Download - 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
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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
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Disclosures
• Research:
– NASA
– CareFusion®
– CCCTG & CIHR
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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
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• 1966• “Oscar” for Special
Effects• Isaac Azimov• Richard Fleischer• Raquel Welch
Fantastic Voyage
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Raquel Welch
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Real-life“Fantastic Voyager”
Gary Nieman, BA
Director:
Critical Care Translational Research LaboratoryORMC, Orlando, FL
Cardiopulmonary and Critical Care LaboratorySUNY, Syracuse, NY
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Labs in Syracuse, NYand Orlando, FL
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How come?
In vivo videomicroscopy
Concept of RACE:Repetitive alveolar closing and expansion
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Mechanisms of VILI
• Barotrauma• Volutrauma• Biotrauma• Atelectrauma
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Mechanisms of VILI
• Barotrauma• Volutrauma• Biotrauma• Atelectrauma
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To understand:abnormal alveolar mechanics
We must first understand:
normal alveolar mechanics
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“The end”of the Bronchial
Tree
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F. Possmayer, PhD. U. of Western Ontario
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F. Possmayer, PhD. U. of Western Ontario
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F. Possmayer, PhD. U. of Western Ontario
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How do we breathe?
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Weibel et al Respir Physiol 1985
Alveolar Duct
Alveolar Duct
Expiration
Inspiration
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Normal alveolar dynamics
G Nieman, SUNY
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G Nieman, SUNY
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G Nieman, SUNY
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G Nieman, SUNY
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Alveoli:Not Just a Bunch of Grapes
Prange H: Adv Physiol Educ 2003
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Alveolar IndependenceStructural Support
Mead: JAP 1970
Honeycomb-like structural support
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Hiroko & Nieman, SUNY 2005
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Hiroko & Nieman, SUNY 2005
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Hiroko & Nieman, SUNY 2005
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Stressed alveolar sac
G Nieman, SUNY
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
Stress
Strain
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
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G r a v i t y
Courtesy of Dr. Marcelo Amato
Pendeluft
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Stresses on the Epithelium during Fluid Displacement
Bilek AM et al. J Appl Physiol 2003;94:770-783
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Rigid airwayCourtesy of Dr. Marcelo Amato
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Stresses on Epithelium during Airway Opening
Bilek AM et al. J Appl Physiol 2003;94:770-783
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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Flexible airway
Courtesy of Dr. Marcelo Amato
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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
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Steinberg J.et al. Am J Resp Crit Care Med 2004
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Heterogeneous Lung Injury
Normal lung: In vivo Microscopy Histology + IHC
Injured lung:In vivo MicroscopyHistology + IHC
Steinberg et al. AJRCCM. 2004;169:57-63
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Steinberg et al. AJRCCM. 2004;169:57-63
Stable Alveoli
Unstable Alveoli
Low PEEP Group(3)
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Steinberg et al. AJRCCM. 2004;169:57-63
Stable Alveoli
Alveoli StabilizedWith PEEP
High PEEP Group(15)
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PEEP = improves oxygenation
![Page 103: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/103.jpg)
PEEP = improves oxygenation
It’s more than that!
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PEEP = stabilizes alveoli
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PEEP = decreases RACE
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PEEP = decreases VILI
![Page 107: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/107.jpg)
ARDSNet (NHLBI)
• NEJM, May – 2000• 10 University Centers• Criteria:
– Bilateral infiltrates– Intubation and mechanical ventilation– PaO2/FiO2 <300
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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
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Respiratory Cycle
Ppeak
PEEPTrigger
Pplat
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Initial table for FiO2 & PEEP
ARDSNet NEJM, 2000
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ARDSNet demonstrated:
An outcome changeprimarily associated to a
change in ventilatory strategy(LV)
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A big question:
Is the ARDS Net Protocol enough?
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Not really
• We may not know the true transpulmonary pressure (Ptp)
• Timid and arbitrary PEEP scale
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Meta-Analysis Based on
• ALVEOLI• LOVS• EXPRESS
Briel, M. et al. JAMA 2010;303:865-873.
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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.
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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.
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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
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CT 1 CT 2CT 3
Froese: Crit Care Med 1997
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How do We Open the Lung and Keep it Open?
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How do We Open the Lung and Keep it Open?
• Open:
Recruitment maneuver
![Page 121: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/121.jpg)
How do We Open the Lung and Keep it Open?
• Open:
Recruitment maneuver
• Keep it open:
PEEP or HFOV
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Ware and Matthay NEJM 342 (18): 1334
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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
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How do we know we have achieved OL-PEEP?
![Page 125: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/125.jpg)
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
![Page 126: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/126.jpg)
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
![Page 127: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/127.jpg)
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
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Can we do better?
![Page 129: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/129.jpg)
Let’s talk about pressure…
![Page 130: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/130.jpg)
Let’s talk about pressure…
and the trumpet player
![Page 131: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/131.jpg)
How much airway pressure can a trumpet player generate?
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Trumpet player
Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
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Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
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Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
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Cook. J Applied Phys. 1964. 1016
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Cook. J Applied Phys. 1964. 1016
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Answer: 100-120 cm H2O
Cook. J Applied Phys. 1964. 1016
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So…
Why don’t we see more ALI and ARDS in these players?
![Page 139: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/139.jpg)
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Answer:
Because they keep the Ptp within tolerable limits
![Page 145: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/145.jpg)
Answer:
Because they keep the Ptp within tolerable limits
with
the use of their respiratory muscles
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Let’s go to extremes ofairway pressure
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Paw at sea level:
![Page 148: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/148.jpg)
Paw at sea level: 1034 cm H2O
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Paw at a 33 ft dive:
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Paw at a 33 ft dive: 2068 cm H2O
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Paw at a 33 ft dive: 2068 cm H2O
Add 1034 cm H2O for every 33 ft.
