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

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

Tidal recruitment Expiração Cortesia Dr. G Janot

Tidal recruitment Inspiração Cortesia Dr. G Janot

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

Pplat > 26 - 27 cm H2O Am J Respir Crit Care Med 2007

Protti CCM 2013

Protti CCM 2013

Aeração CCM 2014

Inflamação Borges - CCM 2014

Imagem de Fusão Borges - CCM 2014

10 compartimentos de aeração Borges - CCM 2014

One size fits all? Bellani CCM 2009

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

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

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

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

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

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

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

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 %

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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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 UNPUBLISHED DATA .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

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

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

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

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

Driving pressure (ΔP) normal Vt = 6-8 ml/kg ~ 500 ml Complacência = 80-100 ml/cmH2O ΔP = Vt / Complacência ~ 7 cmH2O

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

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

Quintiles of ∆P matched for PEEP

Quintiles of PEEP matched for ∆P

Quintiles of ∆P matched for PPLAT

Quintiles of ∆P matched for PPLAT

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 )

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

“negative” clinical studies: Driving P. High Low ALVEOLI 13 15 LOVS 14 15 Express 13 14

Changes in ∆P caused by randomization ( PEEP trials, only ) 100 95 90 P = 0.003 85 Adjusted Survival (%) 80 higher PEEP and ∆P-change = - 3.7 75 higher PEEP and ∆P-change = + 0.4 70 higher PEEP and ∆P-change = + 4 .1 65 10 20 30 40 50 60 Days after randomization Control arm ( ∆P-change = + 1.3 ) (N = 794)

Como mudar o tamanho do pulmão funcionante PEEP e recrutamento revisitados

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

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

Collapse: 55.6 % Patient # 9 Pneumocystis carinii pneumonia

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

PEEP = 5; PPLAT = 25

PEEP = 17; PPLAT = 40

PEEP = 25; PPLAT = 40

PEEP = 25; PPLAT = 60

Vermelho = hiperinsuflado PEEP=25 - Inspiração Vermelho = hiperinsuflado

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

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

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

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

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

N = 25 Rec. Driving pressure PEEP PEEP

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

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

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

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

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

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