estrategia de pulmón abierto
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Edgar Jiménez, MD, FCCM
Director – UCI y Co-Chairman Medicina CríticaOrlando Regional Medical Center
Profesor Asociado de MedicinaUniversity of Florida, Florida State University &
University of Central Florida
PresidenteFederación Mundial de Sociedades de Medicina Crítica
Estrategia de “Pulmón Abierto” Utilizando Presiones Transpulmonares
2º Seminario de Ventilación Mecánica - VAFO
Asociación Panameña de Medicina Crítica y Terapia Intensiva
Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011
Edgar Jiménez, MD, FCCM
Director – UCI y Co-Chairman Medicina CríticaOrlando Regional Medical Center
Profesor Asociado de MedicinaUniversity of Florida, Florida State University &
University of Central Florida
PresidenteFederación Mundial de Sociedades de Medicina Crítica
Estrategia de “Pulmón Abierto” Utilizando Presiones Transpulmonares
2º Seminario de Ventilación Mecánica - VAFO
Asociación Panameña de Medicina Crítica y Terapia Intensiva
Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011
Disclosures
• Research:
– NASA
– CareFusion®
– CCCTG & CIHR
Objectives
Using in vivo videomicroscopy will demonstrate the anatomical, physiological and pathophysiological findings of:
• Normal lungs• Acutely injured lungs• Lung recruitment using Ptp• Intra-abdominal hypertension
• 1966• “Oscar” for Special
Effects• Isaac Azimov• Richard Fleischer• Raquel Welch
Fantastic Voyage
Raquel Welch
Real-life“Fantastic Voyager”
Gary Nieman, BA
Director:
Critical Care Translational Research LaboratoryORMC, Orlando, FL
Cardiopulmonary and Critical Care LaboratorySUNY, Syracuse, NY
Labs in Syracuse, NYand Orlando, FL
How come?
In vivo videomicroscopy
Concept of RACE:Repetitive alveolar closing and expansion
Mechanisms of VILI
• Barotrauma• Volutrauma• Biotrauma• Atelectrauma
Mechanisms of VILI
• Barotrauma• Volutrauma• Biotrauma• Atelectrauma
To understand:abnormal alveolar mechanics
We must first understand:
normal alveolar mechanics
“The end”of the Bronchial
Tree
F. Possmayer, PhD. U. of Western Ontario
F. Possmayer, PhD. U. of Western Ontario
F. Possmayer, PhD. U. of Western Ontario
How do we breathe?
Weibel et al Respir Physiol 1985
Alveolar Duct
Alveolar Duct
Expiration
Inspiration
Normal alveolar dynamics
G Nieman, SUNY
G Nieman, SUNY
G Nieman, SUNY
G Nieman, SUNY
Alveoli:Not Just a Bunch of Grapes
Prange H: Adv Physiol Educ 2003
Alveolar IndependenceStructural Support
Mead: JAP 1970
Honeycomb-like structural support
Hiroko & Nieman, SUNY 2005
Hiroko & Nieman, SUNY 2005
Hiroko & Nieman, SUNY 2005
Stressed alveolar sac
G Nieman, SUNY
G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
Courtesy of Dr. Marcelo Amato
G r a v i t y
Courtesy of Dr. Marcelo Amato
G r a v i t y
Courtesy of Dr. Marcelo Amato
Stress
Strain
G r a v i t y
Courtesy of Dr. Marcelo Amato
G r a v i t y
Courtesy of Dr. Marcelo Amato
G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
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G r a v i t y
Courtesy of Dr. Marcelo Amato
Pendeluft
Stresses on the Epithelium during Fluid Displacement
Bilek AM et al. J Appl Physiol 2003;94:770-783
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Rigid airwayCourtesy of Dr. Marcelo Amato
Stresses on Epithelium during Airway Opening
Bilek AM et al. J Appl Physiol 2003;94:770-783
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
Flexible airway
Courtesy of Dr. Marcelo Amato
VIAS YS He a lthca re , Inc.
Wa re a nd Ma ttha y NEJ M 342 (18): 1334
Capillary LeakCapillary LeakCapillary Leak
Fu Z, JAP 1992; 73:123
Capillary LeakCapillary LeakCapillary Leak
Fu Z, JAP 1992; 73:123
Steinberg J.et al. Am J Resp Crit Care Med 2004
Heterogeneous Lung Injury
Normal lung: In vivo Microscopy Histology + IHC
Injured lung:In vivo MicroscopyHistology + IHC
Steinberg et al. AJRCCM. 2004;169:57-63
Steinberg et al. AJRCCM. 2004;169:57-63
Stable Alveoli
Unstable Alveoli
Low PEEP Group(3)
Steinberg et al. AJRCCM. 2004;169:57-63
Stable Alveoli
Alveoli StabilizedWith PEEP
High PEEP Group(15)
PEEP = improves oxygenation
PEEP = improves oxygenation
It’s more than that!
