Presentazione di PowerPoint - Siaarti di... · Airway pressure [cmH 2 O] 0 10 20 30 40 50 60 70 80...

PEEP nuove indicazioni, stesse problematiche

Franco Valenza

Department of Pathophysiology and Transplantation

Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico

Ossigenazione

Clearance CO2

Kats, Anesthesiology (1982); 56:164

Airway pressure [cmH2O]

0 10 20 30 40 50 60 70 80

Re

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Pressure (cmH2O)

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Volume (ml/kg)

0

10

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Inspiratory Capacity

n=8

0

40

cmH2O

0

150

mmHg time (sec)

Valenza CCM (1997) 99:944


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mmHg time (sec)

Ventilator induced lung injury

Alveolar over-distentionDreyfuss ARRD 1988; 137:1159-64

Bowton CCM 1989; 17:908-11


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mmHg time (sec)


Bowton CCM 1989; 17:908-11

Tidal breathing collapseWebb ARRD 1974; 110:556-65

Parker CCM 1993; 21:131-43

Muscedere AJRCCM; 149:1327-34


Futier, Minerva Anesthesiol (2013)

Alveolar over-distention

Tidal breathing collapse

Oxygenation

Microscopic

Functional

Bio-trauma


Shilling, Anesth Analg 2005;101:957–65)

Serpa Neto, Anesthesiology (2015)

Low tidal volume is a must….

To avoid strain is a must !

Ra

t a

lve

ola

r c

ell

s

50% cell death

Daniel J et al, Am J Respir Crit Care Med 2000, 162, 357-362

IL-8MMP

Mac

rop

hag

es

via

NF

kB

En

do

the

lia

l c

ell

s

A4

59

hu

ma

n e

pit

heli

al II

ce

lls

NO

AC

TIV

AT

ION

10 20 30 40 50 60

40

30

20

10

50

% strain

0

AU

Pugin et al. Am. J. Physiol. 275 (Lung Cell. Mol. Physiol. 19): L1040-L1050, 1998Vlahakis NE et al. Am. J. Physiol. 277 (Lung Cell. Mol. Physiol. 21): L137-L173, 1999

F

L

a

b

L0

S=a*b

Stress = F/S Transpulmonary pressure

Gattinoni, Eur Respir J (2003) 47:15s

Ongoing

recruitment

Ongoing

overdistension

Full

recruitment

Trattamento ventilatorio individualizzato

F

L

a

b

L0

S=a*b

Stress = F/S

Strain =L/L0

Transpulmonary pressure

Vt / EELV

Gattinoni, Eur Respir J (2003) 47:15s

PEEP

Strain =L/L0VOLO trauma Vt / EELV

Distribution of ventilation

Gattinoni, AJRCCM (1995) 151:1807

Pontoppidan, JCI (1972) 51:2315

Simmons, West J Med (1979) 130:229


0 10 20 30 40 50 60 70 80

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Pressure (cmH2O)

0 20 40 60 80 100

Volume (ml/kg)

0

10

20

30

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50

60

70


n=8

0

40

cmH2O

0

150

mmHg time (sec)


Bowton CCM 1989; 17:908-11

Tidal breathing collapseWebb ARRD 1974; 110:556-65

Parker CCM 1993; 21:131-43

Muscedere AJRCCM; 149:1327-34


Muscedere, AJRCCM (1994) 149:1327

Sibilla, ICM (2002) 28:196-203

Valenza, CCM (2003) 31:1993-98

PEEP to the dependent lung... if possible


low FEV1

0 5 10 15 20 25 30 35

0.0

0.2

0.4

0.6

0.8

1.0

high FEV1

Airway pressure (cmH2O)

0 5 10 15 20 25 30 35

Vo

lum

e (

L)

0.0

0.2

0.4

0.6

0.8

1.0

Lateral

Supine


Valenza , EJA Dec 2004

FEV 1

0 1 2 3 4 5

Csta

t 1L

10

20

30

40

50

60

70

80

90

-

Valenza , BJA (17):A199

ZEEP (n=15)

PEEP (n=16)

ZEEP (n=15)

PEEP (n=17)

Randomisation

SUPINE LATERAL LATERAL+TREATMENT

PRE-OPERATIVE INTRA-OPERATIVE

FEV1 stratification

High (n=31)

Low (n=15)


87.4 24

88.0 22

34.0 6

35.1 7

86.2 35

108.0 50 *

33.9 5

46.6 13 *

85.5 24

84.8 19

32.8 6.1

34.2 7.7

87.1 36

114.7 53 *

33.6 3.6

48.4 3.9 *

90.9 25

94.0 27

34.1 6.1

33.8 5.1

83.9 21

92.6 41

32.2 3.8

40.2 6.1

All patients High FEV1 Low FEV1

ZEEP

PEEP

PaO2

Cpleff

PaO2

Cpleff

Ottimizzazione intra-operatoria


Serpa Neto, Anesthesiology (2015)

Liker, Anesth Analg 2003; 97:1558

Bernards, AJRCCM (1994);149:818

Timing

Oxygenation (ALI/ARDS)

Chest radiograph

Wedge pressure


879 pts consecutivi

37 pts (4.2%) ALI

17 pts (1.5%) ARDS

Mortalità intra-ospedaleira: 3.0%

ALI: 43% morti peri-operatorie


PRIMARY 27 pts

SECONDARY 10 pts Polmonite (5)

Inalazione (2)

Fistola (2)

Tromboembolia (1)


Diagnosi 2 giorni 5.5 (P<0.05)

Mortalità 26% 60% (P<0.05)

SOFA 4.1 1.2 7.3 2.5 (P<0.05)


“ Product of inspiratory plateu pressure > 10 cmH2O and duration of OLV”

Perioperative fluids

Zeldin, J Thorac Cardiovasc Surg 1984;87:359

“ the most important thing that we can do in terms of recognizing this problem

is watch our anesthesists as they start loading the patient up with fluids”

Perioperative fluids

Ray, Arch Surg 1974;109:537

Mathru, Chest 1992;103:1644

Verheijen, Thorax 1988;43:323

Patel, Ann Thorac Surg 1992;54:84

Turnage, Chest 1993;103:1646

Waller, Ann Thorac Surg 1993;55:140

Endothelial injury

Jordan, ERJ 2000;15:790

Jordan, ERJ 2000;15:790

Ferguson, JCVA 2003;17:388

AJP Cell Physiol (2005) 290:1178-88

To protect the lung during OLV ….

... more than just safe ventilation!!

… in conclusion

… in conclusion

Pressure (cmH2O)

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Volume (ml/kg)

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n=8

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cmH2O

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mmHg time (sec)

Tidal Volume

PEEP

Stress-Strain

To protect the lung during OLV ….

... more than just safe ventilation!!

… in conclusion

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