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Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares<br />Edgar Jiménez, MD, FCCM<br />Director – UCI y Co-Ch...
Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares<br />Edgar Jiménez, MD, FCCM<br />Director – UCI y Co-Ch...
Disclosures<br />Research:<br />NASA<br />CareFusion®<br />CCCTG & CIHR<br />
Objectives<br />Using in vivovideomicroscopy will demonstrate the anatomical, physiological and pathophysiological finding...
Fantastic Voyage<br />1966<br />“Oscar” for Special Effects<br />Isaac Azimov<br />Richard Fleischer<br />Raquel Welch<br />
Raquel Welch<br />
Real-life“Fantastic Voyager”<br />Gary Nieman, BA<br />Director:<br />Critical Care Translational Research Laboratory<br /...
Labs in Syracuse, NYand Orlando, FL<br />
How come?<br />In vivovideomicroscopy<br />Concept of RACE:<br />Repetitive alveolar closing and expansion<br />
Mechanisms of VILI<br />Barotrauma<br />Volutrauma<br />Biotrauma<br />Atelectrauma<br />
Mechanisms of VILI<br />Barotrauma<br />Volutrauma<br />Biotrauma<br />Atelectrauma<br />
To understand:abnormal alveolar mechanics<br />We must first understand:<br />normal alveolar mechanics<br />
“The end”of the Bronchial Tree<br />
F. Possmayer, PhD. U. of Western Ontario<br />
Alveolar Duct<br />F. Possmayer, PhD. U. of Western Ontario<br />
F. Possmayer, PhD. U. of Western Ontario<br />
How do we breathe?<br />
Alveolar Duct<br />Expiration<br />Alveolar Duct<br />Inspiration<br />Weibel et al Respir Physiol 1985<br />
Normal alveolar dynamics<br />G Nieman, SUNY<br />
G Nieman, SUNY<br />
G Nieman, SUNY<br />
G Nieman, SUNY<br />
Alveoli:Not Just a Bunch of Grapes<br />Prange H: Adv Physiol Educ 2003<br />
Mead: JAP 1970<br />Alveolar Independence<br />Structural Support<br />Honeycomb-like structural support<br />
Hiroko & Nieman, SUNY 2005<br />
Hiroko & Nieman, SUNY 2005<br />
Hiroko & Nieman, SUNY 2005<br />
Stressed alveolar sac<br />G Nieman, SUNY <br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
Strain<br />G r a v i t y<br />Stress<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
G r a v i t y<br />Pendeluft<br />Courtesy of Dr. Marcelo Amato<br />
Stresses on the Epithelium during Fluid Displacement<br />Bilek AM et al. J Appl Physiol 2003;94:770-783<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Rigid  airway<br />Courtesy of Dr. Marcelo Amato<br />
Stresses on Epithelium during Airway Opening<br />Bilek AM et al. J Appl Physiol 2003;94:770-783<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Flexible  airway<br />Courtesy of Dr. Marcelo Amato<br />
Steinberg J.et al. Am J RespCrit Care Med2004<br />
Steinberg et al. AJRCCM.2004;169:57-63<br />Heterogeneous Lung Injury<br />Injured lung:<br />In vivo Microscopy<br />Hist...
Unstable Alveoli<br />Stable Alveoli<br />Low PEEP Group<br />(3)<br />Steinberg et al. AJRCCM.2004;169:57-63<br />
Alveoli Stabilized<br />With PEEP<br />Stable Alveoli<br />High PEEP Group<br />(15)<br />Steinberg et al. AJRCCM.2004;169...
PEEP = improves oxygenation<br />
PEEP = improves oxygenation<br />It’s more than that!<br />
PEEP = stabilizes alveoli<br />
PEEP = decreases RACE<br />
PEEP = decreases VILI<br />
ARDSNet (NHLBI)<br />NEJM, May – 2000<br />10 University Centers<br />Criteria:<br />Bilateral infiltrates<br />Intubation...
28 Day Survival<br />6 ml/kg<br />12 ml/kg<br />ARDSNetNEJM, 2000<br />
Respiratory Cycle<br />Ppeak<br />Pplat<br />Trigger<br />PEEP<br />
Initial table for FiO2 & PEEP<br />ARDSNetNEJM, 2000<br />
ARDSNet demonstrated:An outcome changeprimarily associated to achange in ventilatory strategy(LV)<br />
A big question:<br />Is the ARDS Net Protocol enough?<br />
Not really<br />We may not know the true transpulmonary pressure (Ptp)<br />Timid and arbitrary PEEP scale<br />
Meta-Analysis Based on<br />ALVEOLI<br />LOVS<br />EXPRESS<br />Briel, M. et al. JAMA 2010;303:865-873.<br />
Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline<br />Non-ARDS<br />ARDS<br />All Pts<br />Briel, ...
Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline<br />Non-ARDS<br />ARDS<br />All Pts<br />Briel, ...
Optimized Lung Volume “Safe Window”<br />Overdistension <br />Edema fluid accumulation<br />Surfactant degradation<br />Hi...
CT 2<br />CT 1<br />CT 3<br />Froese: Crit Care Med 1997<br />
How do We Open the Lung and Keep it Open?<br />
How do We Open the Lung and Keep it Open?<br />Open:<br />	Recruitment maneuver<br />
How do We Open the Lung and Keep it Open?<br />Open:<br />	Recruitment maneuver<br />Keep it open:<br />	PEEP or HFOV<br />
Ware and MatthayNEJM 342 (18): 1334<br />
Current Ventilation Practices<br />Volume Ventilation, Low VT, PEEP<br />Pressure Control Ventilation<br /> PEEP, Invers...
How do we know we have achieved OL-PEEP?<br />
How do we do it?<br />ARDS Net<br />ALVEOLI, LOVS, EXPRESS<br />Decremental PEEP Trial<br />Pes and Ptp<br />Volumetric Ca...
How do we do it?<br />ARDS Net<br />ALVEOLI, LOVS, EXPRESS<br />Decremental PEEP Trial<br />Pes and Ptp<br />Volumetric Ca...
How do we do it?<br />ARDS Net<br />ALVEOLI, LOVS, EXPRESS<br />Decremental PEEP Trial<br />Pes and Ptp<br />Volumetric Ca...
Can we do better?<br />
Let’s talk about pressure…<br />
Let’s talk about pressure…<br />and the trumpet player<br />
How much airway pressure can a trumpet player generate?<br />
Trumpet player<br />Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204<br />
Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204<br />
Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204<br />
Cook. J Applied Phys. 1964. 1016<br />
Cook. J Applied Phys. 1964. 1016<br />
Answer: 100-120 cm H2O<br />Cook. J Applied Phys. 1964. 1016<br />
So…<br />Why don’t we see more ALI and ARDS in these players?<br />
Answer:<br />Because they keep the Ptp within tolerable limits<br />
Answer:<br />Because they keep the Ptp within tolerable limits<br />with<br />the use of their respiratory muscles<br />
Let’s go to extremes ofairway pressure<br />
Paw at sea level:<br />
Paw at sea level: 1034 cm H2O<br />
Paw at a 33 ft dive:<br />
Paw at a 33 ft dive: 2068 cm H2O<br />
Paw at a 33 ft dive: 2068 cm H2O<br />Add 1034 cm H2O for every 33 ft.<br />
Paw at a 100 ft dive:<br />Add 1034 cm H2O for every 33 ft.<br />
Paw at a 100 ft dive: 4140 cm H2O<br />Add 1034 cm H2O for every 33 ft.<br />
So…<br />Why don’t we see more ALI and ARDS in these divers?<br />
Answer:<br />Because they keep the Ptp within tolerable limits<br />
Answer:<br />Because they keep the Ptp within tolerable limits<br />with<br />a similar increase in the external environme...
It’s all relative!<br />
<0.5 MPH<br />
17,000 MPH<br /><0.5 MPH<br />17,000 MPH<br />
17,000 MPH<br />Success!<br />
What is the Paw at 10,000 ft?<br />
What is the Paw at 10,000 ft?<br />795 cm H2O<br />
What is the Paw at 10,000 ft?<br />795 cm H2O<br />30% less<br />than MSL<br />
What is the Paw atMt. Everest’s summit?<br />
What is the Paw atMt. Everest’s summit?<br />285 cm H2O<br />
What is the Paw atMt. Everest’s summit?<br />285 cm H2O<br />72% less<br />than MSL<br />
They can get in LOTS of trouble!<br />
They can get in LOTS of trouble!<br />
Management of ALI and ARDS using Transpulmonary Pressures<br />
Management of ALI and ARDS usingTranspulmonarypressures<br />Factorsthatmay alter currentrecomendationsbasedon↓Ccw:<br />O...
The problem???<br />With Pplat, we are measuring only one side of the equation!!!!!<br />What happens with patients with c...
The problem???<br />With Pplat, we are measuring only one side of the equation!!!!!<br />What happens with patients with c...
Intrathoracic pressures<br />PROX. AIRWAY PRESSURE (Paw)<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl...
Pplat<br />PROX. AIRWAY PRESSURE (Paw)<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes)<br />...
Ptp<br />PROX. AIRWAY PRESSURE (Paw)<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes)<br />AL...
