Estrategia de pulmón abierto

1. Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares Edgar Jiménez, MD, FCCM Director – UCI y Co-Chairman Medicina Crítica Orlando Regional Medical Center Profesor Asociado de Medicina University of Florida, Florida StateUniversity & University of Central Florida Presidente Federación Mundial de Sociedades de Medicina Crítica 2º Seminario de Ventilación Mecánica - VAFO Asociación Panameña de Medicina Crítica y Terapia Intensiva Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011

2. Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares Edgar Jiménez, MD, FCCM Director – UCI y Co-Chairman Medicina Crítica Orlando Regional Medical Center Profesor Asociado de Medicina University of Florida, Florida StateUniversity & University of Central Florida Presidente Federación Mundial de Sociedades de Medicina Crítica 2º Seminario de Ventilación Mecánica - VAFO Asociación Panameña de Medicina Crítica y Terapia Intensiva Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011

6. Disclosures Research: NASA CareFusion® CCCTG & CIHR

7. Objectives Using in vivovideomicroscopy will demonstrate the anatomical, physiological and pathophysiological findings of: Normal lungs Acutely injured lungs Lung recruitment using Ptp Intra-abdominal hypertension

8. Fantastic Voyage 1966 “Oscar” for Special Effects Isaac Azimov Richard Fleischer Raquel Welch

9. Raquel Welch

10. Real-life“Fantastic Voyager” Gary Nieman, BA Director: Critical Care Translational Research Laboratory ORMC, Orlando, FL Cardiopulmonary and Critical Care Laboratory SUNY, Syracuse, NY

