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

Safe Zone

Vol

ume

Collapseregion

Pressure

Overdistensionregion

Ventilation Induced Lung Injury

N Engl

J Med

1998;338:347-5

N Engl J Med 2000;342:1301- 8

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

Tidal Recruitment

Vol

ume

Overdistensionregion

Collapseregion

Pressure

Tidal Ventilation

PEEP according to PV curve

Low

Vt‐Plat

benefits

even

at low levels

Hager D, et al. Am J Respir

Crit

Care Med 2005;172(10):1244

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?

DeltaP

from

~17 to

~ 11 cmH2

O

Vol

ume

Overdistensionregion

Collapseregion

Pressure

Tidal Ventilation

PEEP according to PV curve

Vol

ume

Overdistensionregion

Collapseregion

Pressure

Tidal Ventilation

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

Borges JB. Am

J Respir

Crit

care

Med

2006;174:268-278

PaO2

for

defining

an

Open Lung

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)

Vol

ume

Pressure

Tidal Ventilation

Finding OL‐PEEP

OL-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

The heterogeneous ARDS Lung

---------------------------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

PEEP = 23∆P = 12

PEEP = 21∆P = 12

PEEP = 19∆P = 12

PEEP = 17∆P = 12

PEEP = 15∆P = 12

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

Maisch

S, et al. Anesth

Analg

2008;106:175–81

Changes in FRC

Ranieri MV, et al. Anesthesiology

2000; 93:1320–8

Stress Index

ARDSnet

strategy

vs

SI strategy 12h 12h

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

End-insp

End-Exp

PO2

Oscillations

PO2

Oscillations

ARDS Lung after

28 days

of

MV

Curso de Ventilación Mecánica RESPIMAD 2011

Fundación Jiménez Díaz, Madrid, Junio 22-24

Muchas Gracias

Fernando Suarez

Sipmann

Section of Anesthesiology & Critical CareDept of Surgical SciencesHedenstierna LaboratoryUppsala University