Embed Size (px)
Citation preview
1
VI CURSO NACIONAL DE VM
27 de março de 2014
Carmen Silvia Valente BarbasProfessora Livre Docente da Disciplina de
Pneumologia da FMUSP
Médica Intensivista e Pneumologista do Hospital
Albert Einstein
Posição prona e ECMO na SDRA
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
2
G
R
A
V
I
T
Y
G
R
A
V
I
T
Y
RECRUITMENT: PRONE POSITION
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 152 patients prone
Mean increase of PaO2 to FIO2 44.6±68.2 63±66.8 p=0.02
10 Days mortality 25 % 21.1%
ICU discharge Mortality 50.7% 48%
6 months mortality 62.5% 58.6%
Pos Hoc analysis
10 day mortality -PaO2/FIO2<88 47.2% 23.1% p<0.05
SEVERE ARDS
OR DIFFICULT
TO RECRUIT
ARDS
G
R
A
V
I
T
Y
ALVEOLAR RECRUITMENT AND PRONE POSITION
-PULMONARY
HYPERTENSION
AND OR RIGHT
VENTRICULAR
DYSFUNCTION
3
FEATURE ARTICLES
Decrease in PaCO2 with prone position is predictive of improved
outcome in acute respiratory distress syndromeGattinoni 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
4
5
6
7
9
10
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 pacientes90 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
11
12
13
