Como evitar a VILI Eduardo LV Costa Valerie

Como evitar a VILI Eduardo LV Costa Valerie VILI Alt 1, 93 m Peso 120 Kg UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês

Mecanismos de lesão • • • Recrutamento cíclico Colapso focal / Estresse Hiperdistensão cíclica Strain (deformação)

Tidal recruitment Expiração Cortesia Dr. G Janot

Tidal recruitment Inspiração Cortesia Dr. G Janot

Colapso focal (stress raisers) +30 +70 Mead – JAP 1970

Pplat > 26 - 27 cm H 2 O Am J Respir Crit Care Med 2007

Protti CCM 2013

Protti CCM 2013

Aeração CCM 2014

Inflamação Borges - CCM 2014

Imagem de Fusão Borges - CCM 2014

10 compartimentos de aeração Borges - CCM 2014

One size fits all? Bellani CCM 2009

Evolução da ventilação protetora • Volume corrente alto • Volume corrente baixo Amato NEJM 1998

Volume corrente normal Volumes Homem Mulher CPT 6, 0 L 4, 2 L CRF 2, 2 L 1, 8 L Vt (6 -8 ml/kg) 600 m. L 420 m. L Vt < 30% da CRF Strain < 1, 3

Evolução da ventilação protetora • Volume corrente alto • Volume corrente baixo • Vt/peso ideal ARMA NEJM 2000

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

Como evitar a VILI • Ventilando adequadamente o baby lung • Mudando a história pulmonar Sipmann CCM 2007 Gernoth CCF 2009 Retamal CCF 2013

Vt adequado ao baby lung (‘medindo’ o tamanho do baby lung)

FIO 2 = 100 %; VT = 4 m. L/kg; PEEP = 5 cm. H 2 O 6 -8 ml/kg x (1 – 0, 556) = 2, 7 -3, 6 ml/kg Colapso: 55. 6 % Pneumocystis jiroveci

FIO 2 = 100 %; VT = 4 m. L/kg; PEEP = 25 cm. H 2 O ( após recrutamento) 6 -8 ml/kg x (1 – 0, 01) = 6 -8 ml/kg Colapso: 0. 9 %

Hyperdistensão Colapso PEEP 23 decremental Collapse PEEP 07 EIT PEEP = 25 PEEP = 7 EIT

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse 6 -8 ml/kg x (1 – 0, 05) = 5, 7 -7, 6 ml/kg BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

PEEP TITRATION BY EIT Overdistension Collapse 6 -8 ml/kg x (1 – 0, 355) = 3, 9 -5, 2 ml/kg BERALDO, MA. UNPUBLISHED DATA. LIM 09 FMUSP

Medindo o tamanho do pulmão 50% 6 -8 ml/kg x (1 – 0, 355) = 3, 9 -5, 2 ml/kg Hipoxemia Reske CCM 2013

Medindo o tamanho do pulmão Hipoxemia Complacência = Cs * CRF

Vt e VM protetora • Complacência ~ CRF – p. e. Pneumonectomia -> ½ comp Normalização “em vigor” Vt / Peso ideal Proposta Vt / Complacência = Vt / ΔP Vt / Complacência = Vt / (Vt / ΔP) = ΔP

Driving pressure (ΔP) normal Vt = 6 -8 ml/kg ~ 500 ml Complacência = 80 -100 ml/cm. H 2 O ΔP = Vt / Complacência ~ 7 cm. H 2 O

VT Stress raisers PEEP PPlatô CRS Driving Pressure (ΔP) VILI Amato NEJM 1998

Quintiles of ∆P matched for PEEP

Quintiles of PEEP matched for ∆P

Quintiles of ∆P matched for PPLAT

Quintiles of ∆P matched for PPLAT

Patients under stricter “protective” settings ( Plateau-pressure < 32 cm. H 2 O and VT < 8 m. L/ kg / ibw ) High vs. Low VT studies ( n = 883 ) High vs. Low PEEP studies ( n = 1457 )

