APLICAÇÕES DA TOMOGRAFIA
COMPUTADORIZADA DE TÓRAX
EM VENTILAÇÃO MECÂNICA
Carmen Valente Barbas
HOSPITAL DAS CLÍNICAS
FACULDADE DE MEDICINA
UNIVERSIDADE DE SÃO PAULO
E
UTI-ADULTOS HOSPITAL ISRAELITA ALBERT
EINSTEIN
PEEP 10
PEEP 35
PEEP 20
PEEP 45
PEEP 25
PEEP 25 AFTER MAXIMAL RECRUITMENT
HIPOXEMIA
• ASPIRAÇÃO
• HIPOVENTILAÇÃO/
ATELECTASIA
• OBSTRUÇÃO DE VIAS
AÉREAS SUPERIORES
• BRONCOESPASMO
• PNEUMONIA
• SEPSE
• TEP
• CONGESTÃO/ARRITMIA
TOMOGRAFIA DE TÓRAX PROTOCOLO TEP
Analysis of 100 Multislice Thoracic Angiotomography in the
Diagnosis of Acute Dyspnea.
TR Lara, MD, H B Bogosian, MD, F ND Campos, MD, G FJ Matos, MD,PhD, E C Meyer, MD,PhD,
M Funari, MD,PhD and C SV Barbas, MD, PhD.
Albert Einstein Hospital Thoracic Angiotomography Study Group , São Paulo, Brazil.
100 angiotomografias de Tórax Protocolo TEP
(julho a outubro de 2008)
34 Homens /66 mulheres- idade média= 63± 19 anos ( 13-90)
2 pacientes com oclusão de artéria principal e 5 oclusões de artérias lobares
21 pacientes oclusões segmentares , 10 dos quais multisegmentares
65% dos pacientes apresentavam alteração do parênquima pulmonar
Sinais de atelectasias em 53%, derrame pleural em 41% e TEP em 28%
ARDS AND MECHANICAL VENTILATION
HYPERDISTENTION
(VILI)
COLLAPSE AND REOPENING
(VILI)
Thoracic Tomography and Inspiratory and Expiratory PxV curve.
10
10
50
50
10
50
10
50
Lung recruitment manuevers in ARDS .
Barbas CSV, Matos GFJ, Okamoto V, Borges JB,Amato MBP, Carvalho CRR.
Respir Care Clin North Am, 2003 :9(4):401-418
Reversibility of Lung Collapse and Hypoxemia in Early
Acute Respiratory Distress Syndrome.
Borges JB, Okamoto VN, Matos GJF, Caramez MP, Arantes PRR, Barros F, Souza CE,
Victorino JA, Kacmarek RM, Barbas CSV, Carvalho CRR, Amato MBP.
Am J Respir Crit Care Med. 2006
PEEP = 5 cmH2O
Collapse area = 54.3%
Collapse mass = 69.2%
600
Collapse area = 21.9%
Collapse mass = 36.8%
PaO2
PEEP = 19 cmH2O
(Pflex + 2 cmH2O)
(mmHg)
500
R = - 0.91
400
300
200
100
0
PEEP = 25 cmH2O
(after PPLAT = 55 cmH2O)
Collapse area = 0.4%
Collapse mass = 0.9%
0.0
0.2
0.4
0.6
0.8
Mass of collapsed tissue (%)
COLL-GP vs PaO2-corrig-PaCO2+poor
x column vs y column
1.0
Maximal recruitment Strategy guided by Thoracic CT scan in in
severe acute respiratory distress syndrome: a case series report.
Matos GJF, Borges JB, Passos RH, Meyer EC, Hoelz C, Rodrigues M, Carvalho CRR,
Amato MBP, Barbas CSV.
Critical Care, 2007; 11(2): S
76.
45 PACIENTES: APACHE II: 20 ± 6, Maximal recruitment pressure:
60.0 ± 5.0, Titrated PEEP: 24.2 ± 3.5
PaO2/FIO2 pre and post: 130 ± 43
317 ± 99
MORTALITY= 28%
ARDS PROTOCOL: STEPWISE PEEP INCREMENT RECRUIMENT MANUEVER
WITH FIX PRESSURE CONTROL VENTILATION AND PEEP ADJUSTMENT
AT THORACIC TOMOGRAPH.
PEEP 10
PEEP 35
PEEP 20
PEEP 45
PEEP 25
PEEP 25 AFTER MAXIMAL RECRUITMENT
15
P
R
E
S
S
U
R
E
15
15
15
45
15
15
15
35
15
15
20
25
25
25
Inspiration
15
20
15
10
10
Expiration
2 min
TEMPO
Matos GJF, Borges JB, Passos RH, Meyer EC, Hoelz C, Rodrigues M, Carvalho CRR,
Amato MBP, Barbas CSV.
Critical Care, 2007; 11(2): S 76.
PEEP = 10 cmH20 – EXPIRATION
43 years-old, PaO2/FIO2= 134, Nosocomial pneumonia + malaria
APACHE II= 11, SOFA=13, FONP=2, 24 hs installation, shock
PEEP = 10 cmH20 –PCV-15-INSPIRATION
PEEP = 45 cmH20 – EXPIRATION
PEEP = 45 cmH20 –PCV-15-INSPIRATION
PEEP = 25 cmH20 – EXPIRATION
PEEP = 25 cmH20 –PCV-15-INSPIRATION
43 years-old, PaO2/FIO2 pre = 134 PaO2/FIO2 post= 391
EXPIRATION - INSPIRATION-PCV=15
PEEP = 10 cmH20
PaO2/FIO2 = 62
PEEP = 45 cmH20
PaO2/FIO2 = 349
PEEP = 25 cmH20
64 years-old, PaO2/FIO2= 62, aspiration
APACHE II= 18, SOFA=7, FONP=1, 24 hs installation, shock
EXPIRATION - INSPIRATION-PCV=15
PEEP = 10 cmH20
PaO2/FIO2 = 194
PEEP = 45 cmH20
PaO2/FIO2 = 365
PEEP = 25 cmH20
35 years-old, PaO2/FIO2= 194, Alveolar hemorrhage-cocksackie virus
APACHE II= 22, SOFA=9, FONP=2, 24 hs installation
EXPIRATION - INSPIRATION-PCV=15
PEEP = 10 cmH20
PaO2/FIO2 = 170
PEEP = 45 cmH20
PaO2/FIO2 = 397
PEEP = 25 cmH20
23 years-old, PaO2/FIO2= 170, gastric aspiration
APACHE II= 16, SOFA=6, FONP=1, 24 hs installation, shock
PEEP 10
PEEP 35
PEEP 20
PEEP 45
PEEP 25
PEEP 25 AFTER MAXIMAL RECRUITMENT
% GLOBAL COLLAPSE DURING
STEPWISE RECRUITMENT MANEUVER
0,6
MEAN(SEM)
n=12
% GLOBAL COLLAPSE
0,5
0,4
0,3
0,2
0,1
0,0
PEEP
1
10
PEEP
2
20
PEEP
3
25
PEEP
4
35
PEEP
5
45
PEEP
6
25 V
PEEP
7
20 V
PEEP
8
10 V
GLOBAL TIDAL RECRUITMENT
% GLOBAL TIDAL RECRUITMENT
MEAN(SEM)
0,06
n=12
p<0,002
p<0,02
0,04
0,02
0,00
PEEP
1
10
PEEP
2
20
PEEP
3
25
PEEP
4
35
PEEP
5
45
PEEP
6
25 V
PEEP
7
20 V
PEEP
8
10 V
REGIONAL COLLAPSE
REGION 1
REGION 2
REGION 3
1,0
% REGIONAL COLLAPSE
REGION 4
REGION 4
REGION 1
REGION 2
REGION 3
0,8
0,4
0,2
PEEP
10
PEEP
20
PEEP
25
PEEP
35
PEEP
45
PEEP
25 V
REGION 2
REGION 3
REGION 4
Figure 2 – CT scan illustrating the 4 lung reg
0,6
0,0
REGION 1
PEEP
20 V
PEEP
10 V
% TIDAL RECRUITMENT REGION 4
MEAN(SEM)
% TIDAL RECRUITMENT REGION 4
0,14
n=12
0,12
p<0,005
0,10
REGION 1
REGION 1
REGION 2
0,08
REGION 2
REGION 3
REGION 4
REGION 3
REGION 4
0,06
Figure 2 – CT scan illustrating the 4 lung regions.
