salon 1 12 kasim 13.00 13.30. serpi öcal
TRANSCRIPT
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PEEP değerinin belirlenmesiARDS ve KOAH
Dr. Serpil Öcal
11.11.2014
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Sunum planı
• PEEP tanımı
• ARDS ve optimum PEEP
• Kompliyans
• KOAH ve oto-PEEP
• Oto-PEEP tedavisi
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PEEP tanımı
“ekspirasyon sonu pozitif basınç”
“positive end-expiratory pressure”
Pasif ekspirasyon sonunda atmosfer basıncından daha yüksek bir alveol
basıncının olması
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PEEP
• Rutin MV hastalarında 3-5 cm H2O
• ALI /ARDS – Tip I hipoksemik SY
alveolar recruitment
• KOAH- Tip II SY
oto - PEEP tedavisi
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ARDS ve PEEP
Doku oksijeni
PaO2
Optimum
PEEP
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ARDS ve PEEP
• Statik kompliyans “ best- en iyi PEEP”
• Oksijen tüketimi “preferred – tercih edilen PEEP”
• En düşük PEEP PaO2 ≥ 60 mmHg ve FiO2≤%50
ve yeterli kardiyak atım “least-en az PEEP”
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ARDS-PEEP avantajları
• Alveolar recruitment yaparak akciğer ünitelerinin
stabilizayonu
• FRK artış
• Fizyolojik şantta azalma
• Arteriyel oksijenizasyonda düzelme
(PaO2, PvO2, O2 sat)
• Atelektazilerin azalmasıyla –VIP azalması
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ARDS-PEEP dezavantajları
• Pulmoner sistem
– Barotravma
• Kardiyovasküler sistem
– Venöz dönüşte azalma
– Hipotansiyon
– Kardiyak atımda azalma
• Endokrin sistem
– ADH artışı,
– ANP ve BNP azalması
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ARDS-optimal PEEP tayini
• Genellikle PEEP >10 cmH2O çalışmalar
• En iyi yöntem???
• Statik kompliyans ölçümü
• Oksijenizasyon
• CT değişiklikleri
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Pratikte ARDS ve PEEP tayini
• Mekanik kriterler
– PEEP artırılarak en iyi Cst
– Basınç –volüm loop
• Gaz değişim kriterleri
– PEEP titrasyonu arter kan gazına göre
– NIH ARDS Network MV protokol
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ARDS - optimal PEEP tayini
Statik kompliyans ölçümü
Cst = ( TV – tüpün ekspansiyon volümü)/
(Pplato-PEEP)
Tüpün ekspansiyon volümü: Ppik (PİP)X 3 ml
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Statik kompliyans ölçümü
• VCV modu ve kare akım paterni
• Hastalar iyi sedatize olmalı
• “Oklüzyon yöntemi” - Pplato
• İnspiryum sonunda > 3 sn inpiratuvar hold ya da
pause - Pplato
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Ekspirasyon başlar
Pa
w
(cm
H2O
)
Zaman (sn)İnspirasyon başlar
PIP
Pplateau
(Palveolar
Rezistif basınç (PR)}Ekselasyon kapagı açılır
Ekspirasyon
Akı
m (
L/d
k)
Zaman (sn)
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Basınç grafiğinin detaylarıBasınç grafiğinin detayları
Ekspirasyon başlar
Pa
w (
cm H
2O
)
Zaman (sn)
İnspirasyon başlar
PIP
Pplato
Rezistif Basınç (PR)}
Ekspirasyon
Inspiratuar Pause
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Cst ölçümü
• PEEP =0
• PEEP = 5 -8-10-12….
• 0-3-6-9-12-15…
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TV Ppik PEEPDüzeltilmiş
TV P plato C st
700 ml 45 0 39
700 ml 48 3 42
700 ml 50 6 43
700 ml 51 9 44
700 ml 55 12 48
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TV Ppik PEEPDüzeltilmiş TV P plato C st
700 ml 45 0 565 39 14.49
700 ml 48 3 565 42 14.49
700 ml 50 6 568 43 15.35
700 ml 51 9 574 44 16.40
700 ml 55 12 571 48 15.86
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KOMPLİYANS
TV Cst = ––––––––––––– Pplato-PEEP
TV Cdyn = ––––––––––––– Ppik-PEEP
mL/cmH2O
Birim basınç değişikliğinde akciğerlere alınan hava miktarı
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Cst
• Hava akımı olmadığı için gerçek akciğer ve
toraks duvarı patolojilerinden etkilenmekte
• Normalde 70-150 mL/cmH2O
Akciğer dokusu Göğüs duvarı
Plevra patolojileri
Amfizem
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Cdyn
• 50-80 mL/cmH2O
• Cdyn üzerine akımın etkisi olacağından hava
akımına karşı oluşan rezistansdan da etkilenir
ve pür C ölçümü değildir.