PEEP = stabilizes alveoli
PEEP = decreases RACE
PEEP = decreases VILI
ARDSNet (NHLBI)
• NEJM, May – 2000• 10 University Centers• Criteria:
– Bilateral infiltrates– Intubation and mechanical ventilation– PaO2/FiO2 <300
28 Day Survival
0
0.2
0.4
0.6
0.8
1
0 7 14 21 28Days after study entry
Proportion Surviving 12
ml/kg
6 ml/kg
ARDSNet NEJM, 2000
Respiratory Cycle
Ppeak
PEEPTrigger
Pplat
Initial table for FiO2 & PEEP
ARDSNet NEJM, 2000
ARDSNet demonstrated:
An outcome changeprimarily associated to a
change in ventilatory strategy(LV)
A big question:
Is the ARDS Net Protocol enough?
Not really
• We may not know the true transpulmonary pressure (Ptp)
• Timid and arbitrary PEEP scale
Meta-Analysis Based on
• ALVEOLI• LOVS• EXPRESS
Briel, M. et al. JAMA 2010;303:865-873.
Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline
% HPEEP
LPEEP
P H PEEP
L PEEP
P HPEEP
LPEEP
P
D Hosp 32.9 35.2 .25 34.1 39.1 .049 27.2 19.4 .07
D ICU 28.5 32.8 .01 30.3 36.6 .001 19.6 16.8 .71
RESC 12.2 18.6 < .001 13.7 21.3 < .001 4.4 7.3 .70
D RESC 7.5 11.3 < .001 8.6 13.2 < .001 1.6 3.6 .15
All Pts ARDS Non-ARDS
Briel, M. et al. JAMA 2010;303:865-873.
Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline
% HPEEP
LPEEP
P H PEEP
L PEEP
P HPEEP
LPEEP
P
D Hosp 32.9 35.2 .25 34.1 39.1 .049 27.2 19.4 .07
D ICU 28.5 32.8 .01 30.3 36.6 .001 19.6 16.8 .71
RESC 12.2 18.6 < .001 13.7 21.3 < .001 4.4 7.3 .70
D RESC 7.5 11.3 < .001 8.6 13.2 < .001 1.6 3.6 .15
All Pts ARDS Non-ARDS
Briel, M. et al. JAMA 2010;303:865-873.
Volume
Pressure
Zone ofOverdistention
“Safe”Window
Zone ofDerecruitmentand Atelectasis
Injury
Injury
Optimized Lung Volume “Safe Window”
• Overdistension – Edema fluid accumulation– Surfactant degradation– High oxygen exposure– Mechanical disruption
• Derecruitment– Atelectasis– Inflammatory response– Surfactant inhibition – Local hypoxemia– Compensatory overexpansion
Froese: Crit Care Med 1997
CT 1 CT 2CT 3
Froese: Crit Care Med 1997
How do We Open the Lung and Keep it Open?
How do We Open the Lung and Keep it Open?
• Open:
Recruitment maneuver
How do We Open the Lung and Keep it Open?
• Open:
Recruitment maneuver
• Keep it open:
PEEP or HFOV
Ware and Matthay NEJM 342 (18): 1334
Current Ventilation Practices
• Volume Ventilation, Low VT, PEEP
• Pressure Control Ventilation– PEEP, Inverse I:E Ratio
• VCV or PCV with PEEP adjusted by Ptp• Non-Conventional Ventilation
– APRV/Bi-Level– HFOV
• Pronation, iNO• ECMO
How do we know we have achieved OL-PEEP?
How do we do it?• ARDS Net• ALVEOLI, LOVS, EXPRESS• Decremental PEEP Trial• Pes and Ptp• Volumetric Capnography• Auscultation• Ultrasound• Respiratory Impedance Pletysmography• Electrical Impedance Tomography• HFOV - TOOLS
How do we do it?• ARDS Net• ALVEOLI, LOVS, EXPRESS• Decremental PEEP Trial• Pes and Ptp• Volumetric Capnography• Auscultation• Ultrasound• Respiratory Impedance Pletysmography• Electrical Impedance Tomography• HFOV - TOOLS
How do we do it?• ARDS Net• ALVEOLI, LOVS, EXPRESS• Decremental PEEP Trial• Pes and Ptp• Volumetric Capnography• Auscultation• Ultrasound• Respiratory Impedance Pletysmography• Electrical Impedance Tomography• HFOV - TOOLS
Can we do better?