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Paw at a 100 ft dive:
Add 1034 cm H2O for every 33 ft.
![Page 153: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/153.jpg)
Paw at a 100 ft dive: 4140 cm H2O
Add 1034 cm H2O for every 33 ft.
![Page 154: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/154.jpg)
So…
Why don’t we see more ALI and ARDS in these divers?
![Page 155: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/155.jpg)
Answer:
Because they keep the Ptp within tolerable limits
![Page 156: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/156.jpg)
Answer:
Because they keep the Ptp within tolerable limits
with
a similar increase in the external environmental pressure
![Page 157: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/157.jpg)
It’s all relative!
![Page 158: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/158.jpg)
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<0.5 MPH
![Page 160: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/160.jpg)
17,000 MPH
17,000 MPH
<0.5 MPH
![Page 161: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/161.jpg)
17,000 MPHSuccess!
![Page 162: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/162.jpg)
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What is the Paw at 10,000 ft?
![Page 164: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/164.jpg)
What is the Paw at 10,000 ft?
795 cm H2O
![Page 165: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/165.jpg)
What is the Paw at 10,000 ft?
795 cm H2O
30% lessthan MSL
![Page 166: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/166.jpg)
What is the Paw atMt. Everest’s summit?
![Page 167: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/167.jpg)
What is the Paw atMt. Everest’s summit?
285 cm H2O
![Page 168: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/168.jpg)
What is the Paw atMt. Everest’s summit?
285 cm H2O
72% lessthan MSL
![Page 169: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/169.jpg)
They can get in LOTS of trouble!
![Page 170: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/170.jpg)
They can get in LOTS of trouble!
![Page 171: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/171.jpg)
Management of ALI and ARDS using Transpulmonary Pressures
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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
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The problem???
• With Pplat, we are measuring only one side of the equation!!!!!
• What happens with patients with compromised compliances?
![Page 174: Estrategia de pulmón abierto](https://reader030.vdocumento.com/reader030/viewer/2022012916/545c1d77af7959be0e8b465f/html5/thumbnails/174.jpg)
The problem???
• With Pplat, we are measuring only one side of the equation!!!!!
• What happens with patients with compromised compliances?
• We DON’T KNOW!
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Intrathoracic pressures
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
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Pplat
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
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Ptp
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
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Ptp
TRACHEAL PRESSURE
(Ptr)
PROX. AIRWAY PRESSURE (Paw)
PLEURALPRESSURE
(Ppl)(Pes)
ALVEOLAR PRESSURE
(Palv)
Pes
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Position of Esophagus and Pleura
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Position of Esophagus and Pleura
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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
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Relationship Ptp - Tv
Talmor et al. Crit Care Med, 2006
Ptp
(cm H2O)
Tv(mL/kg)
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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
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Kubiak, Jimenez, Nieman, J Surg Trials, 2010
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Kubiak, Jimenez, Nieman, J Surg Trials, 2010
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Kubiak, Jimenez, Nieman, J Surg Trials, 2010
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Jimenez, Nieman ORMC, 2008
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Transpulmonary Pressure, Plateau (Ptp-plat)
Increased Ptp :
↓ compliance
↑ negative Ppl
Decreased Ptp :
normal compliance
not assisting on the ventilator
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Intrathoracic pressures
Tracheal pressures are measured at distal
end of ET Tube
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Ptr (Paw)
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Esophageal Pressure Measurements
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Connections
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Connections
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Connections
Ptp
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• Placed in lower 1/3 of esophagus, above diaphragm
• Measured pressures reflect pleural pressures
Esophageal Balloon
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Paw
Pes
Breath Initiation
20
10
0
-10
-20
20
10
0
-10
-20
cm H2O
The Baydur Maneuver
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Hypothesis
• Patients with ↑ Ppl with conventional settings:– Underinflation → causes hypoxemia– Raising PEEP to maintain a positive Ptp improves
aeration and oxygenation without overdistention.
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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.
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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.
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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
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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
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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
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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]
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Protti A. et al. Am J Respir Crit Care Med. 2011 Feb 4. [Epub ahead of print]
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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
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Table
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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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
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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
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PaO2/FiO2
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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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
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VD/VT
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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PEEP
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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Ptp - EE
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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Ptp - PEEP
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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Pplat
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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Ptp – PLAT
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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Ptp – EI
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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K-M Survival
Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
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ARDSNet Lung (ARMA)
Jimenez E, Nieman G, ORMC 2011
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Ptp Lung
Jimenez E, Nieman G, ORMC 2011
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Talmor presents:
An improvement in oxygenation and compliance with
Ptp significantly lower thanoverestimated Pplat
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Talmor presents:
A persistent negative Ptp-PEEP when using the ARDS Net scale
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A big question:
Is this enough?
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Not really
• Arbitrary PEEP scale• We need to know how to adjust it better• We need to find morbidity/mortality data
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What else can we use?
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Volumetric Capnography
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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.
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Zero baseline (A-B)
Rapid, sharp rise (B-C)Alveolar plateau (C-D)
End tidal value (D)
Rapid, sharp downstroke (D-E)
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• EtCO2 • Capnogram• RR
Capnography Volumetric CO2
• CO2 Elimination• Deadspace• Alveolar Ventilation• Cardiac Output / Perfusion• Physiologic Vd/Vt
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PEEP & VCO2
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VCO2 isCO2 elimination
from CO2 production… …in a steady state!!!
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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?
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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?
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What’s Next ????