11. Labs in Syracuse, NYand Orlando, FL

12. How come? In vivovideomicroscopy Concept of RACE: Repetitive alveolar closing and expansion

13. Mechanisms of VILI Barotrauma Volutrauma Biotrauma Atelectrauma

14. Mechanisms of VILI Barotrauma Volutrauma Biotrauma Atelectrauma

15. To understand:abnormal alveolar mechanics We must first understand: normal alveolar mechanics

16. “The end”of the Bronchial Tree

18. F. Possmayer, PhD. U. of Western Ontario

19. Alveolar Duct F. Possmayer, PhD. U. of Western Ontario

20. F. Possmayer, PhD. U. of Western Ontario

21. How do we breathe?

22. Alveolar Duct Expiration Alveolar Duct Inspiration Weibel et al Respir Physiol 1985

23. Normal alveolar dynamics G Nieman, SUNY

24. G Nieman, SUNY

25. G Nieman, SUNY

26. G Nieman, SUNY

27. Alveoli:Not Just a Bunch of Grapes Prange H: Adv Physiol Educ 2003

28. Mead: JAP 1970 Alveolar Independence Structural Support Honeycomb-like structural support

29. Hiroko & Nieman, SUNY 2005

30. Hiroko & Nieman, SUNY 2005

31. Hiroko & Nieman, SUNY 2005

32. Stressed alveolar sac G Nieman, SUNY

33. G r a v i t y Courtesy of Dr. Marcelo Amato

34. G r a v i t y Courtesy of Dr. Marcelo Amato

35. G r a v i t y Courtesy of Dr. Marcelo Amato

36. G r a v i t y Courtesy of Dr. Marcelo Amato

37. G r a v i t y Courtesy of Dr. Marcelo Amato

38. G r a v i t y Courtesy of Dr. Marcelo Amato

39. G r a v i t y Courtesy of Dr. Marcelo Amato

40. G r a v i t y Courtesy of Dr. Marcelo Amato

41. G r a v i t y Courtesy of Dr. Marcelo Amato

42. G r a v i t y Courtesy of Dr. Marcelo Amato

43. G r a v i t y Courtesy of Dr. Marcelo Amato

44. G r a v i t y Courtesy of Dr. Marcelo Amato

45. G r a v i t y Courtesy of Dr. Marcelo Amato

46. G r a v i t y Courtesy of Dr. Marcelo Amato

47. G r a v i t y Courtesy of Dr. Marcelo Amato

48. G r a v i t y Courtesy of Dr. Marcelo Amato

49. G r a v i t y Courtesy of Dr. Marcelo Amato

50. G r a v i t y Courtesy of Dr. Marcelo Amato

51. G r a v i t y Courtesy of Dr. Marcelo Amato

52. G r a v i t y Courtesy of Dr. Marcelo Amato

53. G r a v i t y Courtesy of Dr. Marcelo Amato

54. G r a v i t y Courtesy of Dr. Marcelo Amato

55. Strain G r a v i t y Stress Courtesy of Dr. Marcelo Amato

56. G r a v i t y Courtesy of Dr. Marcelo Amato

57. G r a v i t y Courtesy of Dr. Marcelo Amato

58. G r a v i t y Courtesy of Dr. Marcelo Amato

59. G r a v i t y Courtesy of Dr. Marcelo Amato

60. G r a v i t y Courtesy of Dr. Marcelo Amato

61. G r a v i t y Courtesy of Dr. Marcelo Amato

62. G r a v i t y Courtesy of Dr. Marcelo Amato

63. G r a v i t y Pendeluft Courtesy of Dr. Marcelo Amato

65. Stresses on the Epithelium during Fluid Displacement Bilek AM et al. J Appl Physiol 2003;94:770-783

66. Rigid airway Courtesy of Dr. Marcelo Amato

67. Rigid airway Courtesy of Dr. Marcelo Amato

68. Rigid airway Courtesy of Dr. Marcelo Amato

69. Rigid airway Courtesy of Dr. Marcelo Amato

70. Rigid airway Courtesy of Dr. Marcelo Amato

71. Rigid airway Courtesy of Dr. Marcelo Amato

72. Rigid airway Courtesy of Dr. Marcelo Amato

73. Rigid airway Courtesy of Dr. Marcelo Amato

74. Rigid airway Courtesy of Dr. Marcelo Amato

75. Rigid airway Courtesy of Dr. Marcelo Amato

76. Rigid airway Courtesy of Dr. Marcelo Amato

77. Rigid airway Courtesy of Dr. Marcelo Amato

78. Stresses on Epithelium during Airway Opening Bilek AM et al. J Appl Physiol 2003;94:770-783

79. Flexible airway Courtesy of Dr. Marcelo Amato

80. Flexible airway Courtesy of Dr. Marcelo Amato

81. Flexible airway Courtesy of Dr. Marcelo Amato

82. Flexible airway Courtesy of Dr. Marcelo Amato

83. Flexible airway Courtesy of Dr. Marcelo Amato

84. Flexible airway Courtesy of Dr. Marcelo Amato

85. Flexible airway Courtesy of Dr. Marcelo Amato

86. Flexible airway Courtesy of Dr. Marcelo Amato

87. Flexible airway Courtesy of Dr. Marcelo Amato

88. Flexible airway Courtesy of Dr. Marcelo Amato

89. Flexible airway Courtesy of Dr. Marcelo Amato

90. Flexible airway Courtesy of Dr. Marcelo Amato

91. Flexible airway Courtesy of Dr. Marcelo Amato

92. Flexible airway Courtesy of Dr. Marcelo Amato

93. Flexible airway Courtesy of Dr. Marcelo Amato

94. Flexible airway Courtesy of Dr. Marcelo Amato

97. Steinberg J.et al. Am J RespCrit Care Med2004

98. Steinberg et al. AJRCCM.2004;169:57-63 Heterogeneous Lung Injury Injured lung: In vivo Microscopy Histology + IHC Normal lung: In vivo Microscopy Histology + IHC

99. Unstable Alveoli Stable Alveoli Low PEEP Group (3) Steinberg et al. AJRCCM.2004;169:57-63

100. Alveoli Stabilized With PEEP Stable Alveoli High PEEP Group (15) Steinberg et al. AJRCCM.2004;169:57-63

102. PEEP = improves oxygenation

103. PEEP = improves oxygenation It’s more than that!

104. PEEP = stabilizes alveoli

105. PEEP = decreases RACE

106. PEEP = decreases VILI

107. ARDSNet (NHLBI) NEJM, May – 2000 10 University Centers Criteria: Bilateral infiltrates Intubation and mechanical ventilation PaO2/FiO2 <300