Ptp<br />PROX. AIRWAY PRESSURE (Paw)<br />Pes<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes...
Position of Esophagus and Pleura<br />
Position of Esophagus and Pleura<br />
Pplat and Ptp<br />Kubiak, Jimenez, Silva, Nieman<br />Marked variability among patients in abdominaland pleural pressures...
Relationship Ptp - Tv<br />Ptp<br />(cm H2O)<br />Tv(mL/kg)<br />Talmor et al. Crit Care Med, 2006<br />
Figure 1<br />Increasing IAP<br />Vt<br />PEEP<br />30<br />25<br />20<br />15<br />10<br />5<br />0<br />0<br />0<br />...
Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
Jimenez, Nieman ORMC, 2008<br />
Transpulmonary Pressure, Plateau (Ptp-plat)<br />Increased Ptp :<br />	↓ compliance<br />	↑ negative Ppl<br />Decreased Pt...
Intrathoracic pressures<br />Tracheal pressures are measured at distal end of ET Tube<br />
Ptr (Paw)<br />
Esophageal Pressure Measurements<br />
Connections<br />
Connections<br />
Connections<br />Ptp<br />
Esophageal Balloon<br /><ul><li>Placed in lower 1/3 of esophagus, above diaphragm
Measured pressures reflect pleural pressures</li></li></ul><li>
The Baydur Maneuver<br />20<br />10<br />0<br />-10<br />-20<br />20<br />10<br />0<br />-10<br />-20<br />Paw<br />cm H2O...
Hypothesis<br />Patients with↑ Pplwith conventional settings:<br />Underinflation -> causeshypoxemia<br />Raising PEEP to ...
Hypothesis<br />Patients with↓ Pplwith conventional settings:<br />Maintaining low PEEP would keep low Ptp<br />Prevents o...
Goal<br />To provide sufficientPtp (Paw - Ppl)to:<br />Maintain acceptable PaO2<br />Minimize repeated alveolar collapse<b...
Methods<br />Supine<br />HOB 30º<br />Esophageal balloon catheter passed to 60 cmfrom incisors<br />Gentle compression of ...
Methods<br />Recruitment maneuver<br />40 cm H2O X 40 sec.<br />Max Ptp-plat < 25 cm H2O<br />VT: 6 mL/kg PBW<br />PBW:<br...
Strategy<br />PaO2: 		55-120 mm Hg<br />Or SpO2: 	88-98 %<br />pH:		7.30-7.45<br />pCO2:		40-60 mm Hg<br />VT: Adjusted to...
Stress-strain curve of healthy pigs<br />Specific Lung <br />Elastance <br />5.8 cmH2O<br />Protti A. et al. Am J RespirCr...
Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]<br />
Strategy<br />PCV or VCV<br />I:E : 		1:1 to 1:3<br />RR:		< 35<br />RM:		PRN for suction/disconnection<br />Talmor D et a...
Table<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095...
Table<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095...
Study<br />Stopped after 61 pts as criteria were met in interim analysis<br />Talmor D et al. Mechanical ventilation guide...
PaO2/FiO2<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: ...
Respiratory System Compliance(mL/cm H2O)<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acut...
VD/VT<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095...
PEEP<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-...
Ptp - EE<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2...
Ptp - PEEP<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359:...
Pplat<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095...
Ptp – PLAT<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359:...
Ptp – EI<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2...
K-M Survival<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 35...
ARDSNetLung(ARMA)<br />Jimenez E, Nieman G, ORMC 2011<br />
Ptp Lung<br />Jimenez E, Nieman G, ORMC 2011<br />
Talmor presents:An improvement in oxygenation and compliance withPtp significantly lower thanoverestimated Pplat<br />
Talmor presents:A persistent negative Ptp-PEEP when using the ARDS Net scale<br />
A big question:<br />Is this enough?<br />
Not really<br />Arbitrary PEEP scale<br />We need to know how to adjust it better<br />We need to find morbidity/mortality...
What else can we use?<br />
Volumetric Capnography<br />
Terminology<br />End-Tidal CO2 (ETCO2)<br />Peak concentration of CO2at end exhalation.<br />Time-Based Capnography<br />	...
Zero baseline (A-B)<br />End tidal value (D)<br />Rapid, sharp rise (B-C)<br />Rapid, sharp downstroke (D-E)<br />Alveolar...
Capnography     Volumetric CO2<br /> EtCO2<br />Capnogram<br /> RR                 <br />CO2 Elimination<br />Deadspace<br...
PEEP & VCO2<br />
VCO2is<br />CO2elimination from CO2production… …in a steady state!!!<br />
Important questions for us:<br />Is the pt OK with LVHP (ARDS Net)?<br />Is the FiO2 > 0.60?<br />Is your Pplat > 30 cm H2...
