Volumen garantizado en ventilación de alta frecuenciaa/Jueves...to conventional ventilation (CV)...
Transcript of Volumen garantizado en ventilación de alta frecuenciaa/Jueves...to conventional ventilation (CV)...
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Volumen garantizado en ventilación de alta frecuencia
Manuel Sánchez Luna, MD, PhDNeonatology Division
Hospital General Universitario “Gregorio Marañón”Complutense University
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Potencial conflicto de interés
• Asesor científico – Dräger
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Elective use of HFOV as comparedto conventional ventilation (CV)
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death or chronic lung disease at 36–37 weeks’ postmenstrual age or discharge.
Cochrane Review Update Neonatology 2013;103:7–9
M Sánchez Luna
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Johnson AH, et al New Engl J Med 2002;347:633–42.
The United Kingdom Oscillation Study(UKOS)
• 400 Infants high-frequency oscillatory ventilation• 397 Infants received conventional ventilation
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Late Outcomes of a Randomized Trialof High-Frequency Oscillation in Neonates
11-14 years
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Zivanovic S, et al N Engl J Med 2014; 370 (12): 1121-30.
M Sánchez Luna
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SensorMedics 3100A ventilator.
The optimal lung-volume strategy (OLVS).
frequency 10–15 Hz,
The pressure amplitude (DP) vibration of the thorax initially, and Lowest value consistent with normocapnia or mild hypercapnia(PaCO2, 35–50 mmHg)
Pediatr Pulmonol. 2006;41:428–43315/10/2019 7M Sánchez Luna
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Pediatr Pulmonol. 2006;41:428–433
118 (55%) normocapnic,median VT,E was 1.67 ml/kg (95% CI, 1.55–1.79)
42 (20%) hypocapnic,median VT,E was 1.94 ml/kg (95% CI, 1.74–2.14)
54 (25%) hypercapnicmedian VT,E was 1.54 ml/kg (95%CI, 1.42–1.66)
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Ventilación alveolar
• Tradicionalmente Fr y Vt Hf• Variables ligadas dependientes
• ¿Podemos independizarlas?
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• DCO2 : Fr x Vt 2
• VAFO es más efectiva en lavarCO2 que VMC
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“Clasica” HFOV sin VGEfecto de la frecuencia sobre el VtHf
0
2
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1 18 35 52 69 86 103
120
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154
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477
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579
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715
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749
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Frequencia
Tidal Volumen
M Sánchez Luna
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VAFO+Volumen GarantizadoDräger
P
V.
P
V.
VT = Constante VThf = Constante
Regulado por presiónRegulado por amplitud (deltaP)
VM;C VAFO
VMC VAFO
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Efecto de la fR en VtHf
5-6-7-8-9-10-11-12-13-14-155-6-7-8-9-10-11-12-13-14-15
Con VGSin VG
fR fR
M Sanchez Luna 201315/10/2019 12M Sánchez Luna
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Preguntas sobre VAFO+VG
1. Podemos modificar DCO2 usando solo VtHf?2. Podemos aumentar DCO2 aumentando la frecuencia dejando
constanteVtHf?3. Podemos usas frecuencias muy elevadas con DCO2 similar y
disminuir VtHf?4. Podemos usar esta estrategia en RN?5. Podemos disminuir el daño pulmonar con esta estrategia?
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• Lechones RN de 2 días de edad
• Peso 2.57 ± 0.26 kg• Pulmón normal• Pulmón con baja
complianza tras BAL
• VAFO +VG
VAFO+VGCambios en VtHf a fR constant de 10 Hz
Sanchez Luna M. Crit Care Res Pract 201315/10/2019 14M Sánchez Luna
Dräger VN500
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Animal modelHFOV+VG
change in VtHf at a constant fR 10 Hz
30
40
50
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2mL/kg 2.5mL/kg 3mL/kg BAL 3mL/kg
PaCO
2 (m
mH
g)*
*
*
Sanchez Luna M et al. Crit Care Res Pract 2013
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BAL
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Animal modelHFOV+VG
change in VtHf at a constant fR 10 Hz
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10
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30
40
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70
2mL/kg 2.5mL/kg 3mL/kg BAL 3mL/kg
∆Phf
(cm
H2O
)*
*
† *BAL
Sanchez Luna M et al. Crit Care Res Pract 2013
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EFFICACY OF HFOV+VG ON DCO2 AT DIFFERENT FREQUENCIES.