108. 28 Day Survival 6 ml/kg 12 ml/kg ARDSNetNEJM, 2000

109. Respiratory Cycle Ppeak Pplat Trigger PEEP

110. Initial table for FiO2 & PEEP ARDSNetNEJM, 2000

111. ARDSNet demonstrated:An outcome changeprimarily associated to achange in ventilatory strategy(LV)

112. A big question: Is the ARDS Net Protocol enough?

113. Not really We may not know the true transpulmonary pressure (Ptp) Timid and arbitrary PEEP scale

114. Meta-Analysis Based on ALVEOLI LOVS EXPRESS Briel, M. et al. JAMA 2010;303:865-873.

115. Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline Non-ARDS ARDS All Pts Briel, M. et al. JAMA 2010;303:865-873.

116. Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline Non-ARDS ARDS All Pts Briel, M. et al. JAMA 2010;303:865-873.

117. Optimized Lung Volume “Safe Window” Overdistension Edema fluid accumulation Surfactant degradation High oxygen exposure Mechanical disruption Derecruitment Atelectasis Inflammatory response Surfactant inhibition Local hypoxemia Compensatory overexpansion Zone of Overdistention Injury “Safe” Window Zone of Derecruitment and Atelectasis Volume Injury Pressure Froese: Crit Care Med 1997

118. CT 2 CT 1 CT 3 Froese: Crit Care Med 1997

119. How do We Open the Lung and Keep it Open?

120. How do We Open the Lung and Keep it Open? Open: Recruitment maneuver

121. How do We Open the Lung and Keep it Open? Open: Recruitment maneuver Keep it open: PEEP or HFOV

122. Ware and MatthayNEJM 342 (18): 1334

123. Current Ventilation Practices Volume Ventilation, Low VT, PEEP Pressure Control Ventilation  PEEP, Inverse I:E Ratio VCV or PCV with PEEP adjusted by Ptp Non-Conventional Ventilation APRV/Bi-Level HFOV Pronation, iNO ECMO

124. How do we know we have achieved OL-PEEP?

125. How do we do it? ARDS Net ALVEOLI, LOVS, EXPRESS Decremental PEEP Trial Pes and Ptp Volumetric Capnography Auscultation Ultrasound Respiratory Impedance Pletysmography Electrical Impedance Tomography HFOV - TOOLS

126. How do we do it? ARDS Net ALVEOLI, LOVS, EXPRESS Decremental PEEP Trial Pes and Ptp Volumetric Capnography Auscultation Ultrasound Respiratory Impedance Pletysmography Electrical Impedance Tomography HFOV - TOOLS

127. How do we do it? ARDS Net ALVEOLI, LOVS, EXPRESS Decremental PEEP Trial Pes and Ptp Volumetric Capnography Auscultation Ultrasound Respiratory Impedance Pletysmography Electrical Impedance Tomography HFOV - TOOLS

128. Can we do better?

129. Let’s talk about pressure…

130. Let’s talk about pressure… and the trumpet player

131. How much airway pressure can a trumpet player generate?

132. Trumpet player Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204

133. Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204

134. Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204

135. Cook. J Applied Phys. 1964. 1016

136. Cook. J Applied Phys. 1964. 1016

137. Answer: 100-120 cm H2O Cook. J Applied Phys. 1964. 1016

138. So… Why don’t we see more ALI and ARDS in these players?

144. Answer: Because they keep the Ptp within tolerable limits

145. Answer: Because they keep the Ptp within tolerable limits with the use of their respiratory muscles

146. Let’s go to extremes ofairway pressure

147. Paw at sea level:

148. Paw at sea level: 1034 cm H2O

149. Paw at a 33 ft dive:

150. Paw at a 33 ft dive: 2068 cm H2O

151. Paw at a 33 ft dive: 2068 cm H2O Add 1034 cm H2O for every 33 ft.

152. Paw at a 100 ft dive: Add 1034 cm H2O for every 33 ft.

153. Paw at a 100 ft dive: 4140 cm H2O Add 1034 cm H2O for every 33 ft.

154. So… Why don’t we see more ALI and ARDS in these divers?

155. Answer: Because they keep the Ptp within tolerable limits

156. Answer: Because they keep the Ptp within tolerable limits with a similar increase in the external environmental pressure

157. It’s all relative!

159. <0.5 MPH

160. 17,000 MPH <0.5 MPH 17,000 MPH

161. 17,000 MPH Success!

