PEEP nuove indicazioni, stesse problematiche

PEEP nuove indicazioni, stesse problematiche Franco Valenza Department of Pathophysiology and Transplantation Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico

Ossigenazione Clearance CO 2

Kats, Anesthesiology (1982); 56:164

70 n=8 40 60 100 50 Recruitment and Inflation 40 30 20 10 80 60 40 20 0 150 cmh 2 O InspiratoryCapacity 0 0 0 mmhg 0 10 20 30 40 50 60 70 80 time (sec) Airway pressure [cmh 2 O] 0 20 40 60 80 10 Presure(cmH 2 O) Valenza CCM (1997) 99:944

Ventilator induced lung injury 70 60 50 Recruitment and Inflation 40 30 20 10 100 80 60 40 20 n=8 40 0 150 cmh 2 O InspiratoryCapacity Alveolar over-distention Dreyfuss ARRD 1988; 137:1159-64 Bowton CCM 1989; 17:908-11 0 0 0 mmhg 0 10 20 30 40 50 60 70 80 time (sec) Airway pressure [cmh 2 O] 0 20 40 60 80 10 Presure(cmH 2 O)

Ventilator induced lung injury 70 60 50 Recruitment and Inflation 40 30 20 10 0 100 80 60 40 20 0 40 n=8 0 cmh 2 O 150 0 mmhg InspiratoryCapacity 0 10 20 30 40 50 60 70 80 Alveolar over-distention Dreyfuss ARRD 1988; 137:1159-64 Bowton CCM 1989; 17:908-11 Tidal breathing collapse Webb ARRD 1974; 110:556-65 Parker CCM 1993; 21:131-43 Muscedere AJRCCM; 149:1327-34 time (sec) Airway pressure [cmh 2 O] 0 20 40 60 80 10 Presure(cmH 2 O)

Alveolar over-distention Tidal breathing collapse Futier, Minerva Anesthesiol (2013)

Ventilator induced lung injury 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!

NO ACTIVATION Rat alveolar cells Macrophages via NFkB Endothelial cells A459 human epithelial II cells AU 50 40 50% cell death 30 20 10 IL-8 MMP % strain 0 10 20 30 40 50 60 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. 357-362 Physiol. 19): L1040-L1050, 21): L137-L173, 19981999

F b L 0 L a S=a*b Stress = F/S Transpulmonary pressure Gattinoni, Eur Respir J (2003) 47:15s

Trattamento ventilatorio individualizzato Ongoing recruitment Full recruitment Ongoing overdistension

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

PEEP Distribution of ventilation Strain VOLO = L/L trauma 0 Vt / EELV

Gattinoni, AJRCCM (1995) 151:1807

Pontoppidan, JCI (1972) 51:2315

Simmons, West J Med (1979) 130:229

Muscedere, AJRCCM (1994) 149:1327

Sibilla, ICM (2002) 28:196-203

Valenza, CCM (2003) 31:1993-98

Trattamento ventilatorio individualizzato

Trattamento PEEP to ventilatorio the dependent individualizzato lung... if possible

Trattamento ventilatorio individualizzato high FEV1 low FEV1 1.0 1.0 0.8 0.8 Volume (L) 0.6 0.4 Supine Lateral 0.6 0.4 0.2 0.2 0.0 0.0 0 5 10 15 20 25 30 35 0 5 10 15 20 25 30 35 Airway pressure (cmh 2 O) Valenza, EJA Dec 2004

Cstat 1L 90 80 70 60-50 40 30 20 10 0 1 2 3 4 5 FEV 1 Valenza, BJA (17):A199

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

Ottimizzazione intra-operatoria All patients High FEV 1 Low FEV 1 ZEEP PaO 2 Cpl eff 87.4 24 88.0 22 34.0 6 35.1 7 85.5 24 84.8 19 32.8 6.1 34.2 7.7 90.9 25 94.0 27 34.1 6.1 33.8 5.1 PEEP PaO 2 Cpl eff 86.2 35 108.0 50 * 33.9 5 46.6 13 * 87.1 36 114.7 53 * 33.6 3.6 48.4 3.9 * 83.9 21 92.6 41 32.2 3.8 40.2 6.1 Valenza, EJA Dec 2004

Serpa Neto, Anesthesiology (2015)

Liker, Anesth Analg 2003; 97:1558

Timing Oxygenation (ALI/ARDS) Chest radiograph Wedge pressure Bernards, AJRCCM (1994);149:818

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

PRIMARY 27 pts SECONDARY 10 pts Polmonite (5) Inalazione (2) Fistola (2) Tromboembolia (1) Liker, Anesth Analg 2003; 97:1558

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) Liker, Anesth Analg 2003; 97:1558

Liker, Anesth Analg 2003; 97:1558

Product of inspiratory plateu pressure > 10 cmh 2 O and duration of OLV Liker, Anesth Analg 2003; 97:1558

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

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

in conclusion To protect the lung during OLV.... more than just safe ventilation!!

in conclusion 70 60 n=8 40 50 40 0 cmh 2 O Tidal Volume Volume (ml/kg) 30 20 10 150 Stress-Strain InspiratoryCapacity PEEP 0 0 mmhg time (sec) 0 20 40 60 80 10 Presure(cmH 2 O)

in conclusion To protect the lung during OLV.... more than just safe ventilation!!