Diapositiva 1

Transcript

Diapositiva 1

Modalità di ventilazione: IPPV vs PCV … oppure?
D. Massullo
U.O.C. Anestesiologia e Terapia Intensiva - Azienda Ospedaliera Sant’ Andrea
Facoltà di Medicina e Psicologia - Sapienza Università di Roma
Mechanical ventilation
Goals in Thoracic Surgery
Adequate
gas exchange
Minimum
hemodynamic impairment
Surgery
(OLV)
Minimum
lung injury
Thoracic surgery at high risk for PPCs (14,5-40%)
Mechanisms for ALI – ARDS
after lung resection surgery
(4-15%)
Lohser J: Evidence-based Management of OneLung Ventilation. Anesthesiology Clin 26 (2008)
241–272
Inflammatory cytokines (TNF α9)
Surgical trauma
Ischemia–reperfusion
Fluid Overload
Lung lymphatics impairment
Ventilatory induced lung injury
VCV
PCV
VOLUME
Volume Controlled Ventilation
PRESSURE
VCV = Increasing Pressure
PEEP
Inspiration
TIME
Expiration
Inspiration
FLOW
VCV = Costant Flow
TIME
Pressure Controlled Ventilation
PRESSURE
PCV = Constant Pressure
PCV
PEEP
Inspiration
TIME
Expiration
Inspiration
FLOW
PCV = Decrescent Flow
TIME
Volume-controlled ventilation
• Advantages
– Maintans costant Tidal Volume
– Precise control of PaCO2
• Disadvantages
– Potential for high airway pressure
– Potential ALI
– Inability to compensate for air leaks
Pressure controlled Ventilation
• Advantages
– Reduction of peak pressure and risk of barotrauma
– Improving gas exchange due to decelerating flow
– More homogeneus ventilation in case of distribution
disorders
– Compensate for air leak
• Disadvantages
– Hypoventilation secondary to changes in lung
compliance and resistance
VCV-PCV pressure differences
Peak Pressure
Paw
PCV
VCV
Plateau Pressure
VCV = PCV
PEEP
Time
VCV
Flow
PCV
Time
Effects on the pressure-time waveform
Increased airway
resistance
Decreased respiratory
system compliance
Lung Mechanics in Ventilation Induced Lung Injury (VILI)
Ventilated
ALI
V
Normal
Oxygenation
Lower
inflection point
P
High Volume Injury
(Volutrauma)
Low Volume Injury
(Atelectrauma)
Mechanotrasduction and acute lung
injury: an enginering approach
Klassen Research Day, OSUWMC
2015
Stress
Strain
Stretch
Shear
ALI
ALI
Unit of pulmonary tissue
RCT, 48 pts
24: OLV (VCV  PCV) 30’
24: OLV ( PCV  VCV) 30’
TV: 10ml/kg, ZEEP, FIO2 1
RR at 4.5-6 kPa PaCO2




* P<0.05 compared with OLV-VCV
*** P<0.001 compared with OLV-VCV
RCT, 25 pts
OLV VCV ZEEP 5’
OLV PCV ZEEP 20’
OLV PCV PEEP (4 cmH2O)
20’
RR at 30-35 mmHg PaCO2




RCT, 58 pts
OLV (VCV  PCV) 30’
OLV ( PCV  VCV) 30’
TV: 9ml/kg
FIO2 1 RR at EtCO2 30-35 mmHg


RCT, 18 pts
9: OLV (VCV  PCV) 30’
9: OLV (PCV  VCV) 30’
TV: 9 ml/kg, ZEEP
RCT, 41 pts, (Thoracoscopy)
TLV: VCV TV 9 ml/Kg
A: OLV (VCV  PCV) TV 6ml/Kg
PEEP 5 cmH2O 30’
B: OLV (PCV  VCV) TV 6ml/Kg
PEEP 5 cmH2O 30’

RCT, 86 pts FEV1 < 1.5 lt
TLV: TV 10 ml/Kg
43 pts: OLV PCV TV 6ml/Kg PEEP 5
cmH2O
43 pts: OLV VCV TV 6ml/Kg PEEP 5
cmH2O
Pressure-controlled versus volume-controlled ventilation for surgical patients
- A systematic review and Meta-analysis
Jia Jiang, Bo Li, Na Kang, Anshi Wu, Yun Yue
Outcomes
Primary Oucome
Secondary Outcome
VCV
PCV
OIintra (SaO2/FIO2)
✗
✓Improved
OIpost6h
-
-
OIpost24h
-
-
SaO2 (%)
-
-
A-aO2 (mmHg)
✗
✓Reduced
PaCO2 (mmHg)
✗
✓Reduced
Qs/Qt (%)
-
-
Vd/Vt (%)
-
-
Ppk (cmH2O)
✗
✓Reduced
Ppl
✗
✓Reduced
Pm
-
-
Cdyn (mLH2O-1)
✗
✓Improved
Csta
✗
✓Improved
Mortality
-
-
Risk PPCs
-
-
LOS
-
-
27 Articles
1643 pts
OIintra
OIpost6h
OIpost24h
SaO2
A-aO2
PaCO2
Qs/Qt
Vd/Vt
Ppk
Ppl,
Pm
Cdyn
Csta
PPCs
LOS
Intraoperative oxygenation index
Postoperative oxygenation indices at 6hr
Postoperative oxygenation index at 24hr
Oxygen saturation;
Alveolar-arterial oxygen gradient
Arterial partial pressure of carbon dioxide
Pulmonary shunt fraction
Dead space to tidal volume ratio
Peak airway pressur
Plateau airway pressure
Mean airway pressure;
Dynamic compliance
Static compliance
Post operative pulmonary complications
Length of hospital stay
PCV-VG
(Pressure Controlled Volume Guarantee Ventilation)
RCT, 40 pts
20 pts (TLV-VCV) TV 8-10 ml/Kg
(OLV-VCV) TV 6ml/kg
20 pts (TLV-PCV-VG) TV 8-10 ml/kg
(OLV –PCV-VG) TV 6ml/Kg
ZEEP FIO2 1
RR at EtCO2 25-30 mmHg
RCT, 27 pts
(TLV-VCV) TV 8 ml/Kg
(OLV-VCV) TV 8ml/kg
ZEEP FIO2 1
* P < 0.001
† P < 0.05
RCT, 20 pts
TLV: VCV TV 8-10 ml/Kg (T1,T4) 30’
A: OLV (VCV  PCV-VG) TV 8-10ml/Kg (T2,T3) 30’
B: OLV (PCV-VG  VCV) TV 8-10ml/Kg (T2,T3) 30’
ZEEP FIO2 1 RR at EtCO2 30-35 mmHg
* Statistically significant differences
RCT, 66 pts
(TLV) TV 10 ml/Kg
(OLV-VCV) TV 8ml/kg
(OLV-PCV) TV 8ml/kg
ZEEP FIO2 1
Conclusions
• Selection of PCV or VCV may be of little difference in healty patients
• In VCV change the ventilation mode to PCV:
– Increasing TV fails to deliver a targeted TV with an unacceptable EtCO2 or fails to
improve hypoxemia
– Extremely high airway pressure
• VILI has been observed in healthy lungs during the perioperative period
• Protective Ventilation:
– Consensus exists regarding the use of MV with low TV (6 mL/kg)
– Controversies persist as to the use of higher or lower levels of PEEP and as to
whether RM should be performed
• PCV-VG may have better effects on patient outcome
• The development of new ventilator strategies for surgical patients are
subject of intense debate

Diapositiva 1

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