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Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
Ventilator Induced Lung Injury
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Ventilator Induced Lung Injury

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Presentation by Lluis Blanch , faculty of 8th Pulmonary Medicine Course 2008 Egypt …

Presentation by Lluis Blanch , faculty of 8th Pulmonary Medicine Course 2008 Egypt
Scribe medical events (www.scribeofegypt.com)

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  • 1. 8th Pulmonary Medicine Update Course The Egyptian Society of ICM & Trauma Ventilator Induced Lung Injury: from Barotrauma to Biotrauma Lluis Blanch M.D. Consultant, Critical Care Center, Hospital of Sabadell Scientific Director, Corporacio Parc Tauli University Institut Fundació Parc Taulí Universitat Autónoma de Barcelona Sabadell, Spain lblanch@tauli.cat Cairo, February 6 - 7, 2008
  • 2. Webb & Tierney 1970. Dreyfuss & Saumon 1998.
  • 3. Alveolar Interdependence Stress (tensión) Strain (deformación) Strech (estiramiento) Shear (cizallamiento) Mead J et al. J Appl Physiol 1970; 28:596-608
  • 4. The concept of “Barotrauma” Increased Microvascular Permeability in Dog Lungs due to High Peak Airway Pressures Parker JC et al. J Appl Physiol 1984;57:1809
  • 5. The concept of “Biotrauma” Mechanical Injury Leads to Inflammation ARDS Baro-Volu-Atelectrauma Surfactant Biotrauma Depletion Stress Failure Shear Forces TNFα Overdistension IL-1 IL-8 Cell Trigger Mechanism
  • 6. Injurious Ventilatory Strategies Increase Cytokines in an isolated Rat Lung Model (Saline Injected Group) Tremblay L et al. J Clin Invest 1997;99:944-952
  • 7. JAMA 2003;289:2104
  • 8. Effect of Mechanical Ventilation Strategy on Dissemination of Intratracheally Instilled Escherichia coli in Dogs “second hit” + Blood Cultures Group Overall 30 min.6 hours Ptp 15, PEEP 3 0/6 0/6 0/6 Ptp 35, PEEP 3 5/6 5/6 2/4 Ptp 35, PEEP 10 1/6 1/6 1/6 Nahum A, et al Crit Care Med 1997; 25:1733-43.
  • 9. VILI & Stress Distribution along the Blood-Gas Barrier Results from a Complex Interplay between • Alveolar pressure • Lung volume • Surface tension • Capillary pressure • Flow through pulmonary vessels • Rate of lung expansion
  • 10. High Capillary Pressure is More Injurious at High Lung Volume Scanning Transmission Electron Microscopy Electron Microscopy Fu Z et al. J Appl Physiol 1992;73:123-133
  • 11. Pulmonary Capillary in an Alveolar Wall Showing The Three Principal Forces to which The Vessel Is Exposed Increase in Lung Inflation Increase in Pcap Stretch & Stress The Capillary Wall West JB & Mathieu-Costello O. Lancet 1992;340:762-767.
  • 12. Perfusion (ml/min) Ptp (cmH2O) Control 500 10 Low Flow 300 30 High Flow 900 30 Am J Respir Crit Care Med 1998; 157:1935-42
  • 13. Prospective study designed to Systolic PAP identify factors influencing pathogenesis, severity and prognosis of ARDS. Patients: 586 (38 European ICUs) Results: - PaO2/FiO2 & Qs/Qt predicted survival. - High PAP and low SAP were strong indicators of survival (adverse prognostic significance).
  • 14. 3 Weight Gain (gm/gm lung) 1 * f: resp. rate * P: PA pressure 0 High f Low f High f Low P High P High P Am J Respir Crit Care Med 2000; 161:463.
  • 15. Contributions of Vascular Flow & Pulmonary Capillary Pressure to VILI Study Design Stabilization 15’ Pressure Controlled Ventilation 30’ Heart-Lung Block Measurements Measuremetns Ischemic Time < 25 min Pump Flow PAP LAP Pcap Paw PEEP (ml/min) (mmHg) (mmHg) (mmHg) (cmH2O) (cmH2O) ↓Flow ↓Pcap 40 20 10 10 30 5 ↑Flow ↑Pcap 500 35 10 20 30 5 ↓Flow ↑Pcap 40 20 20 20 30 5 ↑Flow ↓Pcap 500 35 5 10 30 5
  • 16. Contributions of Vascular Flow & Pulmonary Capillary Pressure to VILI *† *† % change in Cst Vascular * * failure was observed * † ONLY in high * † flow groups *† *†
  • 17. Crit Care Med 2006;34:1106-1112 quot;% quot;$ quot; quot; High Flow & * † Groups % $ ' Low Flow Groups ! quot; quot;! ! # Perfusion at high vascular flow promotes lung damage, edema, and hemorrhage independent of the level of pulmonary capillary pressure
  • 18. Effects of vascular flow and PEEP in a multiple hit model of lung injury in isolated perfused rabbit lung To evaluate the protective role of PEEP in lung injury development in two isolated and perfused lung model of VILI: High vascular flow model (one hit) Oleic acid pre-injury and high vascular flow model (two hit)
  • 19. Effects of vascular flow and PEEP in a multiple hit model of lung injury in isolated perfused rabbit lung • Experimental, prospective and acute study • 30 Isolated perfused and ventilated lungs from New Zealand rabbits ( 3.3 ± 0.5 kg) • 6 Experimental groups (3 with and 3 without OA): Group Flow PAP LAP Pcap ml/min mmHg mmHg mmHg Low Flow/Peep 5 40 20 10 12 High Flow/Peep 5 600 35 10 20 HighFlow/Peep15 600 35 10 20
  • 20. Effects of vascular flow and PEEP in a multiple hit model of lung injury in isolated perfused rabbit lung 6 10 weight gain (g/g lung tissue) † * weight gain (g/g lung tissue) a 5 * + b + 8 4 3 6 * 4 * 2 1 2 0 0 0 5 10 15 20 25 30 0 5 10 15 20 25 30 Time (minutes) Time (minutes) ! quot; # $% ' &' &( ! quot; # $% ' &' &)( $ # $% ' &' &(
  • 21. Effects of vascular flow and PEEP in a multiple hit model of lung injury in isolated perfused rabbit lung a 3 6 * + Perivascular hemorrhage score * + *† Alveolar hemorrhage score † 5 * 4 2 3 2 1 1 0 0 LFLP HFLP HFHP LFLP HFLP HFHP 8 b 4 + + Perivascular hemorrhage score * * * Alveolar hemorrhage score * 7 6 3 5 4 2 3 2 1 1 0 0 LFLPOA HFLPOA HFHPOA LFLPOA HFLPOA HFHPOA
  • 22. Factors Influencing Liquid Movement in the Pulmonary Capillaries: The Starling Equation Qf = Kf {(Pc - Pis) - σ (πpl - πis)} (π Qf: net flow of fluid Kf: capillary filtration coefficient Pc: capillary hydrostatic pressure Pis: hydrostatic pressure of the interstitial fluid σ: reflection coefficient πpl: oncotic pressure of the plasma πis: oncotic pressure of the interstitial fluid
  • 23. Assessing practice changes ),, )- - . )/0(
  • 24. Potential effects of usual practice control group in the ARDSNet low tidal volume (ARMA) trial

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