EFFECT ON DELTA PRESSURES
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Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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CO2Adjustable continuous flow100ml/min
“Lung”Volume: 500 mlAirway Dead Space: 35 ml
Measured Variables• Initial CO2• CO2 25sec• %CO2 25• CO2 50 sec• %CO2 50• Slope• P1 P2 P3
ET CO2
P 1
P 3
P 2
Time Seconds 25 50
Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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VAFO+VG y presiones delta
P1= Proximal P2= MedialP3= Distal
Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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Delta Pressures
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Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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VG ON and OFF
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P1
P2
P3
P1: ProximalP2: Medial
P3: Distal
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25
5 7 9 11 13 15
P1
P2
P3
ON OFF
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Mukerji A Jaques Belik, Manuel Sanchez-Luna, J Perinatol 2014; 34 (6): 464-7.
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Using very high frequencies with verylow lung volumes during high-frequency
oscillatory ventilation to protect theimmature lung. A pilot study. González-Pacheco N, Sánchez-Luna M, Ramos-Navarro
C, Navarro-Patiño N, de la Blanca AR. J Perinatol 2016; (): .
Objective:To use the lowest VtHf and maintain similar PCO2 by increasing the frequency
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N González-Pacheco et al, Journal of Perinatology 201615/10/2019 M Sánchez Luna 26
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N González-Pacheco et al, Journal of Perinatology 201615/10/2019 M Sánchez Luna 27
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N González-Pacheco et al, Journal of Perinatology 201615/10/2019 M Sánchez Luna 28
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N González-Pacheco et al, Journal of Perinatology 201615/10/2019 M Sánchez Luna 29
Frequency Hz
pCO2
pCO2
Vt ml
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HFOV+VG very high frequencies
• 10 Hz vs 20 Hz• Animal newborn model• 12 hours of HFOV after BAL
González Pacheco N, Sanchez Luna M, J of Perinatology 2019
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Efecto sobre el pulmón
10 Hz, 12 horas HFOV+VG 20 Hz, 12 horas HFOV+VG
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González Pacheco N, Sanchez Luna M, animal lab, 2018
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Lung microscopy
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10 Hz, 12 hours of HFOV+VG 20 Hz, 12 hours of HFOV+VG
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Lung microscopy10 Hz group 20 Hz group CMV group
Animal case I II III IV V VI VII VIII IX X XI XII
Inflammation 3 2 4 3 1 2 0 0 1 1 1 3
Hemorrhage 1 1 3 0 0 0 0 0 0 0 0 0
Atelectasis 2 2 4 3 2 3 1 2 1 1 1 3
Edema 0 0 0 0 0 0 0 0 0 0 0 0
Emphysema 0 0 0 0 0 0 0 0 3 3 0 2
TOTAL SCORE 28 11 20
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Preguntas sobre HFOV + VG1. Podemos modificar DCO2 usando solo VtHf?
1. Sí2. Podemos aumentar DCO2 aumentando la frecuencia con VtHf fijo?
1. Sí3. Podemos usar frecuencias muy elevadas con VtHf muy bajos y DCO2
similares?1. Sí
4. Podemos usar esta estrategia en RN?1. Sí
5. Podemos proteger el pulmón inmaduro con esta estrategia?1. Sí
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Noelia González PachecoAna Rodríguez Sánchez de la
BlancaCristina Ramos Navarro
M Ángeles MuñozPaula Palau
Francisco TendilloMartin Santos
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Fis National Grant.:PI 14/00149
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Prof William Benitz Prof Carlos Ramos Dr. Michael Gottschalk Prof Anup Katheria
Prof Avroy Fanaroff Prof Horacio Prof Sergio G. Golombek Prof Jose Honold
SPEAKERS