Curso de Ventilación Mecánica - Aymon 2011... · Curso de Ventilación Mecánica ... la...
Transcript of Curso de Ventilación Mecánica - Aymon 2011... · Curso de Ventilación Mecánica ... la...
Curso de Ventilación Mecánica RESPIMAD 2011
Fundación Jiménez Díaz, Madrid, Junio 22-24
Monitorización durante la ventilación de
protección pulmonarFernando Suarez
Sipmann
Section of Anesthesiology & Critical CareDept of Surgical SciencesHedenstierna LaboratoryUppsala University
ARDSnet
Approach
“Ventilatory strategy adapted tothe size of the ventilated lung”
“Permissive Atelectasis”
Open Lung Approach
“Ventilatory strategy activelyrestoring and maintaining the size of the ventilated lung”
Lung Protective Ventilation: Two
different views
ARDSnet
Approach
Lowest
possible
Pplat
& VtLowest
necessary
PEEP
Lowest
possible
FiO2
Open Lung Approach
Lung recruitmentOpen Lung PEEP titrationLowest
possible
Pplat,deltaP
& Vt
Lowest
possible
FiO2
Schiller et al. Crit Care Med 2001;29:149-1055
Overdistension Normal Collapse
Expi
ratio
nIn
spira
tion
Alveolar behavior
in ALI
Hyperinflated Normally Aerated
Poorly Aerated Non Aerated
End Exp PEEP = 12,6 ±
2,5 cmH2
O
End Insp Pplat
= 28,9 ±
0,9 cmH2
O
Delta vol (ml) (End Ins – End Exp)
Hounsfield Units
Terragni
et al. AJRCCM, 2007;160-166
Limitación del Vt... suficiente?
T = 15 -
30min
Airw
ayP
ress
ures
(cm
H2O
)
0
10
20
30
40
50
60
70PCV delta P 20 cmH2
ORR 15 to
20 I:E
1:1
Initial
Bas
elin
e
Final
RM in Acute
Lung Injury
40
5045
55
T = 2 min
100
Airw
ayP
ress
ure
(cm
H2O
)
0
10
20
30
40
50
60
PaO
2/F
iO2
(mm
Hg)
Gases arteriales continuos
Monitorización durante el reclutamiento: Oxigenación
100
200
300
400
500
2 min
0
10
20
30
40
50
60
70
0
5
10
15
20
25
30
35
Airw
ayPr
essu
res
(cm
H2O
)D
ynam
icC
ompl
ianc
e(m
L/cm
H2O
)
Time (min)
PCVI:E
1.1RR 15
2 min2 min
Monitorización durante el reclutamiento
Borges JB. Am
J Respir
Crit
care
Med
2006;174:268-278
Changes
in compliance: sequential
RM
Cst
> 15%
Sequential
recruitment
maneuvers
(PIP/PEEP)
24 22 20 18 16 14 12 10 8
Airw
ayP
ress
ure
26
Safety
PEEP level
Constant VentilatorySettings. Low Vt/DeltaP
Lung Recruitment
Changes
in oxygenation
and
complianceCTscan
at the
end
of
each
step
Monitoring
PEEP (cmH2O)
Finding Open lung PEEP
The
decremental
PEEP trial
Colapso Progresivo
Alivio de la sobredistensióne inicio del colapso
+Reclutamiento Tidal
Predominio de lasobredistensión
24 22 20 18 16 14 12 10 8 6 0
PEEP levels during decremental PEEP titration (cmH2O)
Cambios en Cdyn
durante PEEP decrementalC
dyn
(mL/
cmH
2O)
Vt
bajo
Courtesy ofCourtesy of Dr.Dr. Gary Gary NiemanNieman, , Upstate New York University, 2007Upstate New York University, 2007
Decremental PEEP trialLung Injury
Model
Cdy
n(m
L/cm
H2O
)
Decremental
PEEP levels
Cdyn for PEEP titration
0
10
20
30
40
50
60
70
CT %
Non-aerated
tissue
24 22 20 18 16 14 12 10 8 6 0
0
5
10
15
20
25
30
Crit
Care Med
2007; 35:214–221
Overdistension Collapse
0%
10%
20%
30%
40%
24 22 20 18 16 14 12 10 8 6 0
RM
*
Tidalrecruitment(%
)
Decremental
PEEP levels
0
5
10
15
20
25
30
Cdy
n(m
L/cm
H2O
)
Vt
6 mL/kg
Crit
Care Med
2007; 35:214–221
Cdyn
for
PEEP titration
Overdistension Collapse
20
25
30
35
40
45
50
55
60
26 24 22 20 18 16 14 12 10 8PEEP levels during a decremental PEEP titration (cmH2 O)
C d
yn(m
L/cm
H2O
)Cambios en Cdyn
durante el SDRA
---------------------------DLL---------------------------Se ha intentado cargar un programa con un formato incorrecto.
---------------------------Aceptar ---------------------------
CT Image(Anatomical)
PEEP 23 cmH2
O PEEP 7 cmH2
O
EIT Image(Functional)
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
Fernando Suarez-Sipmann, Uppsala, 20009
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
PEEP (cmH2
O)
Cdy
n(m
L/cm
H2O
)
0
5
10
15
20
25
30
22 20 18 16 14 12 10 8
PaO
2 /FiO2 (m
mH
g)
100
200
300
400
500
0
VTC
O2b
r(m
L)
1
2
3
4
5
6
7
Cdyn
(mL/cm
H2 O
)
0
5
10
15
20
25
30NormalOverdistension Collapse
Baseline RM 20 18 16 14 12 10 8
PEEP (cmH2
O)
Use of
VC for
PEEP titration
VILI model
Non‐invasive
Bohr’s
Dead
Space
VDVT
=PACO2 – PeCO2
PACO2
Bohr
Tusman
et al. ICM. DOI 10.1007/s00134-011-2164-x
Stress Index
Vt
= 6 ml/kg
PEEP = 5 cmH2
O
Pplat
= 22 cmH2
O
End-Expiration End-Inspiration
b = 1
b = 1
Vt
= 6 ml/kg
PEEP = 17 cmH2
O
Pplat
= 32 cmH2
O
Grasso
S et al. Crit
Care Med
Baumgardner
J et al. Am
J Respir
Crit
Care Med
Vol
2002:1556–1562
PaO2
Oscillations
and
tidal
recruitment