Important questions for us:<br />Is the pt OK with LVHP (ARDS Net)?<br />Is the FiO2 > 0.60?<br />Is your Pplat > 30 cm H2...
What’s Next ????<br />
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  1. 1. Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares<br />Edgar Jiménez, MD, FCCM<br />Director – UCI y Co-Chairman Medicina Crítica<br /> Orlando Regional Medical Center<br />Profesor Asociado de Medicina<br />University of Florida, Florida StateUniversity & University of Central Florida<br />Presidente<br /> Federación Mundial de Sociedades de Medicina Crítica<br />2º Seminario de Ventilación Mecánica - VAFO <br />Asociación Panameña de Medicina Crítica y Terapia Intensiva<br />Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011<br />
  2. 2. Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares<br />Edgar Jiménez, MD, FCCM<br />Director – UCI y Co-Chairman Medicina Crítica<br /> Orlando Regional Medical Center<br />Profesor Asociado de Medicina<br />University of Florida, Florida StateUniversity & University of Central Florida<br />Presidente<br /> Federación Mundial de Sociedades de Medicina Crítica<br />2º Seminario de Ventilación Mecánica - VAFO <br />Asociación Panameña de Medicina Crítica y Terapia Intensiva<br />Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011<br />
  3. 3.
  4. 4.
  5. 5.
  6. 6. Disclosures<br />Research:<br />NASA<br />CareFusion®<br />CCCTG & CIHR<br />
  7. 7. Objectives<br />Using in vivovideomicroscopy will demonstrate the anatomical, physiological and pathophysiological findings of:<br />Normal lungs<br />Acutely injured lungs<br />Lung recruitment using Ptp<br />Intra-abdominal hypertension<br />
  8. 8. Fantastic Voyage<br />1966<br />“Oscar” for Special Effects<br />Isaac Azimov<br />Richard Fleischer<br />Raquel Welch<br />
  9. 9. Raquel Welch<br />
  10. 10. Real-life“Fantastic Voyager”<br />Gary Nieman, BA<br />Director:<br />Critical Care Translational Research Laboratory<br />ORMC, Orlando, FL<br />Cardiopulmonary and Critical Care Laboratory<br />SUNY, Syracuse, NY<br />
  11. 11. Labs in Syracuse, NYand Orlando, FL<br />
  12. 12. How come?<br />In vivovideomicroscopy<br />Concept of RACE:<br />Repetitive alveolar closing and expansion<br />
  13. 13. Mechanisms of VILI<br />Barotrauma<br />Volutrauma<br />Biotrauma<br />Atelectrauma<br />
  14. 14. Mechanisms of VILI<br />Barotrauma<br />Volutrauma<br />Biotrauma<br />Atelectrauma<br />
  15. 15. To understand:abnormal alveolar mechanics<br />We must first understand:<br />normal alveolar mechanics<br />
  16. 16. “The end”of the Bronchial Tree<br />
  17. 17.
  18. 18. F. Possmayer, PhD. U. of Western Ontario<br />
  19. 19. Alveolar Duct<br />F. Possmayer, PhD. U. of Western Ontario<br />
  20. 20. F. Possmayer, PhD. U. of Western Ontario<br />
  21. 21. How do we breathe?<br />
  22. 22. Alveolar Duct<br />Expiration<br />Alveolar Duct<br />Inspiration<br />Weibel et al Respir Physiol 1985<br />
  23. 23. Normal alveolar dynamics<br />G Nieman, SUNY<br />
  24. 24. G Nieman, SUNY<br />
  25. 25. G Nieman, SUNY<br />
  26. 26. G Nieman, SUNY<br />
  27. 27. Alveoli:Not Just a Bunch of Grapes<br />Prange H: Adv Physiol Educ 2003<br />
  28. 28. Mead: JAP 1970<br />Alveolar Independence<br />Structural Support<br />Honeycomb-like structural support<br />
  29. 29. Hiroko & Nieman, SUNY 2005<br />
  30. 30. Hiroko & Nieman, SUNY 2005<br />
  31. 31. Hiroko & Nieman, SUNY 2005<br />
  32. 32. Stressed alveolar sac<br />G Nieman, SUNY <br />
  33. 33. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  34. 34. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  35. 35. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  36. 36. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  37. 37. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  38. 38. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  39. 39. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  40. 40. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  41. 41. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  42. 42. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  43. 43. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  44. 44. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  45. 45. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  46. 46. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  47. 47. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  48. 48. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  49. 49. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  50. 50. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  51. 51. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  52. 52. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  53. 53. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  54. 54. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  55. 55. Strain<br />G r a v i t y<br />Stress<br />Courtesy of Dr. Marcelo Amato<br />
  56. 56. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  57. 57. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  58. 58. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  59. 59. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  60. 60. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  61. 61. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  62. 62. G r a v i t y<br />Courtesy of Dr. Marcelo Amato<br />
  63. 63. G r a v i t y<br />Pendeluft<br />Courtesy of Dr. Marcelo Amato<br />
  64. 64.
