SDRA: VM com baixos volumes correntes

Prof. Dr. Carlos Carvalho

Professor Associado / Livre Docente

HOSPITAL DAS CLNICAS FACULDADE DE MEDICINA UNIVERSIDADE DE SO PAULO

UTI-RESPIRATRIA 26 anos

NDICES DE MORTALIDADE NA SARA

100 80 % Mortalidade 60 40 20

1965

1975

1980

1985

1990

1995

2000

NDICES DE MORTALIDADE NA SARA

100 80 % Mortalidade 60 40 20 Convencional Protetora

1965

1975

1980

1985

1990

1995

2000

ACCP - CONSENSUS CONFERENCE MECHANICAL VENTILATION - ARDS

ventilation mode: clinicians experience oxygenation: SaO2 > 90% plateau pressure < 35 mmHg (low VT if necessary)

permissive hypercapnia (careful with ICP and acidosis)

PEEP: always (the least level according to oxygenation) FIO2: the lowest possible (oxymetry) if hypoxemia: sedation/paralisis and prone position
A. S. Slutsky - Chest 1993

ACCP - CONSENSUS CONFERENCE MECHANICAL VENTILATION - ARDS

ventilation mode: clinicians experience oxygenation: SaO2 > 90% plateau pressure < 35 mmHg (low VT if necessary)

permissive hypercapnia (careful with ICP and acidosis)

PEEP: always (the least level according to oxygenation) FIO2: the lowest possible (oxymetry) if hypoxemia: sedation/paralisis and prone position
A. S. Slutsky - Chest 1993

ESTRATGIAS PROTETORAS MORTALIDADE

80 70 60 50 40 30 20 10 0
BRASIL
n = 53
p < 0,001

Controle Protetora

CANAD
n = 120
p = 0,72

FRANA
n = 116
p = 0,38

EUA
n = 52
no sig

NIH
n = 861
p = 0,007

ESTRATGIAS PROTETORAS MORTALIDADE

80 70 60 50 40 30 20 10 0 Controle Protetora

BRASIL
n = 53
p < 0,001

CANAD
n = 120
p = 0,72

FRANA
n = 116
p = 0,38

EUA
n = 52
no sig

NIH
n = 861
p = 0,007

Chest 2007, 131: 921

Chest 2007, 131: 921

Chest 2007, 131: 921

J Bras Pneumol 2007 (suplemento)

J Bras Pneumol 2007 (suplemento)

CO2 + H2O

H2CO3
HCO3

+ H

CO2 + H2O

H2CO3
HCO3

+ H

CO2 + H2O

H2CO3
HCO3

+ H

Curr Opin Crit Care 2005, 11: 56

Hipercapnia Permissiva
Mecanismo do efeito protetor da Acidose + Hipercapnia
NF-B regula a expresso de genes envolvidos na inflamao

Acidose (PaCO2) inibe a ativao do NF-B endotoxina induzida

Acidose (PaCO2) suprime a produo de ICAM-1 e IL-8

Takeshita et al., Am J Respir Cell Mol Biol 2003, 29:124

Hipercapnia Permissiva
Qual o limite (tolerncia) para o PaCO2 ?
Status Asmaticus em garoto 8 anos - pH 6,77 PaCO2 293
Mazzeo et al., Paediatr Anaesth 2004, 14:596

Mulher idosa, exacerbao DPOC PaCO2 233 mmHg

Urwin et al., Emerg Med J 2004, 21:119

Am J Respir Crit Care Med 1997, 156: 1458

SDRA - PROTOCOLO DE TRATAMENTO

cateter de Swan-Ganz
escore de > 2,5 leso pulmonar

Pwedge < 16 mmHg

30 min de ventilao mecnica padronizada (perodo controle)

Curva P X V esttica
RANDOMIZAO
CONVENCIONAL ESTRATGIA PROTETORA

ARTERIAL PCO2 & pH

p < 0.0001 60
ARTERIAL

p < 0.0001

*
45

PCO2
( mmHg )

