Transcript Advanced Pulmonary Monitoring

ADVANCED
VENTILATOR
MANAGEMENT
Thom Petty BS RRT
Lead Clinical Specialist – East
CareFusion Critical Care Ventilation
 Identify the limitations that current Respiratory Mechanics impose
upon the management of mechanical ventilation.
 Review the hazards associated with positive pressure ventilation
and the sequelae of Ventilator-Induced Lung Injury.
 Discuss the role of chest wall, pleura and abdominal pressures
during positive pressure ventilation
 Introduce the measurement of Transpulmonary Pressure as a
valuable ventilation management tool.
 Review a Case Study regarding the use of transpulmonary pressures
in the management of ventilator settings.
Basic
Ventilator
Mechanics
Mechanics 101: Motion of Air Equation
PAO = ( VL / CRS) + ( F x RAW )
PAO =
VL =
CRS =
F=
RAW =
Pressure at the Airway Opening
Volume in the Lung
Compliance of the Respiratory System
(Lung + Pleura)
Flow Rate of Gas in L/s
Resistance of the Airway and ETT
( pressure /  flow)
As the Lung Inflates
PRESSURE IN THE AIRWAY (PAW)
 Measured at the circuit wye
 Not the actual pressure in the lungs but the
pressure of the entire respiratory system
 Reflects both lung and pleural pressures
PERI-PULMONARY/PLEURAL PRESSURE (PES)
 Pressure that is imposed upon the lungs by
the Chest Wall and Abdomen
 Can be approximated by measuring
pressures within the Esophagus
PRESSURE WITHIN THE ALVEOLI (PTP)
 The TRUE pressure within the lung
 PTP = PAW – PES
Paw
Pes
Ptp
Our Current Respiratory Mechanics Toolbox
Inspiratory Hold
 Measures the Plateau Pressure of the entire Respiratory System
 Indicator of end-inspiratory lung distension
Static Compliance
 Reflects the compliance of the entire Respiratory System
Expiratory Hold
 Measures the amount of intrinsic PEEP of the entire Respiratory System
The Hazard that is Mechanical Ventilation
8
Just What is Positive-Pressure Ventilation?
 Just what is it that is delivered by the ventilator to the patients’ lungs?
 Volume
 Flow
 Pressure
The Alveoli – Not Grapes on a Straw
The Alveolar Structure
 Adjacent alveoli and terminal bronchioles share common walls
 Forces acting on one lung unit are transmitted to those around it
(interdependence)
 Under conditions of uniform expansion, all lung units will be subject to a
similar transpulmonary pressure.
 However, if the lung is unevenly expanded, such forces may vary
considerably.
Dynamic Alveolar Mechanics
in the Uninjured Lung
 Healthy alveoli:
 Undergo relatively small changes in size during ventilation unless they
totally collapse or re-expand.
 Ventilation may occur primarily with changes in the size of the alveolar
duct or conformational changes as a result of alveolar folding
 Alveoli in ALI:
 Undergo large changes in alveolar size
 Widespread alveolar recruitment/derecruitment predominate.
 Can cause significant shear stress-induced lung injury
 Gross tearing of the alveolar wall
 Injury to the cell membrane
 Ultrastructural injury
Wilson, J Appl Physiol, 2001
Carney, CCM, 2005
Steinberg, AJRCCM, 2004
The Problems with
Positive-Pressure Ventilation
 Positive-pressure ventilation departs radically from the physiology of
breathing spontaneously.
 During inhalation positive intrathoracic pressures are created.
 These inspiratory-phase pressures are not homogenously distributed
throughout the lung:
 Effectively distributed through compliant lung
 Flow is attenuated in low-compliant areas
 This heterogenocity can result in overdistension of compliant “healthy”
lung and underdistension of non-compliant “injured” lung
The Problems with
Positive-Pressure Ventilation
 Early on in the history of positive-pressure ventilation it was
recognized that lungs that were ventilated to high pressures have a
propensity to develop air leaks.
 Thus began the early focus on barotrauma
 However, further research has revealed that alveoli that do not
overdistend were unlikely to experience injury.
 Excessive lung volume (volutrauma) rather than excessive airway
pressures produced lung injury.
 At the other end of the spectrum, ventilation using low end
expiratory volumes that allowed repetitive alveolar opening and
collapse (atelectrauma) was also identified as injurious.
Whitehead, Thorax, 2002
Diaz, Crit Care Med 2010
Ventilator-Induced Lung Injury
Volutrauma & Inflammation