  65. 65. Stresses on the Epithelium during Fluid Displacement<br />Bilek AM et al. J Appl Physiol 2003;94:770-783<br />
  66. 66. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  67. 67. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  68. 68. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  69. 69. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  70. 70. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  71. 71. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  72. 72. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  73. 73. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  74. 74. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  75. 75. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  76. 76. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  77. 77. Rigid airway<br />Courtesy of Dr. Marcelo Amato<br />
  78. 78. Stresses on Epithelium during Airway Opening<br />Bilek AM et al. J Appl Physiol 2003;94:770-783<br />
  79. 79. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  80. 80. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  81. 81. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  82. 82. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  83. 83. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  84. 84. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  85. 85. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  86. 86. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  87. 87. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  88. 88. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  89. 89. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  90. 90. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  91. 91. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  92. 92. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  93. 93. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  94. 94. Flexible airway<br />Courtesy of Dr. Marcelo Amato<br />
  95. 95.
  96. 96.
  97. 97. Steinberg J.et al. Am J RespCrit Care Med2004<br />
  98. 98. Steinberg et al. AJRCCM.2004;169:57-63<br />Heterogeneous Lung Injury<br />Injured lung:<br />In vivo Microscopy<br />Histology + IHC<br />Normal lung: In vivo Microscopy<br /> Histology + IHC<br />
  99. 99. Unstable Alveoli<br />Stable Alveoli<br />Low PEEP Group<br />(3)<br />Steinberg et al. AJRCCM.2004;169:57-63<br />
  100. 100. Alveoli Stabilized<br />With PEEP<br />Stable Alveoli<br />High PEEP Group<br />(15)<br />Steinberg et al. AJRCCM.2004;169:57-63<br />
  101. 101.
  102. 102. PEEP = improves oxygenation<br />
  103. 103. PEEP = improves oxygenation<br />It’s more than that!<br />
  104. 104. PEEP = stabilizes alveoli<br />
  105. 105. PEEP = decreases RACE<br />
  106. 106. PEEP = decreases VILI<br />
  107. 107. ARDSNet (NHLBI)<br />NEJM, May – 2000<br />10 University Centers<br />Criteria:<br />Bilateral infiltrates<br />Intubation and mechanical ventilation<br />PaO2/FiO2 <300<br />
  108. 108. 28 Day Survival<br />6 ml/kg<br />12 ml/kg<br />ARDSNetNEJM, 2000<br />
  109. 109. Respiratory Cycle<br />Ppeak<br />Pplat<br />Trigger<br />PEEP<br />
  110. 110. Initial table for FiO2 & PEEP<br />ARDSNetNEJM, 2000<br />
  111. 111. ARDSNet demonstrated:An outcome changeprimarily associated to achange in ventilatory strategy(LV)<br />
  112. 112. A big question:<br />Is the ARDS Net Protocol enough?<br />
  113. 113. Not really<br />We may not know the true transpulmonary pressure (Ptp)<br />Timid and arbitrary PEEP scale<br />
  114. 114. Meta-Analysis Based on<br />ALVEOLI<br />LOVS<br />EXPRESS<br />Briel, M. et al. JAMA 2010;303:865-873.<br />
  115. 115. Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline<br />Non-ARDS<br />ARDS<br />All Pts<br />Briel, M. et al. JAMA 2010;303:865-873.<br />
  116. 116. Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline<br />Non-ARDS<br />ARDS<br />All Pts<br />Briel, M. et al. JAMA 2010;303:865-873.<br />
