UTI Respiratória HCFMUSP UTI Hospital Sírio Libanês Eduardo LV Costa Valerie VILI Alt 193m Peso 120 Kg Mecanismos de lesão Recrutamento cíclico Colapso focal Estresse Hiperdistensão ID: 473031
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Slide1
Como evitar a VILI
UTI Respiratória HC-FMUSPUTI Hospital Sírio Libanês
Eduardo LV Costa
Valerie
VILI
Alt
1,93m
Peso 120 KgSlide2
Mecanismos de lesãoRecrutamento cíclicoColapso focal / EstresseHiperdistensãoHiperdistensão cíclicaStrain (deformação)Slide3
Tidal recruitmentCortesia Dr. G Janot
ExpiraçãoSlide4
Tidal recruitmentCortesia Dr. G JanotInspiraçãoSlide5
Colapso
focal
(stress raisers) +30
+70
Mead
– JAP 1970Slide6
Pplat > 26 - 27 cm H
2O
Am J Respir Crit Care Med 2007Slide7
Protti CCM 2013Slide8
Protti CCM 2013Slide9
Aeração
CCM 2014Slide10
Inflamação
Borges - CCM 2014Slide11
Imagem de Fusão
Borges - CCM 2014Slide12
10 compartimentos de aeração
Borges - CCM 2014Slide13
One size fits all?Bellani CCM 2009Slide14
Evolução da ventilação protetoraVolume corrente altoVolume corrente baixoAmato NEJM 1998Slide15
Volume corrente normalVt < 30% da CRF Strain < 1,3Volumes
HomemMulherCPT
6,0L4,2L
CRF
2,2L
1,8L
Vt (6-8ml/kg)
600mL
420mLSlide16
Evolução da ventilação protetoraVolume corrente altoVolume corrente baixoVt/peso idealARMA NEJM 2000Slide17
Evolução da ventilação protetoraVolume corrente (Vt) altoVt baixoVt/peso idealVt/tamanho do pulmão funcionante?(sizing the lung)
Amato NEJM 1998ARDS Network NEJM 2000Mattingley & Hubmayr CCF 2011Slide18
Como evitar a VILIVentilando adequadamente o baby lungMudando a história pulmonarSipmann CCM 2007Gernoth CCF 2009Retamal CCF 2013Slide19
Vt adequado ao baby lung(‘medindo’ o tamanho do baby lung)Slide20
Colapso:55.6 %
Pneumocystis
jiroveci
FIO2
=
100
%
; V
T
=
4
mL/kg
; PEEP =
5
cmH
2
O
6-8 ml/kg x (1 – 0,556) =
2,7-3,6 ml/kg Slide21
FI
O2 = 100 %; VT = 4 mL/kg; PEEP = 25 cmH2O
( após recrutamento)
Colapso:0.9 %
6-8 ml/kg x (1 – 0,01) =
6-8 ml/kg Slide22Slide23
Collapse
PEEP 23
PEEP 07
PEEP = 25
decremental
PEEP = 7
Hyperdistensão
Colapso
EIT
EITSlide24
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide25
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide26
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide27
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide28
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
6-8 ml/kg x (1 – 0,05) =5,7-7,6 ml/kg Slide29
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide30
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide31
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSPSlide32
Overdistension Collapse PEEP TITRATION BY EIT
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
6-8 ml/kg x (1 – 0,355) =3,9-5,2 ml/kg Slide33
Medindo o tamanho do pulmão
Hipoxemia
50%
6-8 ml/kg x (1 – 0,355) =
3,9-5,2 ml/kg
Reske CCM 2013Slide34
Medindo o tamanho do pulmão
Hipoxemia
Complacência
Complacência = Cs * CRFSlide35
Vt e VM protetoraComplacência ~ CRFp.e. Pneumonectomia -> ½ compNormalização “em vigor” Vt / Peso idealProposta Vt / Complacência Complacência = Vt / ΔP Vt / Complacência = Vt / (Vt / ΔP)
= ΔPSlide36
Driving pressure (ΔP) normalVt = 6-8 ml/kg ~ 500 mlComplacência = 80-100 ml/cmH2OΔP = Vt / Complacência ~ 7 cmH2OSlide37
PEEP
DrivingPressure(ΔP)PPlatô
VT
VILI
C
RS
Stress
raisers
Amato NEJM 1998Slide38