0,04
0,02
0,00
PEEP
1
10
PEEP
2
20
PEEP
3
25
PEEP
4
35
PEEP
5
45
PEEP
6
25 V
PEEP
7
20 V
PEEP
8
10 V
DELTA Vt / FRC - STRAIN
MEAN(SEM)
n=12
1,4
1,2
p<0,00007
1,0
DELTA Vt / FRC
REG 1
REG 2
REG 3
REG 4
STRAIN – TENSION ELASTIC TISSUE
0,8
p<0,03
0,6
0,4
0,2
0,0
PEEP
1
10
PEEP
2
20
PEEP
3
25
PEEP
4
35
PEEP
5
45
PEEP
6
25 V
PEEP
7
20 V
PEEP
8
10 V
%HYPER EXPIRAÇÃO E INSPIRAÇÃO
INSPIRAÇÃO
EXPIRAÇÃO
0,10
MEAN(SEM)
% HIPERDISTENSÃO
0,08
n=12
0,06
0,04
0,02
0,00
P10pre
P20pre
P25pre
P35
P45
P25post
P20post
P10post
Maximal recruitment Strategy guided by Thoracic CT
scan in severe acute respiratory distress syndrome:
a case series report.
Matos GJF, Borges JB, Passos RH, Meyer EC, Hoelz C,
Rodrigues M, Carvalho CRR, Amato MBP, Barbas CSV.
Critical Care, 2007; 11(2): S 76.
•
•
•
•
•
•
•
•
45 patients ,mean age= 49,6± 16,7 years
82%= primary ARDS
Titrated peep= 24,18 ± 3,44, Max plateau= 39,98 ± 4,84
APACHE II = 19,20 ± 7,10, SOFA score= 9,58 ± 3,39
NPOF= 1,76± 1.0 , SEPSIS= 68,8%,
VASOPRESSORS= 84%
Acute renal failure with CRRT= 55%
ICU SURVIVAL= 73%
400
PaO2/FiO2
350
PaO2/FiO2 ALONG 7 DAYS
p<,00000001
MEAN(SEM)
300
n=45
250
200
150
100
RECRUITMENT D 1
D3
D5
D7
DAYS
Figure 6 – PaO2/FiO2 before and after MRS
SOFA SCORE EVOLUTION ALONG 7 DAYS
n=45
■ NON SURVIVORS
12
● ALL PATIENTS
MEAN(SEM)
▲SURVIVORS
SOFA SCORE
10
n=12
8
6
n=45
protocol
n=33
4
1
2
3
4
5
6
7
DAYS
Figure 8 – 7 Plot
day1SOFA score evolution Survivors and Non Survivors after MRS
Plot 2
Plot 3
IP 47a ALCOOLISMO + PNEUMONIA
COMUNITÁRIA GRAVE+
SDRA + CHOQUE SÉPTICO
PEEP 10 PRE RM
PEEP 10 PRE RM
PEEP 10 PRE RM
PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O
PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O
PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O
PEEP TITULADA 25 cmH2O
PEEP TITULADA 25 cmH2O
PEEP TITULADA 25 cmH2O
PEEP 10 PRE RM
PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O
PEEP TITULADA 25 cmH2O