  117. 117. Optimized Lung Volume “Safe Window”<br />Overdistension <br />Edema fluid accumulation<br />Surfactant degradation<br />High oxygen exposure<br />Mechanical disruption<br /> Derecruitment<br />Atelectasis<br />Inflammatory response<br />Surfactant inhibition <br />Local hypoxemia<br />Compensatory overexpansion <br />Zone of<br />Overdistention<br />Injury<br />“Safe”<br />Window<br />Zone of<br />Derecruitment<br />and Atelectasis<br />Volume<br />Injury<br />Pressure<br />Froese: Crit Care Med 1997<br />
  118. 118. CT 2<br />CT 1<br />CT 3<br />Froese: Crit Care Med 1997<br />
  119. 119. How do We Open the Lung and Keep it Open?<br />
  120. 120. How do We Open the Lung and Keep it Open?<br />Open:<br /> Recruitment maneuver<br />
  121. 121. How do We Open the Lung and Keep it Open?<br />Open:<br /> Recruitment maneuver<br />Keep it open:<br /> PEEP or HFOV<br />
  122. 122. Ware and MatthayNEJM 342 (18): 1334<br />
  123. 123. Current Ventilation Practices<br />Volume Ventilation, Low VT, PEEP<br />Pressure Control Ventilation<br /> PEEP, Inverse I:E Ratio<br />VCV or PCV with PEEP adjusted by Ptp<br />Non-Conventional Ventilation<br />APRV/Bi-Level<br />HFOV<br />Pronation, iNO<br />ECMO<br />
  124. 124. How do we know we have achieved OL-PEEP?<br />
  125. 125. How do we do it?<br />ARDS Net<br />ALVEOLI, LOVS, EXPRESS<br />Decremental PEEP Trial<br />Pes and Ptp<br />Volumetric Capnography<br />Auscultation<br />Ultrasound<br />Respiratory Impedance Pletysmography<br />Electrical Impedance Tomography<br />HFOV - TOOLS<br />
  126. 126. How do we do it?<br />ARDS Net<br />ALVEOLI, LOVS, EXPRESS<br />Decremental PEEP Trial<br />Pes and Ptp<br />Volumetric Capnography<br />Auscultation<br />Ultrasound<br />Respiratory Impedance Pletysmography<br />Electrical Impedance Tomography<br />HFOV - TOOLS<br />
  127. 127. How do we do it?<br />ARDS Net<br />ALVEOLI, LOVS, EXPRESS<br />Decremental PEEP Trial<br />Pes and Ptp<br />Volumetric Capnography<br />Auscultation<br />Ultrasound<br />Respiratory Impedance Pletysmography<br />Electrical Impedance Tomography<br />HFOV - TOOLS<br />
  128. 128. Can we do better?<br />
  129. 129. Let’s talk about pressure…<br />
  130. 130. Let’s talk about pressure…<br />and the trumpet player<br />
  131. 131. How much airway pressure can a trumpet player generate?<br />
  132. 132. Trumpet player<br />Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204<br />
  133. 133. Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204<br />
  134. 134. Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204<br />
  135. 135. Cook. J Applied Phys. 1964. 1016<br />
  136. 136. Cook. J Applied Phys. 1964. 1016<br />
  137. 137. Answer: 100-120 cm H2O<br />Cook. J Applied Phys. 1964. 1016<br />
  138. 138. So…<br />Why don’t we see more ALI and ARDS in these players?<br />
  139. 139.
  140. 140.
  141. 141.
  142. 142.
  143. 143.
  144. 144. Answer:<br />Because they keep the Ptp within tolerable limits<br />
  145. 145. Answer:<br />Because they keep the Ptp within tolerable limits<br />with<br />the use of their respiratory muscles<br />
  146. 146. Let’s go to extremes ofairway pressure<br />
  147. 147. Paw at sea level:<br />
  148. 148. Paw at sea level: 1034 cm H2O<br />
  149. 149. Paw at a 33 ft dive:<br />
  150. 150. Paw at a 33 ft dive: 2068 cm H2O<br />
  151. 151. Paw at a 33 ft dive: 2068 cm H2O<br />Add 1034 cm H2O for every 33 ft.<br />
  152. 152. Paw at a 100 ft dive:<br />Add 1034 cm H2O for every 33 ft.<br />
  153. 153. Paw at a 100 ft dive: 4140 cm H2O<br />Add 1034 cm H2O for every 33 ft.<br />
  154. 154. So…<br />Why don’t we see more ALI and ARDS in these divers?<br />
  155. 155. Answer:<br />Because they keep the Ptp within tolerable limits<br />
  156. 156. Answer:<br />Because they keep the Ptp within tolerable limits<br />with<br />a similar increase in the external environmental pressure<br />
  157. 157. It’s all relative!<br />
  158. 158.
  159. 159. <0.5 MPH<br />
  160. 160. 17,000 MPH<br /><0.5 MPH<br />17,000 MPH<br />
  161. 161. 17,000 MPH<br />Success!<br />
  162. 162.
