vi curso nacional de vm 27 de março de 2014 carmen silvia valente barbas

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

GRAVITY

GRAVITY

RECRUITMENT: PRONE POSITION

PaO2 (50-75%)

The New England Journal of Medicine The New England Journal of Medicine Vol.345, n 8, August 23, 2001Vol.345, n 8, August 23, 2001

________________________________________________________________________________________________ EFFECT OF PRONE POSITIONING ON THE SURVIVAL EFFECT OF PRONE POSITIONING ON THE SURVIVAL OF PATIENTS WITH ACUTE RESPIRATORY FAILUREOF PATIENTS WITH ACUTE RESPIRATORY FAILURE

Luciano Gattinoni,MD; Gianni Tognoni,MD...............................Roberto Latini ,MDLuciano Gattinoni,MD; Gianni Tognoni,MD...............................Roberto Latini ,MD for the Prone-Supine Study Groupfor the Prone-Supine Study Group

Italian + Switzerland Multicenter Randomized TrialItalian + Switzerland Multicenter Randomized Trial

152 patients supine 152 patients prone152 patients supine 152 patients prone

Mean increase of PaO2 to FIO2 44.6Mean increase of PaO2 to FIO2 44.6±68.2 ±68.2 63 63±66.8 p=0.02±66.8 p=0.02 10 Days mortality 25 % 21.1% 10 Days mortality 25 % 21.1% ICU discharge Mortality 50.7% 48%ICU discharge Mortality 50.7% 48%6 months mortality 62.5% 58.6% 6 months mortality 62.5% 58.6% Pos Hoc analysis Pos Hoc analysis 10 day mortality -PaO2/FIO2<88 47.2% 23.1% p<0.0510 day mortality -PaO2/FIO2<88 47.2% 23.1% p<0.05

SEVERE ARDSSEVERE ARDSOR DIFFICULTOR DIFFICULTTO RECRUITTO RECRUITARDSARDS

GRAVITY

ALVEOLAR RECRUITMENT AND PRONE POSITION

-PULMONARY PULMONARY HYPERTENSIONHYPERTENSIONAND OR RIGHT AND OR RIGHT VENTRICULAR VENTRICULAR DYSFUNCTIONDYSFUNCTION

FEATURE ARTICLESDecrease 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

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