Study investigating the release of “Lung Flooding” factors in Rodents
ventilated with three modes:

HiP/HiV
 High Pressure (45 cmH2O)
 High Volume

LoP/HiV
 Low Pressure (neg.pres.vent)
 High Volume

HiP/LoV
 High Pressure (45 cmH2O)
 Low Volume (chest bound)
Dreyfuss,D ARRD 1988;137:1159
Ventilator-Induced Lung Injury
Take-Home Points - Volutrauma


Mechanical and Biochemical in nature
Caused by excessive End-Inspiratory Volumes
 Indicated by elevated end-inspiratory (Plateau) pressures
 May result from a combination of “Safe” Vt + PEEP

Even “safe” Vt’s may severely over-inflate normal alveoli due to
heterogenicity of airflow within the lung

QUESTION: How can a clinician determine if alveoli are
over-distended at end-inspiration?
Ventilator-Induced Lung Injury
Atelectrauma
 Research has revealed that repeated cyclical collapse & re-expansion of
alveoli results in a release of cytokines and the reinforcement and
amplification of the local and systemic inflammatory response.
 Interleukin-6
 Interleukin-11
 Interleukin-γ
 Tissue Necrosis Factor-α
Ventilator-Induced Lung Injury
Take-home Points - Atelectrauma

Associated with repeated opening and closing of alveoli during
ventilatory phasing

Associated with regional differences in ventilation

Worsens surfactant dysfunction

Release of inflammatory mediators into alveolar spaces and into the
systemic circulation

QUESTION: How can the clinician determine what PEEP is
necessary to keep the alveoli open at end-exhalation
Presumed Mechanism for VILI
Mechanical Disruption of Pulmonary Epithelium
Mechanotransduction
Cell & Tissue Disruption
Upregulation & release of
Cytokines &, Chemokines
Subsequent leucocyte attraction and
activation
Pulmonary Inflammation:
VILI
Systemic Spillover:
SIRS / MODS
MECHANOTRANSDUCTION – Conversion of Mechanical Stimiuls into Chemical Reaction
SIRS – systemic inflammatory Response Syndrome
MODS – Multi Organ Dysfunction syndrome
Lung-Protective
Ventilation
Safer Ventilator Management
Lung-Protective Ventilation Theory
 1987 - Gattinoni’s CT studies of ALI/ARDS lungs revealed that ALI/ARDS
lung is not a stiff organ made up of homogeneously stiff lung units with
low static compliance but is a multi-compartmental heterogeneous
structure in which there is a portion of aerated normal tissue with
normal compliance (baby lung).
 Limiting VILI should be accomplished through an Lung Protective
approach to ventilator management which includes:
 Volume & pressure limitation
 Modest PEEP & Plateau pressures
 The challenge is to maintain acceptable gas exchange while avoiding
harmful mechanical ventilation practices. The need for potentially
injurious pressures, volumes, and FiO2’s must be weighed against the
benefits of gas exchange support.
Lung-Protective Ventilation Research
1988
Amato et al
Brazil
29 pts: Vt < 6ml/kg, Pplat < 20cmH2O
24 pts: Vt = 12ml/kg, PaCO2 35-38 mmHg
38% Mortality
71% Mortality
1998
Stewart et al
Canada
60 pts: Vt < 8ml/kg, Ppeak < 30cmH2O
60 pts: Vt 10-15ml/kg, Ppeak < 50cmH2O
50% Mortality at disch
47% Mortality at disch
1998
Brochard et al
Multinational
58 pts: Vt 6-10ml/kg, Pplat < 25-30 cmH2O
58 pts: Vt 10-15ml/kg, PaCO2 38-42 mmHg
47% Mortality at 60 days
38% Mortality at 60 days
1999
Brower et al
USA
26 pts: Vt 5-8ml/kg, Pplat <30 cmH2O
26 pts: Vt 10-12ml/kg, Pplat < 45-55 cmH2O
50% Mortality at disch
46% Mortality at disch
2000
ARDSnetwork
USA
432 pts: Vt 6ml/kg, Pplat < 30 cmH2O
429 pts: Vt 12ml/kg, Pplat < 50 cmH2O
31% Mortality at disch/180 d
40% Mortality at disch/180 d
2006
Villar et al
Spain
50 pts: Vt 5-8ml/kg, PEEP @ LIP + 2cmH2O
53 pts: Vt 9-11ml/kg, PEEP >5 cmH2O
32% Mortality in ICU
53% Mortality in ICU
The Handful of Ventilator Settings
FiO2
Accurately measured
Respiratory Rate
PEEP
Accurately measured
Measured but not accurate
Tidal Volume
Accurately measured
Plateau Pressure
Measured but not accurate
The Problem with Airway Pressures
The Two Settings We Estimate
PEEP
Measured but not accurate
Plateau Pressure
Measured but not accurate
The Two Settings we Estimate: PEEP
 Measured at the end of exhalation PEEP is the pressure that is exerted by
the volume of gas that is remaining in the lungs (FRC)
 Although ventilation with Low Vt’s & Plateau Pressures is generally
accepted by the critical-care community, the optimal level of PEEP at
which to ventilate remains unclear.
 PEEP levels exceeding the “traditional” values of 5-12 cmH2O have
been shown to minimize cyclical alveolar collapse and the
corresponding shearing injury.
 However, potential adverse consequences including circulatory
depression and lung overdistension may outweigh the benefits
 Use of PEEP < 10cmH2O leads to an increase in mortality
Amato M., 8th World Congress, Sydney, Australia
Dreyfuss, Crit Care Med, 1998
Gattinoni, NEJM, 2006
Muscedere , Am J Respir Crit Care Med. 1994
The Two we Estimate: PEEP Research
 There have been three randomized controlled trials comparing higher
versus lower levels of PEEP in ALI/ARDS:
2004
ARDSNet
ALVEOLI
USA
276 pts: Mean PEEP = 14.7cmH2O
273 pts: Mean PEEP = 8.9cmH2O
25% Mortality at disch
27.5% Mortality at disch
2008
Meade
LOVS
Multinational
508 pts: Mean PEEP = 15.6cmH2O
475 pts: Mean PEEP = 10.1cmH2O
36% Mortality at disch
40% Mortality at disch
2008
Mercat
EXPRESS
France
382 pts: Mean PEEP = 14.6cmH2O
385 pts: Mean PEEP = 7.1cmH2O
35% Mortality at 60 days
39% Mortality at 60 days
 2010 – Briele Meta-Analysis
 Differences in hospital mortality not statically significant
 Significant reduction of death in the ICU in the High PEEP group
The Two we Estimate: The PEEP Controversy
Low PEEP/High FiO2 Protocol
FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 16 18-24
High PEEP/Low FiO2 Protocol
FiO2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.5-0.8 0.8 0.9 1.0 1.0
PEEP 5 8 10 12 14 14 16 16 18 20 22 22 22 24
The Two we Estimate: Optimal PEEP
Table of FiO2 & PEEP combinations to achieve PaO2 or SpO2 in target
range
Ideal PEEP is
defined as:
PEEP TABLE
•
MAXIMAL PEEP
Use of highest PEEP while maintaining Pplat < 30 cmH2O
enough
to induce alveolar recruitment, keeping the lung
more aerated at end-exhalation, while not distending “good”
Lowest shunt (highest PaO2), lowest deadspace (lowest PaCO2), best
GAS EXCHANGE
alveoli oxygen delivery (CaO2 x C.O.)
• Low enough
to prevent hemodynamic impairment &
Use of the highest PEEP that results in the highest respiratory-system
COMPLIANCE overdistension
compliance
WITHOUT
• High
OVERDISTENSION
STRESS INDEX
Observe the Pressure/Time Curve during constant flow inhalation for
signs of tidal recruitment and overdistension
PRESSURE/VOLUME
CURVE
Set PEEP slightly higher than Lower Inflection Point
