Maniobras de Reclutamiento Alveolar - SDRA
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Maniobras de Reclutamiento Alveolar - SDRA
- 1. MANIOBRAS DE Martes 01 Agosto 2009 Julián Vega Adauy, Residente Medicina Interna. UdeC PRESENTACION FINAL ROTACION UCI RECLUTAMIENTO ALVEOLAR
- 3. ¿En base a que tomamos nuestras decisiones clínicas?
- 4. A Shaughnessy. BMJ 2004
- 6. INTRODUCCION: SDRA Respiratory Management in Critical Care. BMJ 2004.
- 7. INTRODUCCION: SDRA Respiratory Management in Critical Care. BMJ 2004.
- 9. INTRODUCCION: SDRA MORTALIDAD + FR The Irish Critical Care Trials Group. Critical Care 2008
- 11. ND. Ferguson. Crit Care Med 2005 CURVA ROC PaFI + Rx
- 12. ND. Ferguson. Crit Care Med 2005 CURVA ROC IM
- 13. OPCIONES TERAPEUTICAS EN SDRA SEVERO
- 14. ESTRATEGIAS TERAPEUTICAS EN SDRA SEVERO FALLA DE OXIGENACIÓN O VENTILACION RA MRA RotoPRONE PRONO Falla Oxigenación: FiO2>0,7. PEEP>14. IOX>15 Falla Ventilación: pH<7.25 con Vt >6 , No logro Pplt<30
- 15. APRV HFOV PLV eVENT MRA ECMO
- 16. APRV HFOV PLV eVENT MRA OFERTA v/s ECMO
- 19. Pinsky. Applied Physiology in Intensive Care Medicine. Springer 2006. Pelosi et al. Am J Respir Crit Care Med. 1994 SDRA, ZONA DEPENDIENTE SUPERIMPOSED PRESSURE (SP) Nivel de PEEP necesario para reclutar una UA tiene directa relación con la cantidad de SP Áreas dependientes requieren mayor PEEP para su reclutamiento
- 22. VENTILACION PULMONAR PROTECTIVA ARDSnet ARMA. NEJM 2000
- 23. 31% 39.8% RR 22% RAR 8.8 NNT 12 p=0,007 ARDSnet ARMA. NEJM 2000 LOW TIDAL 6 ml/kg TRADITIONAL VOLUME 12 ml/kg
- 24. Única intervención demostrada que disminuye mortalidad en SDRA
- 27. C = V / P Compliance = Vt / Pplat - PEEP LIP UIP
- 28. G Albaiceta. BioMedical Engineering OnLine 2007
- 32. Albaiceta GM. Current Opinion in Critical Care 2008 OBJETIVO VENTILATORIO PMC Punto de máxima compliance
- 34. C Baez, P Pelosi. Revista Brasileira de Terapia Intensiva. 2008 SDRA Primario vs Secundario, ¿son tan diferentes?
- 35. Puybasset L Intensive Care Med 2000 SDRA según patrones de TAC 25% 35% 40% Muchos pacientes tienen componente MIXTO de difícil clasificación: NAVM en paciente con PA G Bugedo. Rev. Chil. Anestesia 2007
- 36. Curvas PV en SDRA con distintos patrones de TAC Rouby et al. Intensive Care Med 2000 Mayor Pflex (M75%)
- 38. ↑ peso pulmonar Colapso de UA en zonas dependiente Distribución selectiva del Vt a UA normales Colapso de UA afectadas VP Protectiva DES RECLU ↑ H2O pulm. extravascular Déficit de Surfactante Heterogenicidad UA
- 42. BENEFICIOS DE LAS MRA A Villagra. Am. J. Respir. Crit. Care Med. 2002 MRA Mayor beneficio al ser aplicadas PRECOZ
- 44. Métodos de RECLUTAMIENTO ALVEOLAR Presión Control PI + Hi PEEP CPAP Extended Sigh
- 45. PROTOCOLOS DE RA Gattinoni. NEJM 2006 P°Control: Pplat 45cm, PEEP desde 5, RR 10/min, I:E-1:1. Pelosi. Am J Respir Crit Care Med. 1999 P°Control: 3 Sighs Plat 45 Grasoo. Anesthesiology 2002. Girgis. Respir Care 2006 CPAP 40 x 40s Brower RG. Crit Care Med 2003 CPAP 40 x 30s
- 46. PROTOCOLOS DE RA
- 47. 1° CPAP 35 x 20s 2° CPAP 40 x 30s 3° CPAP 45 x 40s M O Meade. Repiratory Care. 2008 ¿CUANTAS MRA?
- 48. ¿HASTA CUANDO RECLUTAR? Cadena de tiempo del SDRA UpToDate 17.2, 2009
- 51. ¿CÓMO DETERMINAR EL POTENCIAL DE RA? 1 Gattinoni L et al. N Engl J Med 2006
- 52. ¿CÓMO CUANTIFICAR EL POTENCIAL DE RA? 1 Gattinoni L et al. N Engl J Med 2006 DEFINICIÓN TEÓRICA Aumento >9% peso pulmonar total “ventilado” desde 5 a 45 cm H20
- 54. ¿COMO MEDIR EL DESRECLUTAMIENTO? S. MAGGIORE. Am. J. Respir. Crit. Care Med. 2001 2
- 56. c/r FiO2 c/r PºPlat c/r PºTPM Pflex (PV) TAC Compliance PEEP
- 57. BIOTRAUMA Balance de objetivos PEEP Hi PEEP LOW PEEP INJURIA POR HIPERINSUFLACIÓN INJURIA POR ATL CICLICAS (atelectotrauma, VILI)
- 59. Hi vs Low PEEP Gordo-Vidal F. Med. Intensiva 2007 3 ¿Qué PEEP post MRA?
- 60. Hi PEEP según Pflex (PEEP>LIP) Gordo-Vidal F. Med. Intensiva 2007 3
- 61. ¿Cuanto PEEP post MRA? K. Girgis Respir Care 2006 3
- 62. 3
- 63. Mechanical Ventilation. ACS Surgery Principles & Practice 2006 PEEP ÓPTIMO MÁS QUE MEJOR OXIGENACIÓN 3
- 65. 4 ¿Cuál es la mejor estrategia de RA? J Borges. Am J Respir Crit Care Med. 2006
- 66. J Borges. Am J Respir Crit Care Med. 2006 4
- 67. 4 35 cmH20: Presión de APERTURA
- 68. MAGIC NUMBER >400 PaO2 + PaCO2 > 400 en FiO2 1.0 Mínimo de tejido pulmonar colapsado 4
- 70. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5
- 71. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5 Hipoventilación Reducción en CO Disminución CO Reducción RVS Aumento Espacio muerto Hipercapnia HIPOTENSION Aumento PIT Aumento RVP Ambombamiento Septum VI MRA
- 72. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5
- 73. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5
- 74. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5 Talmor. Chest 2007 Escasa liberación de mediadores inflamatorios post-MRA
- 75. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5 I Toth. Critical Care Med. 2007 Escaso compromiso hemodinámico
- 77. ¿CUÁL ES EL PELIGRO DE LAS MRA? 5 CONTRAINDICACIONES DE MRA 1. Compromiso hemodinámico significativo 2. BLEBS o bulas 3. Barotrauma previo 4. PIC Aumentada
- 79. EVIDENCIAS EN MRA
- 80. MRA sin diferencias en mortalidad
- 81. Hipoxemia Refractaria, RR 0.54 [IC 95% , 0.34-0.86] Muerte con HR 0.56 [IC 95% , 0.34-0.93] Indicación de Rx Rescate, RR 0.61 [IC 95%, 0.38-0.99] Muerte a 28 dias, RR 0.88 [IC95%, 0.73-1.07] OLA Control
- 86. ¿COMO ATERRIZAMOS ESTO A NUESTRA PRÁCTICA DIARIA?
- 87. SDRA <72 hs de evolución. PIC normal, descartado Nt, barotrauma previo. Hemodinamia estable con PAM y DVA estables últimas 6 horas I Toth. Critical Care Med. 2007 EVALUAR EFICACIA Vt>10%, PaO2>10%, Sat>10% GSA GSA EVENTOS A MONITORIZAR EN LA MRA PAS <90 o disminución en 30 mmHg FC>140 lpm o aumento en >20 lpm Sat <90% o disminución >5% Arritmias cardíacas VM PRESION CONTROL PI 40, PEEP 25 x 40 secs I:E-1:1. FIO2 1.0. FR 20
- 88. RESPUESTA (+) AJUSTE EL PEEP Reducir el PEEP en 2 c/5min hasta Reducir PI para Vt 4ml/kg* (pH>7.15) PEEP en el cuál la Sat cae >10% (Mejor CP?) Fijar el PEEP >2 sobre este valor Mantener FiO2 1.0 por 1 hora
- 90. Muchas gracias por su atención foto de la vida real
- 91. Günther et al. Respiratory Research 2001
- 92. SHUNT PULMONAR: V/Q=0 áreas mal ventiladas (V) pero bien perfundidas (Q) PRESIONPositiva
- 93. The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. N Engl J Med 2004 Hi vs Low PEEP in LPV
- 94. ESTRATEGIAS TERAPEUTICAS EN SDRA SEVERO APRV HFOV ECMO PLV eVENT
- 95. Respiratory Management in Critical Care. BMJ 2004. Estudios de Ventilación protectiva en SDRA
- 96. ARDSnet Tidal Volume Study ARDSnet, NEJM 2000
- 97. Lu et al. Critical Care 2006
- 98. I Toth. Critical Care Med. 2007
Notas del editor
- Chile 1.500 casos x año