  163. 163. What is the Paw at 10,000 ft?<br />
  164. 164. What is the Paw at 10,000 ft?<br />795 cm H2O<br />
  165. 165. What is the Paw at 10,000 ft?<br />795 cm H2O<br />30% less<br />than MSL<br />
  166. 166. What is the Paw atMt. Everest’s summit?<br />
  167. 167. What is the Paw atMt. Everest’s summit?<br />285 cm H2O<br />
  168. 168. What is the Paw atMt. Everest’s summit?<br />285 cm H2O<br />72% less<br />than MSL<br />
  169. 169. They can get in LOTS of trouble!<br />
  170. 170. They can get in LOTS of trouble!<br />
  171. 171. Management of ALI and ARDS using Transpulmonary Pressures<br />
  172. 172. Management of ALI and ARDS usingTranspulmonarypressures<br />Factorsthatmay alter currentrecomendationsbasedon↓Ccw:<br />Obesity<br />Edema/anasarca<br />Intra-abdominal pressure<br />Pregnancy<br />Chestwalldeformities<br />Scars<br />
  173. 173. The problem???<br />With Pplat, we are measuring only one side of the equation!!!!!<br />What happens with patients with compromised compliances?<br />
  174. 174. The problem???<br />With Pplat, we are measuring only one side of the equation!!!!!<br />What happens with patients with compromised compliances?<br />We DON’T KNOW!<br />
  175. 175.
  176. 176.
  177. 177. Intrathoracic pressures<br />PROX. AIRWAY PRESSURE (Paw)<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes)<br />ALVEOLAR PRESSURE<br />(Palv)<br />
  178. 178. Pplat<br />PROX. AIRWAY PRESSURE (Paw)<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes)<br />ALVEOLAR PRESSURE<br />(Palv)<br />
  179. 179. Ptp<br />PROX. AIRWAY PRESSURE (Paw)<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes)<br />ALVEOLAR PRESSURE<br />(Palv)<br />
  180. 180. Ptp<br />PROX. AIRWAY PRESSURE (Paw)<br />Pes<br />TRACHEAL PRESSURE (Ptr)<br />PLEURAL<br />PRESSURE<br />(Ppl)<br />(Pes)<br />ALVEOLAR PRESSURE<br />(Palv)<br />
  181. 181. Position of Esophagus and Pleura<br />
  182. 182. Position of Esophagus and Pleura<br />
  183. 183. Pplat and Ptp<br />Kubiak, Jimenez, Silva, Nieman<br />Marked variability among patients in abdominaland pleural pressures<br />For a given PEEP, Ptp may vary unpredictably from patient to patient.<br />Malbrain ML et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study.<br />Crit Care Med 2005;33:315-322. <br />Talmor D et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 2006;34:1389-1394<br />
  184. 184. Relationship Ptp - Tv<br />Ptp<br />(cm H2O)<br />Tv(mL/kg)<br />Talmor et al. Crit Care Med, 2006<br />
  185. 185. Figure 1<br />Increasing IAP<br />Vt<br />PEEP<br />30<br />25<br />20<br />15<br />10<br />5<br />0<br />0<br />0<br />Stage One<br />Stage Two<br />Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
  186. 186. Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
  187. 187. Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
  188. 188. Kubiak, Jimenez, Nieman, J Surg Trials, 2010<br />
  189. 189. Jimenez, Nieman ORMC, 2008<br />
  190. 190.
  191. 191. Transpulmonary Pressure, Plateau (Ptp-plat)<br />Increased Ptp :<br /> ↓ compliance<br /> ↑ negative Ppl<br />Decreased Ptp :<br /> normal compliance<br /> not assisting on the ventilator<br />
  192. 192. Intrathoracic pressures<br />Tracheal pressures are measured at distal end of ET Tube<br />
  193. 193. Ptr (Paw)<br />
  194. 194. Esophageal Pressure Measurements<br />
  195. 195. Connections<br />
  196. 196. Connections<br />
  197. 197. Connections<br />Ptp<br />
  198. 198. Esophageal Balloon<br /><ul><li>Placed in lower 1/3 of esophagus, above diaphragm
  199. 199. Measured pressures reflect pleural pressures</li></li></ul><li>
  200. 200.
  201. 201.
  202. 202.
  203. 203.