163. What is the Paw at 10,000 ft?

164. What is the Paw at 10,000 ft? 795 cm H2O

165. What is the Paw at 10,000 ft? 795 cm H2O 30% less than MSL

166. What is the Paw atMt. Everest’s summit?

167. What is the Paw atMt. Everest’s summit? 285 cm H2O

168. What is the Paw atMt. Everest’s summit? 285 cm H2O 72% less than MSL

169. They can get in LOTS of trouble!

170. They can get in LOTS of trouble!

171. Management of ALI and ARDS using Transpulmonary Pressures

172. Management of ALI and ARDS usingTranspulmonarypressures Factorsthatmay alter currentrecomendationsbasedon↓Ccw: Obesity Edema/anasarca Intra-abdominal pressure Pregnancy Chestwalldeformities Scars

173. The problem??? With Pplat, we are measuring only one side of the equation!!!!! What happens with patients with compromised compliances?

174. The problem??? With Pplat, we are measuring only one side of the equation!!!!! What happens with patients with compromised compliances? We DON’T KNOW!

177. Intrathoracic pressures PROX. AIRWAY PRESSURE (Paw) TRACHEAL PRESSURE (Ptr) PLEURAL PRESSURE (Ppl) (Pes) ALVEOLAR PRESSURE (Palv)

178. Pplat PROX. AIRWAY PRESSURE (Paw) TRACHEAL PRESSURE (Ptr) PLEURAL PRESSURE (Ppl) (Pes) ALVEOLAR PRESSURE (Palv)

179. Ptp PROX. AIRWAY PRESSURE (Paw) TRACHEAL PRESSURE (Ptr) PLEURAL PRESSURE (Ppl) (Pes) ALVEOLAR PRESSURE (Palv)

180. Ptp PROX. AIRWAY PRESSURE (Paw) Pes TRACHEAL PRESSURE (Ptr) PLEURAL PRESSURE (Ppl) (Pes) ALVEOLAR PRESSURE (Palv)

181. Position of Esophagus and Pleura

182. Position of Esophagus and Pleura

183. Pplat and Ptp Kubiak, Jimenez, Silva, Nieman Marked variability among patients in abdominaland pleural pressures For a given PEEP, Ptp may vary unpredictably from patient to patient. Malbrain ML et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study. Crit Care Med 2005;33:315-322. Talmor D et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 2006;34:1389-1394

184. Relationship Ptp - Tv Ptp (cm H2O) Tv(mL/kg) Talmor et al. Crit Care Med, 2006

185. Figure 1 Increasing IAP Vt PEEP 30 25 20 15 10 5 0 0 0 Stage One Stage Two Kubiak, Jimenez, Nieman, J Surg Trials, 2010

186. Kubiak, Jimenez, Nieman, J Surg Trials, 2010

187. Kubiak, Jimenez, Nieman, J Surg Trials, 2010

188. Kubiak, Jimenez, Nieman, J Surg Trials, 2010

189. Jimenez, Nieman ORMC, 2008

191. Transpulmonary Pressure, Plateau (Ptp-plat) Increased Ptp : ↓ compliance ↑ negative Ppl Decreased Ptp : normal compliance not assisting on the ventilator

192. Intrathoracic pressures Tracheal pressures are measured at distal end of ET Tube

193. Ptr (Paw)

194. Esophageal Pressure Measurements

195. Connections

196. Connections

197. Connections Ptp

204. The Baydur Maneuver 20 10 0 -10 -20 20 10 0 -10 -20 Paw cm H2O Pes Breath Initiation

205. Hypothesis Patients with↑ Pplwith conventional settings: Underinflation -> causeshypoxemia Raising PEEP to maintain a positive Ptp improves aeration and oxygenationwithout overdistention.