- Falla Oxigenación: FiO2>0,7. PEEP>14. IOX>15 Falla Ventilación: pH<7.25 con Vt >6 o Imposibilidad de PPLAT<30
- Falla Oxigenación: FiO2>0,7. PEEP>14. IOX>15 Falla Ventilación: pH<7.25 con Vt >6 o Imposibilidad de PPLAT<30
- Point A in figure: Under-inflation: At this point the lung is under-inflated, PVR will be high and relatively large amplitude will produce only small changes in volume. Clinically this manifests as a high oxygen requirement with limited chest vibration. Point B in figure: Optimal recruitment inflation: Once the lung has opened up with higher MAP, the PVR will fall and a smaller amplitude will produce a larger change in volume. Clinically this manifests as falling oxygen requirements and good chest vibration. Point C in figure: Over-inflation: Again more amplitude will be needed to produce volume changes and over inflated lung will compromise the systemic circulation. This is the most dangerous point in HFOV and is to be avoided at all costs. It is difficult to pick clinically because the oxygen requirement stays low, although they will eventually rise and the reduced chest vibration is easy to miss. Chest X-ray is currently the best diagnostic tool for this see below. Point D in figure: Optimal inflation: The goal should be to move the babies lungs from point B to point D avoiding point C (as shown on the arrow marked *** in Figure 2). Having achieved optimal lung inflation by slowly reducing MAP it should be possible to maintain the same lung inflation and ventilation at a low MAP. If MAP is lowered too far oxygen requirements will start to rise.
- ¿Porqué se desreclutan las UA?
- Figure 2. Frequency Distribution of Patients According to the Percentage of Potentially Recruitable Lung (Panel A) and CT Images at Airway Pressures of 5 and 45 cm of Water from Patients with a Lower Percentage of Potentially Recruitable Lung (Panel B) and Those with a Higher Percentage of Potentially Recruitable Lung (Panel C). Panel A shows the frequency distribution of the 68 patients in the overall study group according to the percentage of potentially recruitable lung, expressed as the percentage of total lung weight. Acute lung injury without ARDS was defined by a PaO2:FIO2 of less than 300 but not less than 200, and ARDS was defined by a PaO2:FIO2 of less than 200. The percentage of potentially recruitable lung was defined as the proportion of lung tissue in which aeration is restored at airway pressures between 5 and 45 cm of water. Panel B shows representative CT slices of the lung obtained 2 cm above the diaphragm dome at airway pressures of 5 cm of water (left) and 45 cm of water (right) from a patient with a lower percentage of potentially recruitable lung (at or below the median value of 9 percent of total lung weight). Lung injury developed in the patient after an episode of severe acute pancreatitis (PaO2:FIO2, 296 at an airway pressure of 5 cm of water; PaCO2, 34 mm Hg; and respiratory-system compliance, 44 ml per centimeter of water). The percentage of potentially recruitable lung was 4 percent, and the proportion of consolidated lung tissue was 33 percent of the total lung weight. Panel C shows representative CT slices of the lung obtained 2 cm above the diaphragm dome at airway pressures of 5 cm of water (left) and 45 cm of water (right) from a patient in the group with a higher percentage of potentially recruitable lung. Lung injury developed in the patient after an episode of severe pneumonia (PaO2:FIO2, 106 at a PEEP of 5 cm of water; PaCO2,58 mm Hg; and respiratory-system compliance, 25 ml per cm of water). The percentage of potentially recruitable lung was 37 percent, and the proportion of consolidated lung tissue was 27 percent of the total lung weight.
- Figure 2. Frequency Distribution of Patients According to the Percentage of Potentially Recruitable Lung (Panel A) and CT Images at Airway Pressures of 5 and 45 cm of Water from Patients with a Lower Percentage of Potentially Recruitable Lung (Panel B) and Those with a Higher Percentage of Potentially Recruitable Lung (Panel C). Panel A shows the frequency distribution of the 68 patients in the overall study group according to the percentage of potentially recruitable lung, expressed as the percentage of total lung weight. Acute lung injury without ARDS was defined by a PaO2:FIO2 of less than 300 but not less than 200, and ARDS was defined by a PaO2:FIO2 of less than 200. The percentage of potentially recruitable lung was defined as the proportion of lung tissue in which aeration is restored at airway pressures between 5 and 45 cm of water. Panel B shows representative CT slices of the lung obtained 2 cm above the diaphragm dome at airway pressures of 5 cm of water (left) and 45 cm of water (right) from a patient with a lower percentage of potentially recruitable lung (at or below the median value of 9 percent of total lung weight). Lung injury developed in the patient after an episode of severe acute pancreatitis (PaO2:FIO2, 296 at an airway pressure of 5 cm of water; PaCO2, 34 mm Hg; and respiratory-system compliance, 44 ml per centimeter of water). The percentage of potentially recruitable lung was 4 percent, and the proportion of consolidated lung tissue was 33 percent of the total lung weight. Panel C shows representative CT slices of the lung obtained 2 cm above the diaphragm dome at airway pressures of 5 cm of water (left) and 45 cm of water (right) from a patient in the group with a higher percentage of potentially recruitable lung. Lung injury developed in the patient after an episode of severe pneumonia (PaO2:FIO2, 106 at a PEEP of 5 cm of water; PaCO2,58 mm Hg; and respiratory-system compliance, 25 ml per cm of water). The percentage of potentially recruitable lung was 37 percent, and the proportion of consolidated lung tissue was 27 percent of the total lung weight.
- Figure 2. After plotting the Pel/V curves for the various PEEP levels on the same graph, the volume derecruited from a given PEEP to ZEEP was measured. Alveolar derecruitment (VDER) ( gray double arrow ) is the volume lost between the Pel/V curve from PEEP and the Pel/V curve from ZEEP, at an elastic pressure (Pel) of 20 cm H2O. LIP, lower inflection point on the Pel/V curve from ZEEP; EELVZEEP, end-expiratory lung volume at ZEEP.
- Figura 2. Metaanálisis sobre la mortalidad incluyendo todos los estudios seleccionados. Efecto sobre la mortalidad del empleo de presión positiva al final de la espiración (PEEP) alta frente a control. Total de eventos 110 (PEEP alta) frente a 120 (control). Test de heterogeneidad Chi cuadrado = 8,81, I2 65,9% (p = 0,03). Efecto no estadísticamente significativo (p = 0,13).
- Figura 3. Metaanálisis sobre la mortalidad incluyendo los estudios en los que la presión positiva al final de la espiración (PEEP) en el grupo estudio se estima en función del punto de inflexión (Pflex). Efecto sobre la mortalidad del empleo de PEEP alta frente a control. Total de eventos 34 (PEEP alta) frente a 52 (control). Test de heterogeneidad Chi cuadrado = 0,27, I2 0% (p = 0,88). Efecto estadísticamente significativo (p = 0,001).
- Intrathoracic Blood Volume Index
- Diagram of changes in the surfactant subtype distribution in acute respiratory distress syndrome (ARDS). Under physiological conditions, some 80–90% of the extracellular surfactant material is in the large surfactant aggregate fraction, which has a high surfactant apoprotein B (SP-B) content and excellent surface activity (γmin; = minimum surface tension after 5 min of film oscillation). In inflammatory lung disease (as in severe pneumonia or ARDS), the small surfactant aggregates increase as SP-B and surface activity within the large-aggregate fraction decrease. Günther et al. Respiratory Research 2001 2 :353 doi:10.1186/rr86
- Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.
- Falla Oxigenación: FiO2>0,7. PEEP>14. IOX>15 Falla Ventilación: pH<7.25 con Vt >6 o Imposibilidad de PPLAT<30
- Assessment of alveolar derecruitment by computed tomography (left panel) and pressure-volume curves (right panel). Image 1 shows a computed tomography (CT) section representative of the whole lung obtained at zero end-expiratory pressure (ZEEP). The dashed line separates poorly aerated and nonaerated lung areas (which appear in light gray and red, respectively, on image 2) from normally aerated lung areas (colored in dark gray on image 2 by a color-encoding system included in Lungview). Image 3 shows the same CT section obtained at a positive end-expiratory pressure (PEEP) of 15 cmH2O. The delineation performed at ZEEP has been transposed on the new CT section in accordance with anatomical landmarks such as divisions of pulmonary vessels. Image 4 shows the same CT section with the color-encoding system, the overinflated lung areas appearing in white. Alveolar derecruitment was defined as the decrease in gas volume in poorly aerated and nonaerated lung regions after PEEP withdrawal. In the right panel, the pressure-volume (P–V) curves of the total respiratory system measured at ZEEP and a PEEP of 15 cmH2O are represented. After determining the decrease in total gas volume resulting from PEEP withdrawal (ΔFRC), ΔFRC was added to each volume for constructing the P–V curve in PEEP conditions. The two curves were then placed on the same pressure and volume axis. Derecruitment volume was identified by a downward shift of the ZEEP P–V curve compared with the PEEP P–V curve and computed as the difference in lung volume between PEEP and ZEEP at an airway pressure of 15 cmH2O.