30

Protective Strategy Conventional

7.45
ARTERIAL

pH

7.30 NS

7.15
CONTROL

*
p < 0.0001

36

HOURS
PERIOD ON MECHANICAL VENTILATION

DAYS

Carvalho et al. - AJRCCM 1997

VASCULAR PULMONARY PRESSURES

35 PULMONARY ARTERIAL PRESSURE p = 0.004

NS

*
30

( mmHg )
25

15 WEDGE PRESSURE ( mmHg ) 12

Protective Strategy Conventional

*
NS

9
CONTROL 0

p = 0.001

36

HOURS
PERIOD ON MECHANICAL VENTILATION

DAYS

Carvalho et al. - AJRCCM 1997

VASCULAR RESISTANCES INDEX

p = 0.80
NS
350

PULMONARY RESISTANCE
( dyne.sec/cm5.m2)

200

50

1600

Protective Strategy Conventional

SYSTEMIC RESISTANCE
( dyne.sec/cm5.m2)

1200

NS
800 CONTROL 0 36

p = 0.04

HOURS
PERIOD ON MECHANICAL VENTILATION

DAYS

Carvalho et al. - AJRCCM 1997

CARDIAC EFFECTS
p = 0.04
6.5

NS

CARDIAC INDEX (L /min/ m2)

5.5

4.5

Protective Strategy
140

Conventional

HEART RATE (beats/min)

120

100
CONTROL

p = 0.02

NS

36

HOURS
PERIOD ON MECHANICAL VENTILATION

DAYS

Carvalho et al. - AJRCCM 1997

SYSTEMIC OXIGENATION
1000

p = 0.05

NS

*
INDEX OF OXYGEN DELIVERY (mL /min/ m2) 800

600 40

Protective Strategy Conventional

LACTATE ( mg / dL ) 28

16

p < 0.0001
CONTROL 0 36

p = 0.13

HOURS
PERIOD ON MECHANICAL VENTILATION

DAYS

Carvalho et al. - AJRCCM 1997

INCIDNCIA DE SDRA
Amrica Latina Total SDRA pr-MV SDRA durante MV 10,5% 6,2% 4,3% EUA Canad 7,8% 4,5% 3,3% Europa 8,3% 3,6% 4,7%

Courtesia A Esteban, 2001

Volume Corrente (mL/Kg) Amrica Latina EUA Canad Europa

PEEP (cm H2O) Amrica Latina EUA Canad Europa

Dia 1 9+2 8,5 + 2 9+2

Dia 1 6,5 + 4,5 8+4 7+4

Dia 4 9+2 8+2 9+2

Dia 4 9+5 9,5 + 3 9+4

Dia 7 9+2 9+3 9+2

Dia 7 8+4 9+3 9+4
Courtesia A Esteban, 2001

MORTALIDADE
Amrica Latina Total SDRA pr-MV SDRA durante MV 54% 49% 61% EUA Canad 50% 45% 58% Europa 64% 61% 66%

Courtesia A Esteban, 2001

NDICES DE MORTALIDADE NA SDRA

100 80 % Mortalidade 60 40 20 Convencional Protetora

1965

1975

1980

1985

1990

1995

2000

ESTRATGIAS PROTETORAS MORTALIDADE

80 70 60 50 40 30 20 10 0 Controle Protetora

BRASIL
n = 53
p < 0,001

CANAD
n = 120
p = 0,72

FRANA
n = 116
p = 0,38

EUA
n = 52
no sig

NIH
n = 861
p = 0,007

60

PRESSO de PLAT (cmH2O)

50

40

30

20

10 0
N=

( n = 166 )

( n = 171 )

CONTROL

PROTECTIVE

HIPTESE:
1. Superposio das presses inspiratrias entre as 2 estratgias

2. A sobrevida influenciada pela forma de ventilao aplicada nas primeiras horas

Distribuio das Presses de Plat (conjunto de dados)

70

60

Freqncia

50

40

30

20

10 0 5.3 11.6 17.8 24.1 30.3 36.6 42.8 49.1

8.4

14.7

20.9

27.2

33.4

39.7

45.9

52.2

PRESSO de PLAT (cmH2O)

