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Ventilacion mecanica no invasiva en falla respiratoria hipoxemica

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Ventilacion mecanica, hipoxia, hipoxemia, falla respiratoria.

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Ventilacion mecanica no invasiva en falla respiratoria hipoxemica

  1. 1. VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA EDWARD GARCIA MEDICINA CRITICA Y CUIDADO INTENSIVO UPB
  2. 2. MARCO HISTORICO
  3. 3. MARCO HISTORICO • 1918 Haldane
  4. 4. MARCO HISTORICO
  5. 5. MARCO HISTORICO • Finales 20’s hasta 50´s – Pulmón de hierro • • • • 50´ - VPP con TOT y TQT 1980 – CPAP - AOS – Sullivan 1987 – CPAP - enfermedad neuromuscular 1989 – Meduri – falla respiratoria aguda – 10 pacientes – Falla cardiaca – neumonía – EPOC – 8/10 se recuperaron sin intubación
  6. 6. VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA SDRA
  7. 7. SDRA • Falla 50% • Mortalidad 35% • Alta heterogeneidad • Se necesitan protocolos
  8. 8. SDRA • NIV – Disminuyó FR y mejoró PaFi – Menor requerimiento de intubacion – No impacto en mortalidad – Sugiere inicio en estadios tempranos. – Se requieren mas estudios.
  9. 9. VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA NEUMONIA SEVERA
  10. 10. Antonelli M, Conti G, Moro ML, Esquinas A, Gonzalez-DiazG ,Confalonieri M, et al. Predictors of failure of noninvasive positive pressure ventilation in patients with acute hypoxemic respiratory failure: a multi-center study. Intensive Care Med 2001; 27: 1718–28
  11. 11. Confalonieri M, Potena A, Carbone G et al. Acute respiratory failure in patient with severe community-acquired pneumonia. A prospective randomized evaluation of non-invasive ventilation. Am J Respir Crit Care Med 1999;160:1585-1591
  12. 12. Confalonieri M, Potena A, Carbone G et al. Acute respiratory failure in patient with severe community-acquired pneumonia. A prospective randomized evaluation of non-invasive ventilation. Am J Respir Crit Care Med 1999;160:1585-1591
  13. 13. • Disminuye necesidad de intubación • Disminuye estancia en UCI • Efecto en mortalidad? • Mortalidad disminuye en hipercapnicos
  14. 14. NEUMONIA • Falla respiratoria aguda de novo – Fallaron más frecuentemente – 47,46% versus 21,26%, p=0.007) • Predictores de falla – Empeoramiento de infiltrados radiológicos en 24 horas – SOFA mayor – Después de 1 hora de VNI • FC mayor • Menor PaFi • Menor bicarbonato
  15. 15. VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA PACIENTES INMUNOSUPRIMIDOS
  16. 16. INMUNOSUPRIMIDOS • Causas de ingreso – Infecciones relacionadas a inmunosupresión – Compromiso pulmonar directo por malignidad – Toxicidad orgánica relacionada a quimioterapia – Comorbilidades pulmonares pre existentes
  17. 17. INMUNOSUPRIMIDOS • OBJETIVOS – Evitar complicaciones asociadas con IOT – Mejorar comodidad del paciente – Preservar mecanismos de defensa de la vía aérea
  18. 18. N Engl J Med, Vol. 344, No. 7 · February 15, 2001
  19. 19. INMUNOSUPRIMIDOS • Sobrevida aumentada – Avances en manejo hemato - oncológico – Soporte de disfunción orgánica en UCI • Pacientes hematológicos en falla respiratoria – – – – – – VNI exitosa en 50% Periodos más cortos de estancia en UCI Menos complicaciones infecciosas Menos mortalidad Identificación de predictores de éxito o falla Pacientes en estado terminal
  20. 20. VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA TRAUMA DE TORAX
  21. 21. Trauma de tórax • Ocurre en 20% de politraumas • 20-40% de todas las muertes por trauma • Lesiones más comunes – Fracturas costales – Neumotórax – Hemotórax – Contusión pulmonar – Tórax inestable
  22. 22. Trauma de tórax • Función pulmonar alterada – Lesión de parénquima – Hemorragia – Inflamación – Disfunción alveolo-capilar – Moco bronquial – colonización • Alteración de ventilación perfusión • Hipoxemia leve a SDRA
  23. 23. Trauma de tórax • SDRA – Entre 8 y 37% – Tercer día – Mortalidad entre 16 y 29% – Mayor estancia hospitalaria
  24. 24. Trauma de tórax • 10 estudios / 368 pacientes • 5 estudios / 219 pacientes reportaron mortalidad – RR 0.26 IC 0.09 – 0.71, p= 0.003 – No diferencia entre CPAP y PS • Mejoría de oxigenación • Disminuye intubación • Disminuye complicaciones infecciosas
  25. 25. Trauma de tórax • Limitaciones – Diferencias en criterios de inicio de VNI – No homogeneidad en valores de presión utilizados – No fue posible separar los efectos de BiPAP y CPAP – Numero de estudios elegibles relativamente pequeño

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