Let’s talk about pressure…
Let’s talk about pressure…
and the trumpet player
How much airway pressure can a trumpet player generate?
Trumpet player
Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
Cook. J Applied Phys. 1964. 1016
Cook. J Applied Phys. 1964. 1016
Answer: 100-120 cm H2O
Cook. J Applied Phys. 1964. 1016
So…
Why don’t we see more ALI and ARDS in these players?
Answer:
Because they keep the Ptp within tolerable limits
Answer:
Because they keep the Ptp within tolerable limits
with
the use of their respiratory muscles
Let’s go to extremes ofairway pressure
Paw at sea level:
Paw at sea level: 1034 cm H2O
Paw at a 33 ft dive:
Paw at a 33 ft dive: 2068 cm H2O
Paw at a 33 ft dive: 2068 cm H2O
Add 1034 cm H2O for every 33 ft.
Paw at a 100 ft dive:
Add 1034 cm H2O for every 33 ft.
Paw at a 100 ft dive: 4140 cm H2O
Add 1034 cm H2O for every 33 ft.
So…
Why don’t we see more ALI and ARDS in these divers?
Answer:
Because they keep the Ptp within tolerable limits
Answer:
Because they keep the Ptp within tolerable limits
with
a similar increase in the external environmental pressure
It’s all relative!
<0.5 MPH
17,000 MPH
17,000 MPH
<0.5 MPH
17,000 MPHSuccess!
What is the Paw at 10,000 ft?
What is the Paw at 10,000 ft?
795 cm H2O
What is the Paw at 10,000 ft?
795 cm H2O
30% lessthan MSL
What is the Paw atMt. Everest’s summit?
What is the Paw atMt. Everest’s summit?
285 cm H2O
What is the Paw atMt. Everest’s summit?
285 cm H2O
72% lessthan MSL
They can get in LOTS of trouble!
They can get in LOTS of trouble!
Management of ALI and ARDS using Transpulmonary Pressures
Management of ALI and ARDS using Transpulmonary pressures
• Factors that may alter current recomendations based on ↓Ccw:– Obesity– Edema/anasarca– Intra-abdominal pressure– Pregnancy– Chest wall deformities– Scars
The problem???
• With Pplat, we are measuring only one side of the equation!!!!!
• What happens with patients with compromised compliances?
The problem???
• With Pplat, we are measuring only one side of the equation!!!!!
• What happens with patients with compromised compliances?
• We DON’T KNOW!
Intrathoracic pressures
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
Pplat
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
Ptp
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
Ptp
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
Pes
Position of Esophagus and Pleura
Position of Esophagus and Pleura
Pplat and Ptp
• Kubiak, Jimenez, Silva, Nieman• Marked variability among patients in
abdominal and pleural pressures• For a given PEEP, Ptp may vary
unpredictably from patient to patient.
Malbrain ML et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study.Crit Care Med 2005;33:315-322.
Talmor D et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 2006;34:1389-1394
Relationship Ptp - Tv
Talmor et al. Crit Care Med, 2006
Ptp
(cm H2O)
Tv(mL/kg)
Figure 1
0
5
10
15
20
25
30
Stage One Stage Two
Increasing IAP
0 0
Vt PEEP
Kubiak, Jimenez, Nieman, J Surg Trials, 2010
Kubiak, Jimenez, Nieman, J Surg Trials, 2010
Kubiak, Jimenez, Nieman, J Surg Trials, 2010
Kubiak, Jimenez, Nieman, J Surg Trials, 2010
Jimenez, Nieman ORMC, 2008
Transpulmonary Pressure, Plateau (Ptp-plat)
Increased Ptp :
↓ compliance
↑ negative Ppl
Decreased Ptp :
normal compliance
not assisting on the ventilator
Intrathoracic pressures
Tracheal pressures are measured at distal
end of ET Tube
Ptr (Paw)
Esophageal Pressure Measurements
Connections
Connections
Connections
Ptp
• Placed in lower 1/3 of esophagus, above diaphragm
• Measured pressures reflect pleural pressures
Esophageal Balloon
Paw
Pes
Breath Initiation
20
10
0
-10
-20
20
10
0
-10
-20
cm H2O
The Baydur Maneuver
Hypothesis
• Patients with ↑ Ppl with conventional settings:– Underinflation → causes hypoxemia– Raising PEEP to maintain a positive Ptp improves
aeration and oxygenation without overdistention.