Distribuio das Plateau Pressures (conjunto de dados) Distribution of Presses de Plat (pooled analysis)
70 60

Frequency Freqncia

50 40 30 20 10 0 5.3 8.4 11.6 14.7 17.8 20.9 24.1 27.2 30.3 33.4 36.6 39.7 42.8 45.9 49.1 52.2

PRESSO de PLAT (cmH2O)

Distribuio das Plateau Pressures (conjunto de dados) Distribution of Presses de Plat (pooled analysis)
70 60

Frequency Freqncia

50 40 30 20 10 0 5.3 8.4 11.6 14.7 17.8 20.9 24.1 27.2 30.3 33.4 36.6 39.7 42.8 45.9 49.1 52.2

PRESSO de PLAT (cmH2O)

Distribuio das Plateau Pressures (conjunto de dados) Distribution of Presses de Plat (pooled analysis)
70 60

Frequency Freqncia

50 40 30 20 10 0 5.3 8.4 11.6 14.7 17.8 20.9 24.1 27.2 30.3 33.4 36.6 39.7 42.8 45.9 49.1 52.2

PRESSO de PLAT (cmH2O)

Distribuio das Plateau Pressures (conjunto de dados) Distribution of Presses de Plat (pooled analysis)
70 60

Frequency Freqncia

50 40 30 20 10 0 5.3 8.4 11.6 14.7 17.8 20.9 24.1 27.2 30.3 33.4 36.6 39.7 42.8 45.9 49.1 52.2

PRESSO de PLAT (cmH2O)

BROCHARD & BROWER & STEWART juntos

1.1 1.0 .9

SOBREVIDA CUMULATIVA

.8 .7 .6 .5

P = 0.002 PPLAT < 23

23 27 27 33

.4
.3 .2 .1 0.0

PPLAT > 33 n = 287

0 10 20 30 40 50 60

DIAS APS ENTRADA

BROCHARD & BROWER & STEWART & AMATO

1.1 1.0 .9

SOBREVIDA CUMULATIVA

.8 .7 .6 .5 .4 .3 .2 .1

P < 0.0001

PPLAT < 23
23 27 27 33

PPLAT > 33

n = 341
( Ajustado para APACHE & pH & PEEP )
0 10 20 30 40 50 60

0.0

DIAS APS ENTRADA

60

PRESSO de PLAT (cmH2O)

50

40

30

20

10 0
N=

( n = 166 )

( n = 171 )

CONTROL

PROTECTIVE

1200

VOLUME CORRENTE (mL)

1000

800

600

400

200 0

( n = 166 )

( n = 171 )

CONTROL

PROTECTIVE

Brochard & Brower & Stewart juntos

40

TIDAL VOLUME (mL)

30

20
Std. Dev = 161 Mean = 580.3

10

N = 285

Brochard & Brower & Stewart pooledjuntos Brochard & Brower & Stewart
40

30

VT > 690 mL

20
Std. Dev = 161 Mean = 580.3

10

N = 285

Brochard & Brower & Stewart pooledjuntos Brochard & Brower & Stewart
40

560 690 mL
30

20
Std. Dev = 161 Mean = 580.3

10

N = 285

Brochard & Brower & Stewart pooledjuntos Brochard & Brower & Stewart
40

440 560 mL
30

20
Std. Dev = 161 Mean = 580.3

10

N = 285

Brochard & Brower & Stewart pooledjuntos Brochard & Brower & Stewart
40

30

VT < 430 mL

20
Std. Dev = 161 Mean = 580.3

10

N = 285

(Brochard & Brower & Stewart - juntos)

1.0

VT e Sobrevida

Sobrevida Cumulativa

.9 .8 .7 .6

< 430 mL P = 0.12

440 560 560 690

.5
.4

> 690 mL N = 288

*: adjusted for Apache, pH, FIO2
0 10 20 30 40 50 60

.3
.2 .1 0.0

Dias aps entrada

Mensagem:

Altos VT so delettrios quando

associados a altas PPLAT