Amato…………….…….53Brochard
…………..….116Stewart…………....…..120Brower……………….…52ARDSnet….…………..861ALVEOLI…….………..549LOVS………………….983Express………………..768
3502Slide39
Quintiles
of ∆Pmatched for PEEPSlide40
Quintiles
of PEEPmatched for ∆P Slide41
Quintiles
of ∆P matched for PPLAT Slide42
Quintiles
of ∆P matched for PPLAT Slide43
High vs. Low VT studies ( n = 883 )High vs. Low PEEP studies ( n = 1457 )Patients under stricter “protective” settings ( Plateau-pressure < 32 cmH2O and VT < 8 mL/ kg / ibw )Slide44
P =
marcador de gravidade?P = V
CrsSlide45Slide46
“negative” clinical studies:
Driving P. High Low ALVEOLI 13 15 LOVS 14 15
Express 13 14Slide47
Days after randomization
0
10
20
30
40
50
60
Adjusted Survival (%)
65
70
75
80
85
90
95
100
Control arm ( ∆P-change = + 1.3 )
higher PEEP and ∆P-change =
-
3.7
higher PEEP and ∆P-change = + 0.4
higher PEEP and ∆P-change = + 4 .1
P = 0.003
Changes in ∆P caused by randomization ( PEEP trials, only )
(N = 794)Slide48
Como mudar o tamanho do pulmão funcionantePEEP e recrutamento
revisitadosSlide49
Not Protected
Hyperinflated Normally aerated Poorly aerated Not aeratedEIEESlide50
Stepwise Recruitment Strategy
Time
0
10
20
30
40
50
60
70
45
50
55
60
Baseline
T
MAX
= 20 min
2
5
cmH
2
O
Airway Pressures
(cmH
2
O)
40
CPAP
OLA
D
P
=
15
cmH
2
O
Borges AJRCCM 2006Slide51
Collapse:55.6 %
Patient
# 9Pneumocystiscarinii pneumoniaSlide52
FI
O2 = 100 %; VT = 4 mL/kg; PEEP = 26 cmH2
O( after PPLAT = 55 )
Collapse:
0.9 %
Patient
# 9
Pneumocystis
carinii
pneumoniaSlide53
PEEP = 5; PPLAT = 25Slide54
PEEP = 17; PPLAT = 40Slide55
PEEP = 25; PPLAT = 40Slide56
PEEP = 25; PPLAT = 60Slide57
Vermelho = hiperinsuflado
PEEP=25 - InspiraçãoSlide58
PEEP=25 - Inspiração – após recrutamento
Vermelho = hiperinsufladoSlide59
Time0
102030
4050
60
70
PCV
D
P = 15
cmH
2
O
25
PEEP STEPS - MAXIMUM-RECRUITMENT STRATEGY
Airway Pressure (cmH
2
O)
Recruitment
phase
25
20
Baseline
(PEEP = 10)
10
35
45
2 min
20
15
5 min
PEEP titration
phase
(
: CT scan – end-expiratory pause
)
Borges AJRCCM 2006Slide60
Baseline
PEEP (~10)
Maximum
PEEP
Titrated
PEEP (~24)
Non-aerated Lung Tissue
(
% of total lung mass
)
0
20
40
60
80
Janot
CCF 2012Slide61
Baseline PEEP
Maximum PEEP
Titrated PEEP
PaO
2
/FIO
2
= 113
PaO
2
/FIO
2
= 357
Potential for recruitment: 48%
Relative response: 98%
Potential for recruitment: 36%
Relative response: 45%
Potential for recruitment: 63%
Relative response: 82% Slide62
PEEP titration studyRM
PCVPins 60PEEP 40cmH2O2 min
Incremental PEEP steps
Decremental PEEP steps
VCV
6 ml/kg
8
26
10
12
14
16
18
20
22
24
PEEP steps (10 min at each level))
26
24
22
20
18
16
14
12
10
8
VCV
6 ml/kg
Changes in Cdyn (OLT)
Changes in Oxygenation
Search for Open lung PEEP (Oxyg and Cdyn)Slide63
Driving pressure
PEEP
PEEP
Rec.
N = 25Slide64
Driving pressure
PEEP
PEEP
Rec.
“PEEP table
trial”
N = 25
?Slide65
Driving pressure
PEEP
PEEP
Rec.
“PEEP table
trial”
N = 25Slide66
Driving pressure
PEEP
PEEP
Rec.
“PEEP table
trial”
N = 25Slide67
Driving pressure
PEEP
PEEP
Rec.
“PEEP table
trial”
“decremental
PEEP titration”
N = 25Slide68
Driving pressure
PEEP
PEEP
Rec.
“ Hysteresis “
“PEEP table
trial”
“decremental
PEEP titration”
PaO
2
/FIO
2
= 180
PaO
2
/FIO
2
= 380
N = 25Slide69
Obrigado
UTI Respiratória HC-FMUSPUTI Hospital Sírio Libanês
Eduardo LV
Costa
eduardo.leite@hc.fm.usp.br