Hypothesis
• Patients with ↓ Ppl with conventional settings:– Maintaining low PEEP would keep low Ptp– Prevents overdistention– Minimizing adverse hemodynamic effects of high
PEEP
Beyer J et al: The influence of PEEP ventilation on organ blood flow and peripheral oxygen delivery. Intensive Care Med 1982;8:75-80.
Goal
• To provide sufficient Ptp (Paw - Ppl) to:– Maintain acceptable PaO2
– Minimize repeated alveolar collapse– Minimize overdistention
Ptp = Ptr – Pes
Slutsky AS. Lung injury caused by mechanical ventilation. Chest 1999;116:Suppl:9S-15S.
Methods
• Supine• HOB 30º• Esophageal balloon catheter passed to 60 cm
from incisors– Gentle compression of abdomen
• Then withdrawn to 40 cm– Cardiac artifact
• 1/3 couldn’t be passed into stomach
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Methods
• Recruitment maneuver– 40 cm H2O X 40 sec.
– Max Ptp-plat < 25 cm H2O
• VT: 6 mL/kg PBW
• PBW:– ♂: 50 + 0.91 X (cm – 152.4)– ♀: 45.5 + 0.91 X (cm – 152.4)
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Strategy
• PaO2: 55-120 mm Hg– Or SpO2: 88-98 %
• pH: 7.30-7.45• pCO2: 40-60 mm Hg
• VT: Adjusted to keep Ptp-plat < 25 cm H2O
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Strain (dVgas/Vgas0)
0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0
Stre
ss (
PL
, cm
H2O
)
0
5
10
15
20
25
30
35
40
45
50
55
Stress-strain curve of healthy pigs
Specific Lung Elastance 5.8 cmH2O
Protti A. et al. Am J Respir Crit Care Med. 2011 Feb 4. [Epub ahead of print]
Protti A. et al. Am J Respir Crit Care Med. 2011 Feb 4. [Epub ahead of print]
Strategy
• PCV or VCV• I:E : 1:1 to 1:3• RR: < 35• RM: PRN for suction/disconnection
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Table
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Table
FiO2 0.4 0.5 0.5 0.6 0.6 0.7 0.7 0.8 0.8 0.9 0.9 1.0
Ptp-PEEP
0 0 2 2 4 4 6 6 8 8 10 10
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Study
• Stopped after 61 pts as criteria were met in interim analysis
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
PaO2/FiO2
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Respiratory System Compliance(mL/cm H2O)
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
VD/VT
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
PEEP
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Ptp - EE
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Ptp - PEEP
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Pplat
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Ptp – PLAT
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
Ptp – EI
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
K-M Survival
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
ARDSNet Lung (ARMA)
Jimenez E, Nieman G, ORMC 2011
Ptp Lung
Jimenez E, Nieman G, ORMC 2011
Talmor presents:
An improvement in oxygenation and compliance with
Ptp significantly lower thanoverestimated Pplat
Talmor presents:
A persistent negative Ptp-PEEP when using the ARDS Net scale
A big question:
Is this enough?
Not really
• Arbitrary PEEP scale• We need to know how to adjust it better• We need to find morbidity/mortality data
What else can we use?
Volumetric Capnography
Terminology
• End-Tidal CO2 (ETCO2)
Peak concentration of CO2 at end exhalation.
• Time-Based Capnography
Concentration of CO2 plotted as a scale
• Volumetric Capnography
Concentration of CO2 integrated with flow.
Zero baseline (A-B)
Rapid, sharp rise (B-C)Alveolar plateau (C-D)
End tidal value (D)
Rapid, sharp downstroke (D-E)
• EtCO2 • Capnogram• RR
Capnography Volumetric CO2
• CO2 Elimination• Deadspace• Alveolar Ventilation• Cardiac Output / Perfusion• Physiologic Vd/Vt
PEEP & VCO2
VCO2 isCO2 elimination
from CO2 production… …in a steady state!!!
Important questions for us:
• Is the pt OK with LVHP (ARDS Net)?• Is the FiO2 > 0.60?
• Is your Pplat > 30 cm H2O?
• Is your Paw > 20 cm H2O?
• Is your Ptp plat> 20 cm H2O?
• PEEP > 15 cm H2O?
• OI > 15?
Important questions for us:
• Is the pt OK with LVHP (ARDS Net)?• Is the FiO2 > 0.60?
• Is your Pplat > 30 cm H2O?
• Is your Paw > 20 cm H2O?
• Is your Ptp plat> 20 cm H2O?
• PEEP > 15 cm H2O?
• OI > 15?
What’s Next ????
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