Como evitar a VILI UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês Eduardo LV Costa Valerie...

Como evitar a VILI

UTI Respiratória HC-FMUSP

UTI Hospital Sírio Libanês

Eduardo LV Costa

Valerie VILI

Alt 1,93m

Peso 120 Kg

Mecanismos de lesão

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

Tidal recruitment

Cortesia Dr. G Janot

Expiração

Tidal recruitment

Cortesia Dr. G Janot

Inspiração

+ 15

Pressão de distensão local

Transpulmonary

+ 15

+ 70

Local d istend pressure

ing

Ple u ra l S p a c e

Collapsed zone

Colapso focal(stress raisers)

+30 +30

+70 +70

Mead – JAP 1970

Pplat > 26 - 27 cm H2O

Am J Respir Crit Care Med 2007

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

Vt < 30% da CRF Strain < 1,3

Volumes Homem Mulher

CPT 6,0L 4,2L

CRF 2,2L 1,8L

Vt (6-8ml/kg) 600mL 420mL


• Volume corrente alto• Volume corrente baixo• Vt/peso ideal

ARMA NEJM 2000


• 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)

Colapso:

55.6 %

Pneumocystisjiroveci

FIO2 = 100 %; VT = 4 mL/kg; PEEP = 5 cmH2O

6-8 ml/kg x (1 – 0,556) =2,7-3,6 ml/kg


( após recrutamento)

Colapso:

0.9 %

6-8 ml/kg x (1 – 0,01) =6-8 ml/kg

Collapse

PEEP 23

PEEP 07

PEEP = 25

decr

em

en

tal

PEEP = 7

Hyperdistensão Colapso

EIT EIT

Overdistension Collapse

PEEP TITRATION BY EIT

BERALDO, MA. UNPUBLISHED DATA . LIM 09 FMUSP




6-8 ml/kg x (1 – 0,05) =5,7-7,6 ml/kg




6-8 ml/kg x (1 – 0,355) =3,9-5,2 ml/kg

Medindo o tamanho do pulmão

Hipoxemia

50%6-8 ml/kg x (1 – 0,355) =

3,9-5,2 ml/kg

Reske CCM 2013

Medindo o tamanho do pulmão

Hipoxemia

Complacência

Complacência = Cs * CRF

Vt e VM protetora

• Complacência ~ CRF– p.e. Pneumonectomia -> ½ comp

Normalização “em vigor”

Vt / Peso ideal

Proposta

Vt / Complacência

Complacência = Vt / ΔP

Vt / Complacência = Vt / (Vt / ΔP)= ΔP

Driving pressure (ΔP) normal

Vt = 6-8 ml/kg ~ 500 ml

Complacência = 80-100 ml/cmH2O

ΔP = Vt / Complacência ~ 7 cmH2O

PEEP

DrivingPressure

(ΔP)

PPlatôVT

VILI

CRS

Stressraisers

Amato NEJM 1998

Amato…………….…….53

Brochard…………..….116

Stewart…………....…..120

Brower……………….…52

ARDSnet….…………..861

ALVEOLI…….………..549

LOVS………………….983

Express………………..768

3502

Quintile of PPLAT

0 1 2 3 4 5

Ad

juste

d R

ela

tive

Ris

k

0.5

0.7

1

1.4

2

P < 0.0001

0 1 2 3 4 5

0

10

20

30

40

Quintiles of ∆Pmatched for PEEP

Quintile of PPLAT

0 1 2 3 4 5

Ad

juste

d R

ela

tive

Ris

k

0.5

0.7

1

1.4

2

P = 0.61

0 1 2 3 4 5

0

10

20

30

40

Quintiles of PEEPmatched for ∆P

Quintile of PPLAT

123456

Ad

juste

d R

ela

tive

Ris

k

0.5

0.7

1

1.4

2

P < 0.0001

123456

0

10

20

30

40

Quintiles of ∆P matched for PPLAT

Quintile of PPLAT

123456

Ad

juste

d R

ela

tive

Ris

k

0.5

0.7

1

1.4

2

P < 0.0001

123456

0

10

20

30

40

Quintiles of ∆P matched for PPLAT

Quintile of PPLAT

0 1 2 3 4 5

Adjusted Relative Risk

0.5

0.7

1

1.4

2

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

Quintiles of Plateau-pressure

Increasing Plateau and increasing ΔP

( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airway pressure(cmH

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP

P = 0.19 (negative trend)P < 0.0001 (positive trend)Adjusted Relative-risk

of Death

0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP

Increasing Plateau but Similar ΔP

Number of pts:

0

1 2 3 4 5 1 2 3 4 5

0 1 2 3 4 5

0

10

20

30

40

0 1 2 3 4 5

0

10

20

30

40

Briel – quintiles PPLAT

Drivingpressure

PEEP 0 1 2 3 4 5

0

10

20

30

40

Briel – quintiles PEEP

Drivingpressure

PEEP

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P = 0.09

P = 0.09 ( negative trend)P = 0.007 ( positive trend)

( 335 ) ( 397 ) ( 251 ) ( 459 ) ( 322 ) ( 270 ) ( 312 ) ( 413 ) ( 320 ) ( 449 )

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P = 0.007

11 2 3 4 5

Quintiles of Plateau - pressure

1 2 3 4 5

P = 0.002( positive trend )

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2



( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airway pressure(cmH

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP


of Death0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP


Number of pts:

0

1 2 3 4 5 1 2 3 4 5

0 1 2 3 4 5

0

10

20

30

40

0 1 2 3 4 5

0

10

20

30

40


Drivingpressure

PEEP 0 1 2 3 4 5

0

10

20

30

40


Drivingpressure

PEEP

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P = 0.09


( 335 ) ( 397 ) ( 251 ) ( 459 ) ( 322 ) ( 270 ) ( 312 ) ( 413 ) ( 320 ) ( 449 )

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P = 0.007

11 2 3 4 5

P = 0.24( negative trend )

Quintiles of PEEP

11 2 3 4 5

P = 0.06( negative trend )

Quintiles of PEEP

PEEP

∆P

Quintiles of PEEP

Increasing Plateau and increasing ∆P Increasing Plateau but similar ∆P

High vs. Low PEEP studies (n = 2360)

High vs. Low VTstudies (n = 1197)

High vs. Low PEEP studies (n = 2360)

0 1 2 3 4 5

0

10

20

30

40

0 1 2 3 4 5

0

10

20

30

40

0 1 2 3 4 5

0

10

20

30

40

0 1 2 3 4 5

0

10

20

30

40

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P < 0.0001( positive trend )

Q u in t i le o f P P L A T

0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0.5

0.7

1

1.4

2


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0 .5

0.7

1

1.4

2



( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airw

ay p

re

ssu

re

(cm

H

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP

P = 0.19 (negative trend)P < 0.0001 (positive trend)Ad

ju

sted

R

ela

tive

-risk

of D

ea

th

0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP


Number of pts:

0

1 2 3 4 5 1 2 3 4 5


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0.5

0.7

1

1.4

2


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0 .5

0.7

1

1.4

2



( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airw

ay p

re

ssu

re

(cm

H

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP


ju

sted

R

ela

tive

-risk

of D

ea

th

0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP


Number of pts:

0

1 2 3 4 5 1 2 3 4 5


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0.5

0.7

1

1.4

2


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0 .5

0.7

1

1.4

2



( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airw

ay p

re

ssu

re

(cm

H

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP


ju

sted

R

ela

tive

-risk

of D

ea

th

0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP


Number of pts:

0

1 2 3 4 5 1 2 3 4 5


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0.5

0.7

1

1.4

2


0 1 2 3 4 5

Ad

ju

ste

d R

ela

tiv

e R

is

k

0 .5

0.7

1

1.4

2



( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airw

ay p

re

ssu

re

(cm

H

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP


ju

sted

R

ela

tive

-risk

of D

ea

th

0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP


Number of pts:

0

1 2 3 4 5 1 2 3 4 5

High vs. Low VTstudies (n = 1197)

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2



( 313 ) ( 323 ) ( 315 ) ( 314 ) ( 316 )


