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PublicouRaíssa Sampaio Alterado mais de 9 anos atrás
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Como evitar a VILI Eduardo LV Costa Valerie VILI
Alt 1,93m Peso 120 Kg UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês
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Mecanismos de lesão Recrutamento cíclico Colapso focal / Estresse
Hiperdistensão Hiperdistensão cíclica Strain (deformação)
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Tidal recruitment Expiração Cortesia Dr. G Janot
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Tidal recruitment Inspiração Cortesia Dr. G Janot
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+30 Colapso focal (stress raisers) +70 Mead – JAP 1970
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Pplat > cm H2O Am J Respir Crit Care Med 2007
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Protti CCM 2013
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Protti CCM 2013
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Aeração CCM 2014
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Inflamação Borges - CCM 2014
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Imagem de Fusão Borges - CCM 2014
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10 compartimentos de aeração
Borges - CCM 2014
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One size fits all? Bellani CCM 2009
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Evolução da ventilação protetora
Volume corrente alto Volume corrente baixo Amato NEJM 1998
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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
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Evolução da ventilação protetora
Volume corrente alto Volume corrente baixo Vt/peso ideal ARMA NEJM 2000
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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
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Como evitar a VILI Ventilando adequadamente o baby lung
Mudando a história pulmonar Sipmann CCM 2007 Gernoth CCF 2009 Retamal CCF 2013
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Vt adequado ao baby lung (‘medindo’ o tamanho do baby lung)
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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
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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 %
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PEEP = 25 decremental PEEP = 7 Hyperdistensão Colapso EIT EIT Collapse
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP
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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
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 29
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 30
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PEEP TITRATION BY EIT Overdistension Collapse
BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP 31
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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
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Medindo o tamanho do pulmão
50% 6-8 ml/kg x (1 – 0,355) = 3,9-5,2 ml/kg Hipoxemia Reske CCM 2013
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Medindo o tamanho do pulmão
Hipoxemia Complacência Complacência = Cs * CRF
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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
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Driving pressure (ΔP) normal
Vt = 6-8 ml/kg ~ 500 ml Complacência = ml/cmH2O ΔP = Vt / Complacência ~ 7 cmH2O
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PEEP CRS VT PPlatô Stress Driving raisers Pressure (ΔP) VILI
Amato NEJM 1998
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Amato…………….…….53 Brochard…………..….116 Stewart…………....…..120 Brower……………….…52 ARDSnet….…………..861 ALVEOLI…….………..549 LOVS………………….983 Express………………..768 3502
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Quintiles of ∆P matched for PEEP
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Quintiles of PEEP matched for ∆P
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Quintiles of ∆P matched for PPLAT
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Quintiles of ∆P matched for PPLAT
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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 )
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P = marcador de gravidade?
P = V Crs
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“negative” clinical studies: Driving P.
High Low ALVEOLI LOVS Express
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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)
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Como mudar o tamanho do pulmão funcionante PEEP e recrutamento revisitados
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Hyperinflated Normally aerated Poorly aerated Not aerated
Not Protected EI EE Hyperinflated Normally aerated Poorly aerated Not aerated
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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
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Collapse: 55.6 % Patient # 9 Pneumocystis carinii pneumonia
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FIO2 = 100 %; VT = 4 mL/kg; PEEP = 26 cmH2O
( after PPLAT = 55 ) Collapse: 0.9 % Patient # 9 Pneumocystis carinii pneumonia
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PEEP = 5; PPLAT = 25
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PEEP = 17; PPLAT = 40
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PEEP = 25; PPLAT = 40
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PEEP = 25; PPLAT = 60
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Vermelho = hiperinsuflado
PEEP=25 - Inspiração Vermelho = hiperinsuflado
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Vermelho = hiperinsuflado
PEEP=25 - Inspiração – após recrutamento Vermelho = hiperinsuflado
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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
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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
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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
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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
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N = 25 Rec. Driving pressure PEEP PEEP
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? N = 25 Rec. “PEEP table trial” Driving pressure PEEP PEEP
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Driving pressure PEEP Rec. “PEEP table trial” N = 25
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N = 25 Rec. “PEEP table trial” Driving pressure PEEP PEEP
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Rec. N = 25 Driving pressure PEEP PEEP “PEEP table trial” “decremental
PEEP titration” Driving pressure PEEP PEEP
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Rec. “ Hysteresis “ N = 25 Driving pressure PEEP PEEP “PEEP table
trial” “decremental PEEP titration” Driving pressure PaO2/FIO2 = 180 PaO2/FIO2 = 380 PEEP PEEP
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Obrigado Eduardo LV Costa eduardo.leite@hc.fm.usp.br
UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês
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