CON: Presin Esofgica

CON: Baln Esofgico y Pes

For information to be important in clinical decision making it must do more than merely direct a clinical decision.

It must provide information that is not available by simplermeans, and it should direct a decision that improves important patient outcomes.

One must first establish whether Pes accurately represents pleural pressure in critically ill patients. If the measured pressure does not represent the physiologic variable for which it is a surrogate, then any decisions based on it are suspect.

Like the pulmonary artery catheter, the measurement of Pes is physiologically appealing but clinically unrevealing

Lo mismo pero ms complicado?

Es la presin igual en todo el esfago?Pressure within the esophagus varies considerably between the gastroesophageal junction and the thoracic inlet

Cmo se valid la presin esofgica a la pleural?

Pacientes de pieCooperadoresNO SUPINO; NO VMA, NO PEEPSe ha validado la Cest segn la pTP en ARDS?

Fig. 5. Hypothetical pressure-volume relationships in the lungs ofa normal subject and in a patient with acute respiratory distresssyndrome (ARDS). The solid line indicates the true relationshipbetween lung volume and transpulmonary pressure. The dashedline shows the relationship as estimated from esophageal pressure, in which esophageal pressure slightly overestimates pleuralpressure. This leads to a small leftward shift of the pressure-volume relationship, and underestimation of transpulmonary pressure. Because the normal lung compliance is high and tidal breathing occurs on the linear portion of this relationship, the errors intranspulmonary pressure at end-expiration and end-inspiration aresimilar and small. In a patient with ARDS, lung compliance is reduced and the relationship is curvilinear. If the tidal volume endson the more horizontal portion of the lung compliance curve, smallerrors in transpulmonary pressure at end-expiration can nevertheless be associated with large underestimations of transpulmonarypressure at end-inspiration. This can falsely reassure the clinicianthat lung over-distention is not present.

10Artefacto Mediastinal y PosturalPresin del Corazn2.1 hasta 5 cmH20 o ms

Cambios en un sujeto durante dos noches

Caractersticas heterogneas del Pulmn

Entonces

Show me the data!!!

Y para el ARDS??? Show me the data!!!

Recordemos este nombre.

PEEP de 6 para ARDS???Y todo este cuento del baln no era para optimizar la PTP???PaO2 menor a 100 eso es ARDS severo. Aplica hoy en dia?PEEP de 6 para ARDSPTP no era la fucking meta

20

1. PEEP se optimiz para PTP de 0-10Cul es la ideal?2. Cul es la presin pleural del pte crtico?Edema, derrame pleural, hemotorax3. La presin transmural del esfago es 0?No tenemos idea4. Cul es el artefacto mediastinalCreemos que 5. De dnde se calcul? No sabemos

5. en 30% de los pacientes el baln estaba mal colocado. Y las lecturas fueron errneas.6. Es la PaO2/FiO2 la meta en ARDSNO7. Y el PEEP en otros estudios

Ojo el grupo convencional no respondio al PEEP wtf----23Y finalmente debemos preguntarnos

8. Hay Otras maneras ms sencillas y con mayor evidencia de fijar el PEEP?

Intensivistas???Gadgetologists???Juguetitos NuevosGadgetThere is no need to relive, with yet another physiologic variable, the folly of our 30-year infatuation with the pulmonary artery catheter.

Y este no era el que public aquel estudio en el 2008 en el NEJM???