  204. 204. The Baydur Maneuver<br />20<br />10<br />0<br />-10<br />-20<br />20<br />10<br />0<br />-10<br />-20<br />Paw<br />cm H2O<br />Pes<br />Breath Initiation<br />
  205. 205. Hypothesis<br />Patients with↑ Pplwith conventional settings:<br />Underinflation -> causeshypoxemia<br />Raising PEEP to maintain a positive Ptp improves aeration and oxygenationwithout overdistention. <br />
  206. 206. Hypothesis<br />Patients with↓ Pplwith conventional settings:<br />Maintaining low PEEP would keep low Ptp<br />Prevents overdistention<br />Minimizing adversehemodynamic effects of high PEEP<br />Beyer J et al: The influence of PEEP ventilation on organ blood flow and peripheral oxygen delivery. Intensive Care Med 1982;8:75-80. <br />
  207. 207. Goal<br />To provide sufficientPtp (Paw - Ppl)to:<br />Maintain acceptable PaO2<br />Minimize repeated alveolar collapse<br />Minimize overdistention<br />Ptp = Ptr – Pes<br />Slutsky AS. Lung injury caused by mechanical ventilation. Chest 1999;116:Suppl:9S-15S. <br />
  208. 208. Methods<br />Supine<br />HOB 30º<br />Esophageal balloon catheter passed to 60 cmfrom incisors<br />Gentle compression of abdomen<br />Thenwithdrawn to 40 cm<br />Cardiac artifact<br />1/3 couldn’t be passed into stomach<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  209. 209. Methods<br />Recruitment maneuver<br />40 cm H2O X 40 sec.<br />Max Ptp-plat < 25 cm H2O<br />VT: 6 mL/kg PBW<br />PBW:<br />♂: 50 + 0.91 X (cm – 152.4)<br />♀: 45.5 + 0.91 X (cm – 152.4)<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  210. 210. Strategy<br />PaO2: 55-120 mm Hg<br />Or SpO2: 88-98 %<br />pH: 7.30-7.45<br />pCO2: 40-60 mm Hg<br />VT: Adjusted to keep Ptp-plat < 25 cm H2O<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  211. 211. Stress-strain curve of healthy pigs<br />Specific Lung <br />Elastance <br />5.8 cmH2O<br />Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]<br />
  212. 212. Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]<br />
  213. 213. Strategy<br />PCV or VCV<br />I:E : 1:1 to 1:3<br />RR: < 35<br />RM: PRN for suction/disconnection<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  214. 214. Table<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  215. 215. Table<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  216. 216. Study<br />Stopped after 61 pts as criteria were met in interim analysis<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  217. 217. PaO2/FiO2<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  218. 218. Respiratory System Compliance(mL/cm H2O)<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  219. 219. VD/VT<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  220. 220. PEEP<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  221. 221. Ptp - EE<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  222. 222. Ptp - PEEP<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  223. 223. Pplat<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  224. 224. Ptp – PLAT<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  225. 225. Ptp – EI<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  226. 226. K-M Survival<br />Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014<br />
  227. 227. ARDSNetLung(ARMA)<br />Jimenez E, Nieman G, ORMC 2011<br />
  228. 228. Ptp Lung<br />Jimenez E, Nieman G, ORMC 2011<br />
  229. 229. Talmor presents:An improvement in oxygenation and compliance withPtp significantly lower thanoverestimated Pplat<br />
  230. 230. Talmor presents:A persistent negative Ptp-PEEP when using the ARDS Net scale<br />
  231. 231. A big question:<br />Is this enough?<br />
  232. 232. Not really<br />Arbitrary PEEP scale<br />We need to know how to adjust it better<br />We need to find morbidity/mortality data<br />
  233. 233. What else can we use?<br />
  234. 234. Volumetric Capnography<br />
  235. 235. Terminology<br />End-Tidal CO2 (ETCO2)<br />Peak concentration of CO2at end exhalation.<br />Time-Based Capnography<br /> Concentration of CO2 plotted as a scale<br />Volumetric Capnography<br /> Concentration of CO2 integrated with flow.<br />
  236. 236. Zero baseline (A-B)<br />End tidal value (D)<br />Rapid, sharp rise (B-C)<br />Rapid, sharp downstroke (D-E)<br />Alveolar plateau (C-D)<br />
  237. 237. Capnography Volumetric CO2<br /> EtCO2<br />Capnogram<br /> RR <br />CO2 Elimination<br />Deadspace<br />Alveolar Ventilation<br />Cardiac Output / Perfusion<br />Physiologic Vd/Vt<br />
  238. 238. PEEP & VCO2<br />
  239. 239. VCO2is<br />CO2elimination from CO2production… …in a steady state!!!<br />
  240. 240. Important questions for us:<br />Is the pt OK with LVHP (ARDS Net)?<br />Is the FiO2 > 0.60?<br />Is your Pplat > 30 cm H2O?<br />Is your Paw > 20 cm H2O?<br />Is your Ptp plat> 20 cm H2O?<br />PEEP > 15 cm H2O?<br />OI > 15?<br />
  241. 241. Important questions for us:<br />Is the pt OK with LVHP (ARDS Net)?<br />Is the FiO2 > 0.60?<br />Is your Pplat > 30 cm H2O?<br />Is your Paw > 20 cm H2O?<br />Is your Ptp plat> 20 cm H2O?<br />PEEP > 15 cm H2O?<br />OI > 15?<br />
  242. 242. What’s Next ????<br />
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