PEEP nuove indicazioni, stesse problematiche
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1 PEEP nuove indicazioni, stesse problematiche Franco Valenza Department of Pathophysiology and Transplantation Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
2 Ossigenazione Clearance CO 2
3 Kats, Anesthesiology (1982); 56:164
4 Kats, Anesthesiology (1982); 56:164
5 70 n= Recruitment and Inflation cmh 2 O InspiratoryCapacity mmhg time (sec) Airway pressure [cmh 2 O] Presure(cmH 2 O) Valenza CCM (1997) 99:944
6 Ventilator induced lung injury Recruitment and Inflation n= cmh 2 O InspiratoryCapacity Alveolar over-distention Dreyfuss ARRD 1988; 137: Bowton CCM 1989; 17: mmhg time (sec) Airway pressure [cmh 2 O] Presure(cmH 2 O)
7 Ventilator induced lung injury Recruitment and Inflation n=8 0 cmh 2 O mmhg InspiratoryCapacity Alveolar over-distention Dreyfuss ARRD 1988; 137: Bowton CCM 1989; 17: Tidal breathing collapse Webb ARRD 1974; 110: Parker CCM 1993; 21: Muscedere AJRCCM; 149: time (sec) Airway pressure [cmh 2 O] Presure(cmH 2 O)
8 Alveolar over-distention Tidal breathing collapse Futier, Minerva Anesthesiol (2013)
9 Ventilator induced lung injury Oxygenation Microscopic Functional Bio-trauma
10 Shilling, Anesth Analg 2005;101:957 65)
11 Shilling, Anesth Analg 2005;101:957 65)
12 Shilling, Anesth Analg 2005;101:957 65)
13 Shilling, Anesth Analg 2005;101:957 65)
14 Shilling, Anesth Analg 2005;101:957 65)
15 Serpa Neto, Anesthesiology (2015)
16 Low tidal volume is a must. To avoid strain is a must!
17 NO ACTIVATION Rat alveolar cells Macrophages via NFkB Endothelial cells A459 human epithelial II cells AU % cell death IL-8 MMP % strain Pugin Vlahakis Daniel et J al. NE et Am. al, et Am al. J. Physiol. Am. J Respir J. Physiol. 275 Crit (Lung Care 277 Cell. Med (Lung 2000, Mol. Cell. Physiol. 162, Mol Physiol. 19): L1040-L1050, 21): L137-L173,
18 F b L 0 L a S=a*b Stress = F/S Transpulmonary pressure Gattinoni, Eur Respir J (2003) 47:15s
19 Trattamento ventilatorio individualizzato Ongoing recruitment Full recruitment Ongoing overdistension
20 Trattamento ventilatorio individualizzato Ongoing recruitment Full recruitment Ongoing overdistension
21 F b L 0 L a S=a*b Stress = F/S Strain = L/L 0 Transpulmonary pressure Vt / EELV Gattinoni, Eur Respir J (2003) 47:15s
22 PEEP Distribution of ventilation Strain VOLO = L/L trauma 0 Vt / EELV
23 Gattinoni, AJRCCM (1995) 151:1807
24 Pontoppidan, JCI (1972) 51:2315
25 Simmons, West J Med (1979) 130:229
26 Ventilator induced lung injury Recruitment and Inflation n=8 0 cmh 2 O mmhg InspiratoryCapacity Alveolar over-distention Dreyfuss ARRD 1988; 137: Bowton CCM 1989; 17: Tidal breathing collapse Webb ARRD 1974; 110: Parker CCM 1993; 21: Muscedere AJRCCM; 149: time (sec) Airway pressure [cmh 2 O] Presure(cmH 2 O)
27 Muscedere, AJRCCM (1994) 149:1327
28 Sibilla, ICM (2002) 28:
29 Valenza, CCM (2003) 31:
30 Trattamento ventilatorio individualizzato
31 Trattamento PEEP to ventilatorio the dependent individualizzato lung... if possible
32 Trattamento PEEP to ventilatorio the dependent individualizzato lung... if possible
33 Trattamento ventilatorio individualizzato high FEV1 low FEV Volume (L) Supine Lateral Airway pressure (cmh 2 O) Valenza, EJA Dec 2004
34 Cstat 1L FEV 1 Valenza, BJA (17):A199
35 SUPINE LATERAL LATERAL+TREATMENT FEV 1 stratification High (n=31) Low (n=15) Randomisation ZEEP (n=15) PEEP (n=16) ZEEP (n=15) PEEP (n=17) PRE-OPERATIVE INTRA-OPERATIVE Valenza, EJA Dec 2004
36 Ottimizzazione intra-operatoria All patients High FEV 1 Low FEV 1 ZEEP PaO 2 Cpl eff PEEP PaO 2 Cpl eff * * * * Valenza, EJA Dec 2004
37 Ottimizzazione intra-operatoria All patients High FEV 1 Low FEV 1 ZEEP PaO 2 Cpl eff PEEP PaO 2 Cpl eff * * * * Valenza, EJA Dec 2004
38 Serpa Neto, Anesthesiology (2015)
39 Serpa Neto, Anesthesiology (2015)
40 Serpa Neto, Anesthesiology (2015)
41 Serpa Neto, Anesthesiology (2015)
42 Serpa Neto, Anesthesiology (2015)
43 Serpa Neto, Anesthesiology (2015)
44 Serpa Neto, Anesthesiology (2015)
45 Liker, Anesth Analg 2003; 97:1558
46 Timing Oxygenation (ALI/ARDS) Chest radiograph Wedge pressure Bernards, AJRCCM (1994);149:818
47 879 pts consecutivi 37 pts (4.2%) ALI 17 pts (1.5%) ARDS Mortalità intra-ospedaleira: 3.0% ALI: 43% morti peri-operatorie Liker, Anesth Analg 2003; 97:1558
48 PRIMARY 27 pts SECONDARY 10 pts Polmonite (5) Inalazione (2) Fistola (2) Tromboembolia (1) Liker, Anesth Analg 2003; 97:1558
49 Diagnosi 2 giorni 5.5 (P<0.05) Mortalità 26% 60% (P<0.05) SOFA (P<0.05) Liker, Anesth Analg 2003; 97:1558
50 Liker, Anesth Analg 2003; 97:1558
51 Liker, Anesth Analg 2003; 97:1558
52 Liker, Anesth Analg 2003; 97:1558
53 Liker, Anesth Analg 2003; 97:1558
54 Product of inspiratory plateu pressure > 10 cmh 2 O and duration of OLV Liker, Anesth Analg 2003; 97:1558
55 Perioperative fluids 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 Zeldin, J Thorac Cardiovasc Surg 1984;87:359
56 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
57 Endothelial injury Jordan, ERJ 2000;15:790
58 Jordan, ERJ 2000;15:790
59 Ferguson, JCVA 2003;17:388
60 AJP Cell Physiol (2005) 290:
61 in conclusion To protect the lung during OLV.... more than just safe ventilation!!
62 in conclusion n= cmh 2 O Tidal Volume Volume (ml/kg) Stress-Strain InspiratoryCapacity PEEP 0 0 mmhg time (sec) Presure(cmH 2 O)
63 in conclusion To protect the lung during OLV.... more than just safe ventilation!!
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