206. Hypothesis Patients with↓ Pplwith conventional settings: Maintaining low PEEP would keep low Ptp Prevents overdistention Minimizing adversehemodynamic effects of high PEEP Beyer J et al: The influence of PEEP ventilation on organ blood flow and peripheral oxygen delivery. Intensive Care Med 1982;8:75-80.

207. Goal To provide sufficientPtp (Paw - Ppl)to: Maintain acceptable PaO2 Minimize repeated alveolar collapse Minimize overdistention Ptp = Ptr – Pes Slutsky AS. Lung injury caused by mechanical ventilation. Chest 1999;116:Suppl:9S-15S.

208. Methods Supine HOB 30º Esophageal balloon catheter passed to 60 cmfrom incisors Gentle compression of abdomen Thenwithdrawn to 40 cm Cardiac artifact 1/3 couldn’t be passed into stomach Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

209. Methods Recruitment maneuver 40 cm H2O X 40 sec. Max Ptp-plat < 25 cm H2O VT: 6 mL/kg PBW PBW: ♂: 50 + 0.91 X (cm – 152.4) ♀: 45.5 + 0.91 X (cm – 152.4) Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

210. Strategy PaO2: 55-120 mm Hg Or SpO2: 88-98 % pH: 7.30-7.45 pCO2: 40-60 mm Hg VT: Adjusted to keep Ptp-plat < 25 cm H2O Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

211. Stress-strain curve of healthy pigs Specific Lung Elastance 5.8 cmH2O Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]

212. Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]

213. Strategy PCV or VCV I:E : 1:1 to 1:3 RR: < 35 RM: PRN for suction/disconnection Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

214. Table Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

215. Table Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

216. Study Stopped after 61 pts as criteria were met in interim analysis Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

217. PaO2/FiO2 Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

218. Respiratory System Compliance(mL/cm H2O) Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

219. VD/VT Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

220. PEEP Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

221. Ptp - EE Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

222. Ptp - PEEP Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

223. Pplat Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

224. Ptp – PLAT Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

225. Ptp – EI Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

226. K-M Survival Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014

227. ARDSNetLung(ARMA) Jimenez E, Nieman G, ORMC 2011

228. Ptp Lung Jimenez E, Nieman G, ORMC 2011

229. Talmor presents:An improvement in oxygenation and compliance withPtp significantly lower thanoverestimated Pplat

230. Talmor presents:A persistent negative Ptp-PEEP when using the ARDS Net scale

231. A big question: Is this enough?

232. Not really Arbitrary PEEP scale We need to know how to adjust it better We need to find morbidity/mortality data

233. What else can we use?

234. Volumetric Capnography

235. Terminology End-Tidal CO2 (ETCO2) Peak concentration of CO2at end exhalation. Time-Based Capnography Concentration of CO2 plotted as a scale Volumetric Capnography Concentration of CO2 integrated with flow.

236. Zero baseline (A-B) End tidal value (D) Rapid, sharp rise (B-C) Rapid, sharp downstroke (D-E) Alveolar plateau (C-D)

237. Capnography Volumetric CO2 EtCO2 Capnogram RR CO2 Elimination Deadspace Alveolar Ventilation Cardiac Output / Perfusion Physiologic Vd/Vt

238. PEEP & VCO2

239. VCO2is CO2elimination from CO2production… …in a steady state!!!

240. Important questions for us: Is the pt OK with LVHP (ARDS Net)? Is the FiO2 > 0.60? Is your Pplat > 30 cm H2O? Is your Paw > 20 cm H2O? Is your Ptp plat> 20 cm H2O? PEEP > 15 cm H2O? OI > 15?

241. Important questions for us: Is the pt OK with LVHP (ARDS Net)? Is the FiO2 > 0.60? Is your Pplat > 30 cm H2O? Is your Paw > 20 cm H2O? Is your Ptp plat> 20 cm H2O? PEEP > 15 cm H2O? OI > 15?

242. What’s Next ????