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Carmen Valente Barbas HOSPITAL DAS CLÍNICAS FACULDADE DE MEDICINA UNIVERSIDADE DE SÃO PAULO E

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. HIPOXEMIA. ASPIRAÇÃO HIPOVENTILAÇÃO/ ATELECTASIA

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Carmen Valente Barbas HOSPITAL DAS CLÍNICAS FACULDADE DE MEDICINA UNIVERSIDADE DE SÃO PAULO E

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  1. 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

  2. HIPOXEMIA • ASPIRAÇÃO • HIPOVENTILAÇÃO/ • ATELECTASIA • OBSTRUÇÃO DE VIAS • AÉREAS SUPERIORES • BRONCOESPASMO • PNEUMONIA • SEPSE • TEP • CONGESTÃO/ARRITMIA

  3. TOMOGRAFIA DE TÓRAX PROTOCOLO TEP

  4. 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%

  5. ARDS AND MECHANICAL VENTILATION (VILI) HYPERDISTENTION (VILI) COLLAPSE AND REOPENING

  6. Thoracic Tomography and Inspiratory and Expiratory PxV curve. 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

  7. 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% PEEP = 19 cmH2O (Pflex + 2 cmH2O) Collapse area = 21.9% Collapse mass = 36.8% PEEP = 25 cmH2O (after PPLAT = 55 cmH2O) Collapse area = 0.4% Collapse mass = 0.9%

  8. 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%

  9. 15 15 15 15 P R E SS U R E 15 45 15 15 35 15 Inspiration 15 15 20 20 25 25 25 15 Expiration 10 10 2 min T E M P O ARDS PROTOCOL: STEPWISE PEEP INCREMENT RECRUIMENT MANUEVER WITH FIX PRESSURE CONTROL VENTILATION AND PEEP ADJUSTMENT AT THORACIC TOMOGRAPH. 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.

  10. PEEP = 10 cmH20 – EXPIRATION 43 years-old, PaO2/FIO2= 134, Nosocomial pneumonia + malaria APACHE II= 11, SOFA=13, FONP=2, 24 hs installation, shock

  11. PEEP = 10 cmH20 –PCV-15-INSPIRATION

  12. PEEP = 45 cmH20 – EXPIRATION

  13. PEEP = 45 cmH20 –PCV-15-INSPIRATION

  14. PEEP = 25 cmH20 – EXPIRATION

  15. PEEP = 25 cmH20 –PCV-15-INSPIRATION 43 years-old, PaO2/FIO2 pre = 134 PaO2/FIO2 post= 391

  16. EXPIRATION - INSPIRATION-PCV=15 PaO2/FIO2 = 62 PEEP = 10 cmH20 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

  17. EXPIRATION - INSPIRATION-PCV=15 PaO2/FIO2 = 194 PEEP = 10 cmH20 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

  18. EXPIRATION - INSPIRATION-PCV=15 PaO2/FIO2 = 170 PEEP = 10 cmH20 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

  19. PEEP 10 PEEP 20 PEEP 25 PEEP 35 PEEP 45 PEEP 25 V PEEP 20 V PEEP 10 V MEAN(SEM) n=12

  20. p<0,002 p<0,02 PEEP 10 PEEP 20 PEEP 25 PEEP 35 PEEP 45 PEEP 25 V PEEP 20 V PEEP 10 V MEAN(SEM) n=12

  21. PEEP 10 PEEP 20 PEEP 25 PEEP 35 PEEP 45 PEEP 25 V PEEP 20 V PEEP 10 V

  22. p<0,005 PEEP 10 PEEP 20 PEEP 25 PEEP 35 PEEP 45 PEEP 25 V PEEP 20 V PEEP 10 V MEAN(SEM) n=12

  23. p<0,00007 p<0,03 PEEP 10 PEEP 20 PEEP 25 PEEP 35 PEEP 45 PEEP 25 V PEEP 20 V PEEP 10 V MEAN(SEM) n=12 STRAIN – TENSION ELASTIC TISSUE

  24. P10pre P20pre P25pre P35 P45 P25post P20post P10post MEAN(SEM) n=12

  25. Maximalrecruitment 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%

  26. IP 47a ALCOOLISMO + PNEUMONIA COMUNITÁRIA GRAVE+ SDRA + CHOQUE SÉPTICO

  27. PEEP 10 PRE RM

  28. PEEP 10 PRE RM

  29. PEEP 10 PRE RM

  30. PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O

  31. PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O

  32. PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O

  33. PEEP TITULADA 25 cmH2O

  34. PEEP TITULADA 25 cmH2O

  35. PEEP TITULADA 25 cmH2O

  36. PEEP 10 PRE RM

  37. PRESSÃO MÁXIMA RECRUTAMENTO 65 cmH2O

  38. PEEP TITULADA 25 cmH2O

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