Ventilacin Mecnica en SDRA

Oscar M. Ardila S.

Consecuencias fisiolgicas

Inicialmente: edema pulmonar

Disminucin intercambio gaseoso

Destruccin de clulas alveolares tipo II

No produccin de surfactante

Colapso alveolar

Atelectasias

Disminucin de la distensibilidad pulmonar

Aumento del esfuerzo respiratorio

Barotrauma

Dao pulmonar inducido por

ventilacin mecnica

Volutrauma

Atelectrauma

Bajo volumen tidal

Control de presiones plateau (28-30 cm H2O)
PEEP apropiada

Ventilacin protectiva

12 ml/kg de VT + Presin plateau < 50 cmH2O

vs

6ml/kg + PP 30 cm H2O

Primaba la PP sobre el VT (mnimo era 4 ml/kg)

PEEP: 9.43.6 cm H2O

Mortality was significantly reduced at day 28

and at the end of the hospital stay. The effects
on long-term mortality are unknown, although
the possibility of a clinically relevant benefit
cannot be excluded. Ventilation with lower tidal
volumes is becoming a routine strategy of
treatment of acute respiratory distress
syndrome and acute lung injury, stopping
investigators from carrying out additional trials.

Published Online: 28 FEB 2013

N Engl J Med 2004;351:327-36.

JAMA. 2010;303(9):865-873

Maniobras de reclutamiento

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High-frequency oscillatory ventilation

VT aprox. 4 ml/kg
FR elevada
Presiones elevadas

Otras alternativas

Medicin de mecnica pulmonar

Curvas de Presin/volumen

Medicin de presin esofgica y presin

transpulmonar

Ajuste de PEEP segn tomografa

Medicin de impediancia elctricaClinics in Chest

Ventilacin en prono

Medicine
Volume 35, Issue 4,
December 2014,
Pages 729741

Ventilacin en prono

Am Rev Respir Dis 1987;135(3):62833.)

Compliance regional pulmonar

Clinics in Chest Medicine Volume 35, Issue 4, December 2014, Pages

Prono: estudios clnicos

C. Gurin, S. Gaillard, S. Lemasson, et al. Effects of

systematic prone positioning in hypoxemic acute
respiratory failure JAMA, 292 (19) (2004), p. 2379

L. Gattinoni, G. Tognoni, A. Pesenti, et al. Effect of prone

positioning on the survival of patients with acute
respiratory failure N Engl J Med, 345 (8) (2001), pp. 568
573

J. Mancebo, R. Fernndez, L. Blanch, et al. A multicenter

trial of prolonged prone ventilation in severe acute
respiratory distress syndrome Am J Respir Crit Care Med,
173 (11) (2006), pp. 12331239

P. Taccone, A. Pesenti, R. Latini, et al. Prone positioning in

patients with moderate and severe acute respiratory
distress syndrome JAMA, 302 (18) (2009),

Ventilacin en prono

Prono por 1397/2756 dias/paciente (51%)

Promedio de 8.4 sesiones de pronacin
Duracin de sesin: 18 horas/da (meta era 20
horas)

JAMA November 11, 2009, Vol 302, No. 18

NEJM

N Engl J
Med
2013;368
:2159-68.

Ventilacin en prono

Cuando instaurar el prono?

Estudios clnicos: a todos

Fisiolgico (prono reduce VILI): a todos

Otro planteamiento: slo a hipoxemia refractaria

con tratamiento estndar.

Bloqueantes neuromusculares