( 338 ) ( 317 ) ( 382 ) ( 335 ) ( 209 )

10

20

30

40

Airway pressure(cmH

2O)

Driving-pressure

PEEP

Driving-pressure

PEEP

Quintiles of PEEP


of Death

0.5

1.0

1.4

2.0

40

30

20

10

0.7

0.5

1.0

1.4

2.0

0.7

Quintiles of PEEP


Number of pts:

0

1 2 3 4 5 1 2 3 4 5

0 1 2 3 4 50

10

20

30

40

0 1 2 3 4 50

10

20

30

40


Drivingpressure

PEEP 0 1 2 3 4 5

0

10

20

30

40


Drivingpressure

PEEP

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P = 0.09


( 335 ) ( 397 ) ( 251 ) ( 459 ) ( 322 ) ( 270 ) ( 312 ) ( 413 ) ( 320 ) ( 449 )

Quintile of PPLAT

0 1 2 3 4 5


0.5

0.7

1

1.4

2

P = 0.007

Mor

talit

yRi

sk( a

djus

ted

)Ai

rway

pres

sure

( cm

H2O

)

PEEP

∆P

100

95

90

85

80

75

70

0 10 20 30 40 50 60

100

95

90

85

80

75

70

0 10 20 30 40 50 60

100

95

90

85

80

75

70

0 10 20 30 40 50 60

ΔP ≤ 14 cmH2O

Plateau-pressure < 32 cmH2O

and VT < 8 mL / kg / ibw

ΔP > 14 cmH2O

Plateau ≤ 26 cmH2O

Plateau > 26 cmH2O

VT < 7 mL / kg

VT ≥ 7 mL / kg

Only patients under “protective-settings”:

( N = 883 )

P = 0.15

P = 0.10

P = 0.005

Days of mechanical ventilation - after randomization

Adj

uste

d C

umul

ativ

e S

urvi

val (

%)

Adj

uste

d C

umul

ativ

e S

urvi

val (

%)

Adj

uste

d C

umul

ativ

e S

urvi

val (

%)

100

95

90

85

80

75

70

0 10 20 30 40 50 60

100

95

90

85

80

75

70

0 10 20 30 40 50 60

100

95

90

85

80

75

70

0 10 20 30 40 50 60

ΔP ≤ 14 cmH2O

Plateau-pressure < 32 cmH2O

and VT < 8 mL / kg / ibw

ΔP > 14 cmH2O


Plateau > 26 cmH2O

VT < 7 mL / kg

VT ≥ 7 mL / kg

Only patients under “protective-settings”:

( N = 883 )

P = 0.15

P = 0.10

P = 0.005

Days of mechanical ventilation - after randomization

Adj

uste

d C

umul

ativ

e S

urvi

val (

%)

Adj

uste

d C

umul

ativ

e S

urvi

val (

%)

Adj

uste

d C

umul

ativ

e S

urvi

val (

%)

∆P ≤ 14 cmH2O

( N = 1457 )

∆P > 14 cmH2O

Plateau > 26 cmH2O


VT > 6 mL / kg

VT ≤ 6 mL / kg

P = 0.006

P = 0.55

P = 0.67

High vs. Low VT studies ( n = 883 )

High vs. Low PEEP studies ( n = 1457 )

Patients under stricter “protective” settings ( Plateau-pressure < 32 cmH2O and VT < 8 mL/ kg / ibw )

P = marcador de gravidade?

P = VCrs

Reduction in Driving-Pressure driven by Randomization

0 2 4 6 8 10 12 14 16 18

Adj

uste

d r

elat

ive

ris

k

( in

rel

atio

n to

res

pect

ive

cont

rol a

rm )

0.1

0.5

1.0

2.0

3 “negative” clinical studies:

Driving P.

