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

http://www.headprone.com/photo_three.html

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