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Cdyn azalma
CT azalma Raw artma
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Basınç-volüm loop
• Süper şırınga
• Çoklu oklüzyon
• Sabit düşük akım
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1.Süper şırınga
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Date of download: 11/5/2014
Copyright © American College of Chest Physicians. All rights reserved.
Safety of Pressure-Volume Curve Measurement in Acute Lung Injury and ARDS Using a Syringe Technique *
Chest. 2002;121(5):1595-1601. doi:10.1378/chest.121.5.1595
Representative PV curve from a patient, illustrating identification of the LIP and UIP. Line A: central and most linear segment of the curve. Line B: data points below the linear segment. Line C: data points above the linear segment. See text for further description.
Figure Legend:
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2. Çoklu oklüzyon yöntemi
• Volüm kontrollü modda
• İyi bir sedasyon ve paralizi
• Peryodik olarak farklı tidal volümlerde hava akımı kesilir-
Pplato
• Sonrasında 4 solunum normal TV
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3. Sabit düşük akım yöntemi
• VCV modunda
• Kare akım paterni
• İnspiratuvar akım yavaşlatılarak
• 3 L/dak 500ml veya 9 L/dak 1500 ml
• Toplam süre 2 dak
• Hasta ventilatörden ayrılmıyor
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ALVEOLI: NEJM 2004;351:327-336
LOVES: JAMA 2008;299(6):637-645
ARDS Network 6 versus 12 ml/kg: NEJM 2000;342:1301-1308
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Fig.
Am J Respir Crit Care Med, http://www.atsjournals.org/doi/abs/10.1164/ajrccm.159.5.9805112
Published in: SILVIA R. R. VIEIRA; LOUIS PUYBASSET; QIN LU; JACK RICHECOEUR; PHILIPPE CLUZEL; PIERRE CORIAT; JEAN-JACQUES ROUBY; Am J Respir Crit Care Med 1999, 159, 1612-1623.DOI: 10.1164/ajrccm.159.5.9805112© 1999 The American Thoracic Society
One PowerPoint slide of each figure may be downloaded and used for educational not promotional purposes by an author for slide presentations only. The ATS citation line must appear in at least 10-point type on all figures in all presentations. Pharmaceutical and Medical Education companies must request permission to download and use slides, and authors and/or publishing companies using the slides for new article creations for books or journals must apply for permission. For permission requests, please contact the Publisher at [email protected] or 212-315-6441.
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Oto-PEEP
• MV uygulanan hastalarda sanıldığından daha
yaygın
• Wheezing ve KOAH hikayesi olmayan hastaların
%35’inde açıklanmayan oto-PEEP
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Oto-PEEP mekanik nedenleri
• Ekspirasyona artmış rezistans ( KOAH ve
astım)
• Dakika ventilasyonun yüksek olması
• Ekspiratuvar zamanın kısa olması
• Bu faktörlerin kombinasyonu
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Oto-PEEP tipleri
• İntrensek ekspiratuvar akım kısıtlanması ile oluşan dinamik
hiperinflasyon- KOAH
• Herhangi bir intrensek ekspiratuvar akım kısıtlanması
olmaksızın dinamik hiperinflasyon
Solunum paterni ve ventilatör ayarları
İlave akım rezistansı
• Dinamik hiperinflasyon olmaksızın aşırı ekspiratuvar aktivite
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Oto-PEEP sonuçları
• Solunum işinde artma
• Gaz alışverişinde bozulma
• Hemodinamik bozulma
• Uygunsuz tedavi
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Oto-PEEP
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Oto-PEEP
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Statik oto-PEEP
• Aktif solunum çabası olmayan sedatize / paralizi
• End- ekspiratuvar oklüzyon
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Basınç-volüm loop
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Dinamik oto-PEEP
• Spontan solunumu olan hastalarda
• Özefagial balon kateter ile ölçüm yapılmakta
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Oto-PEEP tedavisi
Ventilatör ayarlarını değiştir
• Ekspirasyon zamanını artırmak
• Solunum hızını azaltmak
• Tidal volümü azaltmak
Solunum ihtiyacını azaltmak
• Anksiyete, ağrı, ateş ve titremenin azaltılması
• Ölü boşluğun azaltılması
• Sedatif / paralitik verilmesi
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Oto-PEEP tedavisi
Akım rezistansının azaltılması
• Geniş lümenli ETT kullanımı
• Sık aspirasyon
• Bronkodilatör verilmesi
Ekspiratuvar akım limitasyonuna karşılık
eksternal PEEP
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KOAH
• Statik PEEP• en azından % 85
İMV
• Dinamik PEEP• ??
MV
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Çözmemiz gereken sorunlar
Artmış PEEP
Azalmış kompliyans
Artmış akım rezistansı
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TEŞEKKÜRLER