IMAGING
Computed tomography, Electrical impedence tomography,
Ultrasound
ESOPHAGEAL
PRESSURE
MONITORING
Estimate the intra-pleural pressure with the measurement of
Esophageal Pressure then determine optimal PEEP
The Two we Estimate: Alveolar Recruitability
• Briele also suggests that the beneficial impact of reducing intra-tidal
alveolar opening and closing by increasing PEEP prevailed over the
effects of increasing alveolar distention in ALI/ARDS patients with
higher lung recruitability
• In ALI/ARDS patients with low potential for recruitment, the
resulting over-distension associated with PEEP increases was
harmful
• How To Determine Lung Recruitability:
• Non-Recruitable – If PEEP is  and Plateau Pressure then  in
an equal or greater increment.
• Recruitable – If PEEP is  and Plateau Pressure then  in a
lesser increment
The Two We Estimate
PEEP
Measured but not accurate
Plateau Pressure
Measured but not accurate
The Two We Estimate: Plateau Pressure
 Plateau Pressure is the pressure exerted by the volume of gas in the
lungs after an inhalation.
 Indicator of “lung fullness”
Plateau Pressure Goal: Keep < 30 cmH2O
The Two We Estimate: Plateau Pressure
 Check PPLAT (with a minimum 0.5 second inspiratory pause) at least q 4h
and after each change in PEEP or VT.
 If PPLAT >30 cmH2O:
 VT by 1ml/kg to minimum of 4 ml/kg.
 If PPLAT < 25 cmH2O and VT< 6 ml/kg:
  VT by 1 ml/kg until PPLAT > 25 cmH2O or VT = 6 ml/kg.
 If PPLAT < 30 but patient/ventilator dysynchrony is evident:
  VT by 1ml/kg to a VT of 7-8 ml/kg if PPLAT remains < 30 cm
Transpulmonary
Guided
Ventilation
Solving The Problem with Airway Pressures
 REMEMBER: Airway pressures displayed by ventilators do not reflect
pressures within the lung but within the Entire Respiratory System
 To truly know the pressure within the lung (Transpulmonary Pressure) it
is necessary to measure and account for the pressures outside of the
lung (Peripulmonary Pressures)
 Very difficult to directly measure pressure in the pleura
 A number of historic studies have demonstrated reasonable correlation
between Esophageal Pressures and Pleural Pressures
 Pressure in the pleura adjacent to the esophagus is transmitted to the
esophagus.
 Pressure within the pleural space is not uniform
 Pressure in the dependent & basal regions is greater than in the
upper regions of the thoracic cage
Solving The Problem with Airway Pressures
 Patients on mechanical ventilation are usually supine or semirecumbent so it is important to account for the effect that mediastinal
structures such as the heart have on esophageal pressures.
 Washko (2006) and Talmor (2008) have recommended that
approximately 2-5 cmH2O be subtracted from the esophageal pressure
to more accurately reflect pleural pressures.
Stiff Lung or Stiff Chest Wall?
PAW = PTP + PES
30 = 25 + 5
PAW = PTP + PES
30 = 15 + 15
Gattinoni, Crit Care, Oct 2004;
How Common are Increased
Intra-Abdominal Pressures?
Abdominal Pressure
Total Prevalence
MICU Prevalence
SICU Prevalence
>12 mmHg
58.8%
54.4%
65%
>15 mmHg
28.9%
29.8%
27.5%
>20 mmHg
8.2%
10.5%
5.0%
13 ICU’s, 6 countries, 97 patients
Malbrain et al, Intensive Care Med (2004) 30:822–829
Can High Intra-abdominal Pressures
Really Affect Ventilation?
Rigid Abdomen in ACS
S/P Decompressive Laparotomy
Transpulmonary-Guided Ventilation
3 Basic Concepts
 To exploit the potential for alveolar recruitment, a transpulmonary
pressure that is greater than the opening pressure of the lung must be
applied to the lung.
 To avoid alveolar collapse after recruitment, a PEEP that is greater than
the compressive forces operating on the lung and alveolar ventilation
that is sufficient to prevent absorption atelectasis must be provided.
 Avoidance of stretch (by maintaining a low plateau pressure) and
prevention of cyclic collapse and reopening (by maintaining adequate
PEEP and alveolar ventilation) are the physiologic cornerstones of
mechanical ventilation in acute lung injury/acute respiratory distress
syndrome.
Gattinoni et al,CritCareMed2003Vol.31,No.4(Suppl.)
45
The Talmor/Ritz Study
 Survival of ALI/ARDS patients has improved in recent years with the
advent of low Vt’s and the use PEEP
 Optimal level of PEEP is difficult to determine.
 Could the use of Transpulmonary Pressure Measurements (as
estimated by esophageal pressure measurements) enable the clinician
to determine a PEEP value that would maintain oxygenation while
preventing lung injury due to repeated alveolar collapse and/or
overdistention?
 Mechanically-ventilated ALI/ARDS patients randomly assigned to one
of two groups:
 CONTROL GROUP: PEEP adjusted as per ARDSNet recommendations
 PES-GUIDED GROUP: PEEP was adjusted to achieve a PTP PEEP of 0 to
+10 cmH2O
The Results
• The primary end point of the study was improvement in oxygenation.
• Secondary end points respiratory-system compliance & pt outcomes.
• The study reached its stopping criterion and was terminated after 61
patients had been enrolled.
• The PaO2/FiO2 ratio at 72 hours was 88 mmHg higher in the Pes-group
than in the control group
• This effect was persistent through the 24, 48 & 72 hour follow-up time.
• Respiratory-system compliance was also significantly improved at 24, 48,
and 72 hours in the Pes-guided group
Outcomes
A Sampling of What’s in the Journals

Basing ventilator settings on a maximum allowable airway plateau
pressure may leave large portions of the lung under-inflated and at risk
of VILI from repeated airway opening and closing.

It is logical that estimating pleural pressures from PES and setting PEEP
to achieve a target PTP may allow higher PEEP in many patients without
overdistending lung regions that are already recruited.
A Sampling of What’s in the Journals

Systematic use of esophageal manometry has the potential to
improve ventilator management in acute respiratory failure by
providing more direct assessment of lung distending pressure.
A Sampling of What’s in the Journals


The use of airway Plateau Pressures to set ventilation may underventilate patients with intra-abdominal hypertension and overdistend
the lungs of patients with atelectasis.
Thus PTP must be used to accurately set mechanical ventilation in the
critically ill.
A Sampling of What’s in the Journals

Increases in peak airway pressure without a concomitant increase
in alveolar distension are unlikely to cause damage.
 Critical variable is not PIP but PTP

In patients with a stiff chest wall from non-pulmonary ARDS that
may have elevated pleural pressures airway Plateau Pressures may
exceed 35 cmH2O without causing alveolar distension
A Sampling of What’s in the Journals

PES can be used to estimate transpulmonary pressures that are
consistent with known physiology, and can provide meaningful
information, otherwise unavailable, in critically ill patients.
One Hospital’s Protocol for Identification
of Pes Candidates
 Pplat > 25 cmH2O
 Static Lung Compliance < 40 ml/cmH2O
 P/F Ratio < 300
 PEEP > 10 cmH2O to maintain SaO2 > 90%
 PaCO2 > 60 mmHg or pH < 7.2 attributable to respiratory acidosis
Wolfson Medical Center, Holon, Israel
Esophageal Balloonary:
The Catheter
 Can utilize either a 5 or 7fr balloon-tipped catheter or
a specialized NG/OG catheter that is inserted into the
lower third of the esophagus, above the diaphragm.
 Pressures that are exerted on the balloon are
measured by a transducer either integral in the
ventilator or in a separate box
 An approximation of proper placement can be made
by measuring the distance from the tip of the nose to
the bottom of the earlobe and then from the earlobe
to the distal tip of the xiphoid process of the
sternum.
Esophageal Balloonary:
Catheter Placement

Properly inserted the esophageal balloon will show simultaneous
negative deflections in airway and esophageal pressures during an
expiratory hold during a patient-initiated breath (Baydur Method).
 If balloon is inserted too far into the esophagus Pes will deflect
positively during a spontaneous inspiration.

PES tracing may show small cardiac oscillations reflective of cardiac
activity.

PES should be similar (+ 10) to PGA (Bladder Pressure)

Measurements should match the patients clinical presentation.
Esophageal Numerology: PTP PLAT
Transpulmonary Pressure at End-Inspiratory Plateau
 Increased abdominal pressure
and/or decreased chest wall
compliance is imposing a load on
the lungs which is reflected in an
increased pleural pressure during
an inspiratory plateau.
 PAW PLAT = 39 cmH2O
 PTP PLAT = 9 cmH2O
 Keep PTP PLAT < 20 cmH2O
Esophageal Numerology: PTP PEEP
Transpulmonary Pressure at End-Expiratory Plateau
P AW = 15 cmH2O
P ES = 10 cmH2O
P TP PEEP = 5 cmH2O
15
10
10
5
10
Esophageal Numerology: PTP PEEP
Transpulmonary Pressure at End-Expiratory Plateau

Goal is to adjust PEEP to
maintain PTP PEEP between 0 - +2
cmH2O
 Negative PTP PEEP = pressure
outside the lung is greater
than pressure inside the lung.
 Positive PTP PEEP = pressure
inside the lung is greater than
pressure outside the lung
 May cause end-expiratory
overdistension if too high
Esophageal Numerology: PES
Delta Esophageal Pressure

Good indicator of Work of Breathing
 Values <15 cmH2O may indicate patient is a good candidate for
weaning.

The difference between PEAK esophageal pressure (PPEAK ES ) and
BASELINE esophageal pressure (PEEPES)
 PES = PPEAK ES – PPEEP ES
 Adult Normal:
 Pediatric Normal:
10 – 15 cm H2O
7 – 19 cm H2O
Interpretation of the
Esophageal Pressure Tracing

Analyzing the shape of the esophageal pressure tracing may provide
information regarding lung compliance.
 Stiff lung – airway pressures only partially transmitted to pleura
 Compliant lung – airway pressures readily transmitted to pleura
 Clear differences between end-expiratory and end-inspiratory
Sorosky A, Crit Care Research and Practice
Case Study 1:
Transpulmonary-Guided Ventilation
in Increased Abdominal Pressures
Transpulmonary-Guided Ventilation
•HPX:
CXR on current vent settings:
• Any heart
silhouette?
Morbidly
Obese
24 yo Female
• Any
diaphragms?
with
Pancreatitis
• Any aeration?
Settings:
• Esophageal Balloon inserted
PRVC-AC,
Vt-340,
• Initial PTPRR-24,
PEEP = -12.3 cmH2O
PEEP-7, FiO2-.45, Ti-.7
• A negative PTP PEEP indicates the
lung is being derecruited from
elevated external (pleural and/or
ABG:
abdominal) pressures.
pH-7.36, PaCO2-50,
PaO2-57, SaO2-93%
Pump Up the PEEP
 Placed on PC/AC, RR-16, PIP36, Ti-.70 & PEEP-20.
 PTP PEEP now -3.7 cmH2O
Some Heart Border & Diaphragm now visible
Which Plateau Pressure is Correct?
• PAW Plateau
• 41 cmH2O
• PTP PLAT
• 21 cmH2O
Further PEEP Pumpage
• PEEP Increased to 25
cmH2O
• Ptp PEEP now +2.4 cmH2O
• Lungs are remaining
open at end-exhalation
Hey, Let’s Try APRV!
• PLOW of 0
• PTP PEEP of -15 cmH2O
• IMMEDIATE
Derecruitment!
Now What?
 Returned to PC/AC with
PEEP of 25 cmH20
 PTP PEEP now +2.4 cmH2O
 No derecruitment!
 PAW PEAK of 46 cmH2O
 PTP PEAK of 27 cmH2O
 Physicians were hesitant
to maintain PEEP of 25
Now What?
 CXR six day post PEEP adjustment using PES monitoring
 PEEP 16cmH2O with FiO2 of .40
 Heart border and diaphragms visible
Case Study 2:
Transpulmonary-Guided Ventilation
Identifying Post-Code Derecruitment
PTP Pre & Post Instillation of Oleic Acid
• Pre-Instillation
• PTP PEEP = +2 cmH2O
• No Derecruitment
•
Post-Instillation
• PTP PEEP = -2 cmH2O
• Derecruitment on
PEEP of 4
PEEP Increased to 8
• PEEP increased to 8 cmH2O
• PTP PEEP increased to +1.2
cmH2O
Changes Following Resuscitative-Fluid Bolus
• Following multiple fluid
boluses during resuscitation it
was noticed that PES increased
from 8 cmH2O to 12 cmH2O
• PTP PLAT increased to 27 cmH2O
• PEEP immediately increased to
10 cmH2O
• This kept PTP PEEP from dropping
into negative
• No “Post-Code
Derecruitment”
One Last Point
Quality Requires Standardization
The most meaningful cost reduction
strategies will involve standardization
of clinical care and elimination of
variation in patient procedures.
May 9, 2012
We Need to Define Quality
Q = A x (O + S)
W
Q – Quality
A – Appropriateness
O – Outcomes
S – Service
W – Waste
Questions?
Email: [email protected]
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2008
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78
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2010
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