Posição prona e ECMO na SDRA
VI CURSO NACIONAL DE VM
27 de março de 2014
Carmen Silvia Valente Barbas
Professora Livre Docente da Disciplina de
Pneumologia da FMUSP
Médica Intensivista e Pneumologista do Hospital
Albert Einstein
ACUTE RESPIRATORY DISTRESS
SYNDROME
• Less than 1 week
bilateral infiltrate
• Not explained by CHF or
hypervolemia
• Presence of risk factor
• PaO2/FIO2 <300- mild
• PaO2/FIO2 <200-moderate
• PaO2/FIO2<100- severe
JAMA 2012; 307(23): 2526-2533
RECRUITMENT: PRONE POSITION
G
R
A
V
I
T
Y
 PaO2 (50-75%)
The New England Journal of Medicine
Vol.345, n 8, August 23, 2001
________________________________________________
EFFECT OF PRONE POSITIONING ON THE SURVIVAL
OF PATIENTS WITH ACUTE RESPIRATORY FAILURE
Luciano Gattinoni,MD; Gianni Tognoni,MD...............................Roberto Latini ,MD
for the Prone-Supine Study Group
Italian + Switzerland Multicenter Randomized Trial
152 patients supine
Mean increase of PaO2 to FIO2
10 Days mortality
ICU discharge Mortality
6 months mortality
Pos Hoc analysis
10 day mortality -PaO2/FIO2<88
44.6±68.2
25 %
50.7%
62.5%
47.2%
152 patients prone
63±66.8
21.1%
48%
58.6%
p=0.02
23.1%
p<0.05
ALVEOLAR RECRUITMENT AND PRONE POSITION
G
R
A
V
I
T
Y
SEVERE ARDS
OR DIFFICULT
TO RECRUIT
ARDS
PULMONARY
HYPERTENSION
AND OR RIGHT
VENTRICULAR
DYSFUNCTION
FEATURE ARTICLES
Decrease in PaCO2 with prone position is predictive of improved
outcome in acute respiratory distress syndrome
Gattinoni L,Vagginelli F; Carlesso E; Taccone P; Conte V; Chiumello D; Valenza F; Caironi
P; Pesenti A
Crit Care Med - 01-DEC-2003; 31(12): 2727-33
CESAR TRIAL : EXTRACORPOREAL MEMBRANE
OXYGENATION IMPROVES SURVIVAL IN PATIENTS
WITH SEVERE RESPIRATORY FAILURE.
Peek GJ et al
Lancet , 2009.
Glenfield (Leicester-Julho 2001-Agosto 2006)
• Insuficiencia respiratória grave , mas
potencialmente reversivel
• Escore de Murray 3 ou maior
• pH < 7,2
Exclusões : altas pressões em vias aéreas ou
FIO2 > 80% mais de 7 dias e ou contraindicações
para tratamento
CESAR TRIAL : EXTRACORPOREAL MEMBRANE
OXYGENATION IMPROVES SURVIVAL IN PATIENTS
WITH SEVERE RESPIRATORY FAILURE.
Peek GJ et al
Lancet , 2009.
180 pacientes
90 ECMO
90 CMV
sobrevida em 6 meses
57/90 (63%) versus 41/90 (47%)
– RR= 0.69(0.05-0.97-p=0.03)
1 Sobrevivente extra para cada 6 pacientes tratados
2 ECMO aumenta a sobrevida após 6 meses e é custo efetiva
comparada com CMV