P = marcador de gravidade? P = V Crs

3 “negative” clinical studies: Driving P. High Low ALVEOLI 13 15 LOVS 14 15 Express 13 14

Adjusted Survival (%) Changes in ∆P caused by randomization ( PEEP trials, only ) 100 95 90 P = 0. 003 85 80 higher PEEP and ∆P-change = 75 - 3. 7 higher PEEP and ∆P-change = + 0. 4 70 higher PEEP and ∆P-change = + 4. 1 65 0 10 20 30 40 50 Days after randomization 60 Control arm ( ∆P-change = + 1. 3 ) (N = 794)

Como mudar o tamanho do pulmão funcionante PEEP e recrutamento revisitados

Not Protected EI EE Hyperinflated Normally aerated Poorly aerated Not aerated

Stepwise Recruitment Strategy 70 60 55 50 P = 15 cm. H 2 O 40 OLA 40 30 45 CPAP 50 Baseline Airway Pressures (cm. H 2 O) 60 25 cm. H 2 O 20 10 0 T MAX = 20 min Time Borges AJRCCM 2006

Collapse: 55. 6 % Patient # 9 Pneumocystis carinii pneumonia

FIO 2 = 100 %; VT = 4 m. L/kg; PEEP = 26 cm. H 2 O ( after PPLAT = 55 ) Collapse: 0. 9 % Patient # 9 Pneumocystis carinii pneumonia

PEEP = 5; PPLAT = 25

PEEP = 17; PPLAT = 40

PEEP = 25; PPLAT = 40

PEEP = 25; PPLAT = 60

PEEP=25 - Inspiração Vermelho = hiperinsuflado

PEEP=25 - Inspiração – após recrutamento Vermelho = hiperinsuflado

70 Recruitment phase PEEP titration phase Airway Pressure (cm. H 2 O) 60 50 45 40 2 min 5 min 35 30 25 20 10 25 PCV P = 15 cm. H 2 O 20 20 15 10 Baseline (PEEP = 10) 0 Time PEEP STEPS - MAXIMUM-RECRUITMENT STRATEGY ( : CT scan – end-expiratory pause ) Borges AJRCCM 2006

Non-aerated Lung Tissue ( % of total lung mass ) 80 60 40 20 0 Baseline PEEP (~10) Maximum PEEP Titrated PEEP (~24) Janot CCF 2012

Potential for recruitment: 63% Relative response: 82% Pa. O 2/FIO 2 = 113 Titrated PEEP Maximum PEEP Baseline PEEP Potential for recruitment: 48% Relative response: 98% Pa. O 2/FIO 2 = 357 Potential for recruitment: 36% Relative response: 45%

PEEP titration study RM al ent P E E P m cre In 8 10 12 14 16 18 De cr s tep em s 20 22 24 26 VCV 6 ml/kg PCV Pins 60 PEEP 40 cm. H 2 O 26 24 22 18 tal P 16 EE 14 Ps 12 tep s 10 8 VCV 6 ml/kg 2 min PEEP steps (10 min at each level)) 20 en Search for Open lung PEEP (Oxyg and Cdyn) Changes in Cdyn (OLT) Changes in Oxygenation

N = 25 Driving pressure Rec. PEEP

Driving pressure ? N = 25 Rec. “PEEP table trial” PEEP

N = 25 Driving pressure Rec. “PEEP table trial” PEEP

N = 25 Driving pressure Rec. “PEEP table trial” PEEP

N = 25 Driving pressure Rec. “PEEP table trial” PEEP “decremental PEEP titration” PEEP

“ Hysteresis “ N = 25 Driving pressure Rec. “PEEP table trial” Pa. O 2/FIO 2 = 180 PEEP “decremental PEEP titration” Pa. O 2/FIO 2 = 380 PEEP

Obrigado Eduardo LV Costa eduardo. leite@hc. fm. usp. br UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês