Titration HR 80-99 HR 100-119
% of time with HR > 80/min
50 FreeO2/92% 20%
FreeO2/97%
40
15%
30
10%
20
5%
10 * * * **
0 0%
Time (min) with % of patients with Premature Manual FreeO2 FreeO2
SpO2 < 90% Ventricular Contraction (92%) (97%)
Figure 2: Mean total duration (minutes) with SpO2 Figure 3: % of time with HeartYou can also read
