PEEP nuove indicazioni, stesse problematiche
Franco Valenza
Department of Pathophysiology and Transplantation
Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico
Airway pressure [cmH2O]
0 10 20 30 40 50 60 70 80
Re
cru
itm
en
t a
nd
In
fla
tio
n
0
20
40
60
80
100
Pressure (cmH2O)
0 20 40 60 80 100
Volume (ml/kg)
0
10
20
30
40
50
60
70
Inspiratory Capacity
n=8
0
40
cmH2O
0
150
mmHg time (sec)
Valenza CCM (1997) 99:944
Airway pressure [cmH2O]
0 10 20 30 40 50 60 70 80
Re
cru
itm
en
t a
nd
In
fla
tio
n
0
20
40
60
80
100
Pressure (cmH2O)
0 20 40 60 80 100
Volume (ml/kg)
0
10
20
30
40
50
60
70
Inspiratory Capacity
n=8
0
40
cmH2O
0
150
mmHg time (sec)
Ventilator induced lung injury
Alveolar over-distentionDreyfuss ARRD 1988; 137:1159-64
Bowton CCM 1989; 17:908-11
Airway pressure [cmH2O]
0 10 20 30 40 50 60 70 80
Re
cru
itm
en
t a
nd
In
fla
tio
n
0
20
40
60
80
100
Pressure (cmH2O)
0 20 40 60 80 100
Volume (ml/kg)
0
10
20
30
40
50
60
70
Inspiratory Capacity
n=8
0
40
cmH2O
0
150
mmHg time (sec)
Alveolar over-distentionDreyfuss ARRD 1988; 137:1159-64
Bowton CCM 1989; 17:908-11
Tidal breathing collapseWebb ARRD 1974; 110:556-65
Parker CCM 1993; 21:131-43
Muscedere AJRCCM; 149:1327-34
Ventilator induced lung injury
Ra
t a
lve
ola
r c
ell
s
50% cell death
Daniel J et al, Am J Respir Crit Care Med 2000, 162, 357-362
IL-8MMP
Mac
rop
hag
es
via
NF
kB
En
do
the
lia
l c
ell
s
A4
59
hu
ma
n e
pit
heli
al II
ce
lls
NO
AC
TIV
AT
ION
10 20 30 40 50 60
40
30
20
10
50
% strain
0
AU
Pugin et al. Am. J. Physiol. 275 (Lung Cell. Mol. Physiol. 19): L1040-L1050, 1998Vlahakis NE et al. Am. J. Physiol. 277 (Lung Cell. Mol. Physiol. 21): L137-L173, 1999
Ongoing
recruitment
Ongoing
overdistension
Full
recruitment
Trattamento ventilatorio individualizzato
Ongoing
recruitment
Ongoing
overdistension
Full
recruitment
Trattamento ventilatorio individualizzato
F
L
a
b
L0
S=a*b
Stress = F/S
Strain =L/L0
Transpulmonary pressure
Vt / EELV
Gattinoni, Eur Respir J (2003) 47:15s
Airway pressure [cmH2O]
0 10 20 30 40 50 60 70 80
Re
cru
itm
en
t a
nd
In
fla
tio
n
0
20
40
60
80
100
Pressure (cmH2O)
0 20 40 60 80 100
Volume (ml/kg)
0
10
20
30
40
50
60
70
Inspiratory Capacity
n=8
0
40
cmH2O
0
150
mmHg time (sec)
Alveolar over-distentionDreyfuss ARRD 1988; 137:1159-64
Bowton CCM 1989; 17:908-11
Tidal breathing collapseWebb ARRD 1974; 110:556-65
Parker CCM 1993; 21:131-43
Muscedere AJRCCM; 149:1327-34
Ventilator induced lung injury
low FEV1
0 5 10 15 20 25 30 35
0.0
0.2
0.4
0.6
0.8
1.0
high FEV1
Airway pressure (cmH2O)
0 5 10 15 20 25 30 35
Vo
lum
e (
L)
0.0
0.2
0.4
0.6
0.8
1.0
Lateral
Supine
Trattamento ventilatorio individualizzato
Valenza , EJA Dec 2004
ZEEP (n=15)
PEEP (n=16)
ZEEP (n=15)
PEEP (n=17)
Randomisation
SUPINE LATERAL LATERAL+TREATMENT
PRE-OPERATIVE INTRA-OPERATIVE
FEV1 stratification
High (n=31)
Low (n=15)
Valenza , EJA Dec 2004
87.4 24
88.0 22
34.0 6
35.1 7
86.2 35
108.0 50 *
33.9 5
46.6 13 *
85.5 24
84.8 19
32.8 6.1
34.2 7.7
87.1 36
114.7 53 *
33.6 3.6
48.4 3.9 *
90.9 25
94.0 27
34.1 6.1
33.8 5.1
83.9 21
92.6 41
32.2 3.8
40.2 6.1
All patients High FEV1 Low FEV1
ZEEP
PEEP
PaO2
Cpleff
PaO2
Cpleff
Ottimizzazione intra-operatoria
Valenza , EJA Dec 2004
87.4 24
88.0 22
34.0 6
35.1 7
86.2 35
108.0 50 *
33.9 5
46.6 13 *
85.5 24
84.8 19
32.8 6.1
34.2 7.7
87.1 36
114.7 53 *
33.6 3.6
48.4 3.9 *
90.9 25
94.0 27
34.1 6.1
33.8 5.1
83.9 21
92.6 41
32.2 3.8
40.2 6.1
All patients High FEV1 Low FEV1
ZEEP
PEEP
PaO2
Cpleff
PaO2
Cpleff
Ottimizzazione intra-operatoria
Valenza , EJA Dec 2004
Liker, Anesth Analg 2003; 97:1558
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
“ Product of inspiratory plateu pressure > 10 cmH2O and duration of OLV”
Perioperative fluids
Zeldin, J Thorac Cardiovasc Surg 1984;87:359
“ 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”
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
… in conclusion
Pressure (cmH2O)
0 20 40 60 80 100
Volume (ml/kg)
0
10
20
30
40
50
60
70
Inspiratory Capacity
n=8
0
40
cmH2O
0
150
mmHg time (sec)
Tidal Volume
PEEP
Stress-Strain