High Low

ALVEOLI 13 15

LOVS 14 15

Express 13 14

Days after randomization0 10 20 30 40 50 60

Adj

uste

d

Sur

viva

l (%

)

65

70

75

80

85

90

95

100

Control arm ( ∆P-change = + 1.3 )

higher PEEP and ∆P-change = - 3.7

higher PEEP and ∆P-change = + 0.4

higher PEEP and ∆P-change = + 4 .1

P = 0.003

Changes in ∆P caused by randomization ( PEEP trials, only )

(N = 794)

Como mudar o tamanho do pulmão funcionante

PEEP e recrutamento revisitados

Not Protected

Hyperinflated Normally aerated Poorly aerated Not aerated

EI EE

Stepwise Recruitment Strategy

Time0

10

20

30

40

50

60

70

4550

5560

Ba

selin

e

TMAX = 20 min

25 cmH2O

Airw

ay P

ress

ures

(cm

H2O

)

40CPAP

OLA

DP = 15 cmH2O

Borges AJRCCM 2006

Collapse:

55.6 %

Patient # 9Pneumocystiscarinii pneumonia


( after PPLAT = 55 )

Collapse:

0.9 %

Patient # 9Pneumocystiscarinii pneumonia

PEEP = 5; PPLAT = 25

Vermelho = hiperinsufladoVermelho = hiperinsuflado

PEEP=25 - Inspiração

PEEP=25 - Inspiração – após recrutamento

Vermelho = hiperinsufladoVermelho = hiperinsuflado

Time0

10

20

30

40

50

60

70

PCV DP = 15 cmH2O

25

PEEP STEPS - MAXIMUM-RECRUITMENT STRATEGY

Airw

ay P

ress

ure

(cm

H2O

)Recruitment

phase

25

20

Baseline (PEEP = 10)

10

35

452 min

20

15

5 min

PEEP titrationphase

( : CT scan – end-expiratory pause )

Borges AJRCCM 2006

1 2 3

0.0

0.2

0.4

0.6

0.8

Baseline PEEP (~10)

MaximumPEEP

TitratedPEEP (~24)

No

n-a

era

ted

L

ung

T

issu

e

(

%

of

tota

l lu

ng

mas

s )

0

20

40

60

80

Janot CCF 2012

Bas

elin

e P

EE

P

Max

imum

PE

EP

T

itrat

ed

PE

EP

PaO2/FIO2 = 113

PaO2/FIO2 = 357

Potential for recruitment: 48% Relative response: 98%



PEEP titration study

RM

PCVPins 60PEEP 40cmH2O

2 min

Incremental PEEP steps Decremental PEEP steps

VCV6 ml/kg

8

26

1012

1416

1820

2224

PEEP steps (10 min at each level))

2624

2220

1816

1412

108

VCV6 ml/kg

Changes in Cdyn (OLT)Changes in Oxygenation

Search for Open lung PEEP (Oxyg and Cdyn)

0

5

10

15

20

25

8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8

Pres

sure

(cm

H2O

)D

rivin

g

pre

ssu

re

PEEP PEEP

Rec.

N = 25

0

5

10

15

20

25

8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8

Pres

sure

(cm

H2O

)D

rivin

g

pre

ssu

re

PEEP PEEP

Rec.

“PEEP table trial”

N = 25?

0

5

10

15

20

25

8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8

Pres

sure

(cm

H2O

)D

rivin

g

pre

ssu

re

PEEP PEEP

Rec.


N = 25

0

5

10

15

20

25

8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8

Pres

sure

(cm

H2O

)D

rivin

g

pre

ssu

re

PEEP PEEP

Rec.


“decrementalPEEP titration”

N = 25

0

5

10

15

20

25

8 10 12 14 16 18 20 22 24 26 RM 26 24 22 20 18 16 14 12 10 8

Pres

sure

(cm

H2O

)D

rivin

g

pre

ssu

re

PEEP PEEP

Rec.

“ Hysteresis “


“decrementalPEEP titration”

PaO2/FIO2 = 180 PaO2/FIO2 = 380

N = 25

Obrigado

UTI Respiratória HC-FMUSP

UTI Hospital Sírio Libanês

Eduardo LV Costa

[email protected]

Como evitar a VILI UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês Eduardo LV Costa Valerie...

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Transcript of Como evitar a VILI UTI Respiratória HC-FMUSP UTI Hospital Sírio Libanês Eduardo LV Costa Valerie...