Como evitar a VILI Eduardo LV Costa Valerie VILI

Apresentação em tema: "Como evitar a VILI Eduardo LV Costa Valerie VILI"— Transcrição da apresentação:

1 Como evitar a VILI Eduardo LV Costa Valerie VILI
Alt 1,93m Peso 120 Kg UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês

2 Mecanismos de lesão Recrutamento cíclico Colapso focal / Estresse
Hiperdistensão Hiperdistensão cíclica Strain (deformação)

3 Tidal recruitment Expiração Cortesia Dr. G Janot

4 Tidal recruitment Inspiração Cortesia Dr. G Janot

5 +30 Colapso focal (stress raisers) +70 Mead – JAP 1970

6 Pplat > cm H2O Am J Respir Crit Care Med 2007

7 Protti CCM 2013

8 Protti CCM 2013

9 Aeração CCM 2014

10 Inflamação Borges - CCM 2014

11 Imagem de Fusão Borges - CCM 2014

12 10 compartimentos de aeração
Borges - CCM 2014

13 One size fits all? Bellani CCM 2009

14 Evolução da ventilação protetora
Volume corrente alto Volume corrente baixo Amato NEJM 1998

15 Volume corrente normal
Volumes Homem Mulher CPT 6,0L 4,2L CRF 2,2L 1,8L Vt (6-8ml/kg) 600mL 420mL Vt < 30% da CRF  Strain < 1,3

16 Evolução da ventilação protetora
Volume corrente alto Volume corrente baixo Vt/peso ideal ARMA NEJM 2000

17 Evolução da ventilação protetora
Volume corrente (Vt) alto Vt baixo Vt/peso ideal Vt/tamanho do pulmão funcionante? (sizing the lung) Amato NEJM 1998 ARDS Network NEJM 2000 Mattingley & Hubmayr CCF 2011

18 Como evitar a VILI Ventilando adequadamente o baby lung
Mudando a história pulmonar Sipmann CCM 2007 Gernoth CCF 2009 Retamal CCF 2013

19 Vt adequado ao baby lung (‘medindo’ o tamanho do baby lung)

20 FIO2 = 100 %; VT = 4 mL/kg; PEEP = 5 cmH2O
6-8 ml/kg x (1 – 0,556) = 2,7-3,6 ml/kg Colapso: 55.6 % Pneumocystis jiroveci

21 FIO2 = 100 %; VT = 4 mL/kg; PEEP = 25 cmH2O
( após recrutamento) 6-8 ml/kg x (1 – 0,01) = 6-8 ml/kg Colapso: 0.9 %

22

23 PEEP = 25 decremental PEEP = 7 Hyperdistensão Colapso EIT EIT Collapse

24 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP

25 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP

26 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP

27 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP

28 PEEP TITRATION BY EIT 6-8 ml/kg x (1 – 0,05) = 5,7-7,6 ml/kg
Overdistension Collapse 6-8 ml/kg x (1 – 0,05) = 5,7-7,6 ml/kg BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP

29 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 29

30 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 30

31 PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 31

32 PEEP TITRATION BY EIT 6-8 ml/kg x (1 – 0,355) = 3,9-5,2 ml/kg
Overdistension Collapse 6-8 ml/kg x (1 – 0,355) = 3,9-5,2 ml/kg BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 32

33 Medindo o tamanho do pulmão
50% 6-8 ml/kg x (1 – 0,355) = 3,9-5,2 ml/kg Hipoxemia Reske CCM 2013

34 Medindo o tamanho do pulmão
Hipoxemia Complacência Complacência = Cs * CRF

35 Vt e VM protetora Complacência ~ CRF p.e. Pneumonectomia -> ½ comp
Normalização “em vigor” Vt / Peso ideal Proposta Vt / Complacência Complacência = Vt / ΔP Vt / Complacência = Vt / (Vt / ΔP) = ΔP

36 Driving pressure (ΔP) normal
Vt = 6-8 ml/kg ~ 500 ml Complacência = ml/cmH2O ΔP = Vt / Complacência ~ 7 cmH2O

37 PEEP CRS VT PPlatô Stress Driving raisers Pressure (ΔP) VILI
Amato NEJM 1998

38 Amato…………….…….53 Brochard…………..….116 Stewart…………....…..120 Brower……………….…52 ARDSnet….…………..861 ALVEOLI…….………..549 LOVS………………….983 Express………………..768 3502

39 Quintiles of ∆P matched for PEEP

40 Quintiles of PEEP matched for ∆P

41 Quintiles of ∆P matched for PPLAT

42 Quintiles of ∆P matched for PPLAT

43 High vs. Low PEEP studies
Patients under stricter “protective” settings ( Plateau-pressure < 32 cmH2O and VT < 8 mL/ kg / ibw ) High vs. Low VT studies ( n = 883 ) High vs. Low PEEP studies ( n = 1457 )

44 P = marcador de gravidade?
P = V Crs

45

46 “negative” clinical studies: Driving P.
High Low ALVEOLI LOVS Express

47 Changes in ∆P caused by randomization ( PEEP trials, only )
100 95 90 P = 0.003 85 Adjusted Survival (%) 80 higher PEEP and ∆P-change = 75 higher PEEP and ∆P-change = 70 higher PEEP and ∆P-change = 65 10 20 30 40 50 60 Days after randomization Control arm ( ∆P-change = ) (N = 794)

48 Como mudar o tamanho do pulmão funcionante PEEP e recrutamento revisitados

49 Hyperinflated Normally aerated Poorly aerated Not aerated
Not Protected EI EE Hyperinflated Normally aerated Poorly aerated Not aerated

50 60 55 50 45 40 Stepwise Recruitment Strategy DP = 15 cmH2O
70 60 60 55 50 DP = 15 cmH2O 50 45 CPAP 40 40 OLA Airway Pressures (cmH2O) 30 Baseline 25 cmH2O 20 10 T MAX = 20 min Time Borges AJRCCM 2006

51 Collapse: 55.6 % Patient # 9 Pneumocystis carinii pneumonia

52 FIO2 = 100 %; VT = 4 mL/kg; PEEP = 26 cmH2O
( after PPLAT = 55 ) Collapse: 0.9 % Patient # 9 Pneumocystis carinii pneumonia

53 PEEP = 5; PPLAT = 25

54 PEEP = 17; PPLAT = 40

55 PEEP = 25; PPLAT = 40

56 PEEP = 25; PPLAT = 60

57 Vermelho = hiperinsuflado
PEEP=25 - Inspiração Vermelho = hiperinsuflado

58 Vermelho = hiperinsuflado
PEEP=25 - Inspiração – após recrutamento Vermelho = hiperinsuflado

59 Airway Pressure (cmH2O) PEEP STEPS - MAXIMUM-RECRUITMENT STRATEGY
70 Recruitment phase PEEP titration phase 60 50 45 40 2 min 5 min Airway Pressure (cmH2O) 35 30 25 25 PCV DP = 15 cmH2O 20 20 20 15 10 Baseline (PEEP = 10) 10 Time PEEP STEPS - MAXIMUM-RECRUITMENT STRATEGY ( : CT scan – end-expiratory pause ) Borges AJRCCM 2006

60 Non-aerated Lung Tissue ( % of total lung mass )
80 60 Non-aerated Lung Tissue ( % of total lung mass ) 40 20 Baseline PEEP (~10) Maximum PEEP Titrated PEEP (~24) Janot CCF 2012

61 PaO2/FIO2 = 113 PaO2/FIO2 = 357 Baseline PEEP Maximum PEEP
Potential for recruitment: 48% Relative response: 98% Potential for recruitment: 63% Relative response: 82% Potential for recruitment: 36% Relative response: 45% Baseline PEEP PaO2/FIO2 = 113 Maximum PEEP PaO2/FIO2 = 357 Titrated PEEP 61

62 PEEP titration study RM
PCV Pins 60 PEEP 40 cmH2O 2 min Incremental PEEP steps 26 26 Decremental PEEP steps 24 24 22 22 20 20 18 18 16 16 14 14 12 12 10 10 8 8 VCV 6 ml/kg VCV 6 ml/kg PEEP steps (10 min at each level)) Search for Open lung PEEP (Oxyg and Cdyn) Changes in Cdyn (OLT) Changes in Oxygenation

63 N = 25 Rec. Driving pressure PEEP PEEP

64 ? N = 25 Rec. “PEEP table trial” Driving pressure PEEP PEEP

65 Driving pressure PEEP Rec. “PEEP table trial” N = 25

66 N = 25 Rec. “PEEP table trial” Driving pressure PEEP PEEP

67 Rec. N = 25 Driving pressure PEEP PEEP “PEEP table trial” “decremental
PEEP titration” Driving pressure PEEP PEEP

68 Rec. “ Hysteresis “ N = 25 Driving pressure PEEP PEEP “PEEP table
trial” “decremental PEEP titration” Driving pressure PaO2/FIO2 = 180 PaO2/FIO2 = 380 PEEP PEEP

69 Obrigado Eduardo LV Costa eduardo.leite@hc.fm.usp.br
UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês