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MANEJO NO CONVENCIONAL
DE FALLA RESPIRATORIA
AGUDA PEDIÁTRICA
DR PABLO CRUCES R.
MEDICINA INTENSIVA PEDIÁTRICA
TEMARIO
POSICIÓN PRONO
BLOQUEADORES NEUROMUSCULARES
HIPEROXIA
AGUA
b2
RETRASO DE INICIO DE ATB
DISINCRONÍA PACIENTE VENTILADOR
POSICIÓN PRONO
ACOPLAMIENTO V/Q
Heterogeneidad de la perfusión pulmonar
en planos isogravitacionales:
Conductancia vascular mayor en
regiones dorso-caudales.
Gradiente gravitacional de presión
pleural
Angulaciones en las dicotomías
vasculares pulmonares
Mayor liberación de NO endotelial en
vasos arteriales pulmonares dorsales
Mejor perfusión pulmonar caudal
Reducción de la distorsión de corazón y diafragma: menor compresión y colapso pulmonar
Reorientación de las fuerzas compresivas ejercidas por el mediastino y contenido abdominal
Mejor distribución que adopta el tejido pulmonar dentro de la cavidad toráxica
ACOPLAMIENTO V/Q
BLOQUEADORES
NEUROMUSCULARES
MANEJO CONSERVADOR
DE FLUIDOS
EVLW
EVLW
Común a muchas patologías
Causa frecuente de falla respiratoria aguda
de riesgo vital.
Clasificación:
Permeabilidad
Hidrostático o cardiogénico
EDEMA PULMONAR
SDRA
• Edema pulmonar rico en proteínas
• Disrupción de membrana alveolo capilar.
• Descenso de clearence de fluido alveolar.
• Resolución depende de remoción activa de
agua y sal desde espacios aéreos distales.
SDRA
EVLW
Safety and efficacy of a preventive strategy for fluid
overload in children with sepsis and pARDS
Blaha K, Díaz F, Quilodran J, Medina T, Nuñez MJ, Cruces P.,
SCCM 46th Annual Congress
Results :Fluids Overload (FO)
Daily FO
Conventional
Restrictive *p < 0,05
-3
-2
-1
0
1
2
3
4
Ingreso Día 1 Día 2 Día 3
0
1
2
3
4
Ingreso Día 1 Día 2 Día 3
* **
%% Cummulative FO
Clinical outcomes
Conventional Restrictive
MV (h) 124 (96-141) 63 (45-72) *
LOS 8 (7-9) 6 (5-9) *
Log rank < 0.01
conventional
restrictive
MV duration (h)
0
10
20
30
40
50
60
70
80
dia 1 dia2 dia 3
MIVF
mL
/kg
*
Conventional
Restrictive *p < 0,05
Results: Safety
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Bolosreanimación
TxGR enteral0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Reanimation
Bolus
RBC Transfusion Enteral Intake
*
*
*
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
DIA 1 DIA 2 DIA 3
Results: Safety
0
2
4
6
8
10
12
DIA 1 DIA 2 DIA 30
0,05
0,1
0,15
0,2
0,25
0,3
DIA 1 DIA 2 DIA 3
BUN Creatinine
Diuretics
0%
10%
20%
30%
40%
50%
60%
DIA 1 DIA 2 DIA 3
Administration K
* ** *
*p <
0,05
Day 1 Day 2 Day 3 Day 1 Day 2 Day 3
Day 1 Day 2 Day 3 Day 1 Day 2 Day 3Conventional
Restrictive
HIPEROXIA
USO JUICIOSO DE ESTIMULACIÓN b
SDRA es la primera causa de falla
respiratoria en niños, 66-79% de los
casos.
Zhu YF, Chin Med J (Engl) 2012;125:2265-
2271.
Hu X, Acta Paediatr 2010;99:715-721.
Yu WL, Intensive Care Med 2009;35:136-
143.
Causas de sibilancias
LE HICE UN SET DE
NEBULIZACIONES Y
QUEDÓ TAQUICARDICO…
RETRASO EN INICIO DE
ANTIBIOTICO EFECTIVO
ASINCRONÍA PACIENTE
VENTILADOR
How Often Does Patient-Ventilator Asynchrony Occurand What Are the Consequences?
Scott K Epstein MD
Introduction
Factors to Consider in Analyzing the Prevalence of Patient-Ventilator
Asynchrony
Detecting Patient-Ventilator Asynchrony
How Often Does Patient-Ventilator Asynchrony Occur?
Effect of Patient-Ventilator Asynchrony on Outcomes
Summary
Mechanical ventilation can be life-saving for patientswith acute respiratory failure. In between the
2 extremes of complete and no ventilatory support, both patient and machine contribute to venti-
latory work. Ideally, ventilator gas delivery would perfectly match patient demand. This patient-
ventilator interaction depends on how the ventilator responds to patient respiratory effort and, in
turn, how the patient responds to the breath delivered by the ventilator. I t isnow evident that the
interaction between patient and ventilator is frequently suboptimal and that patient-ventilator
asynchrony iscommon. Itsprevalence dependson numerousfactors, includingtimingand duration
of observation, technique used for detection, patient population, type of asynchrony, ventilation
mode and settings (eg, trigger, flow, and cycle criteria), and confounding factors (eg, state of
wakefulness, sedation). Patient-ventilator asynchrony is associated with adverse effects, including
higher/wasted work of breathing, patient discomfort, increased need for sedation, confusion during
the weaning process, prolonged mechanical ventilation, longer stay, and possibly higher mortality.
Whether asynchrony isa marker of poor prognosisor causesthese adverse outcomesremainsto be
determined. Key words: patient-ventilator asynchrony; trigger asynchrony; mechanical ventilation;
weaning. [Respir Care 2011;56(1):25–35. © 2011 Daedalus Enterprises]
Introduction
Mechanical ventilation can be life-saving for patients
with acute respiratory failure. Once established, the objec-
tive of mechanical ventilation should be to assume the
work of breathing (WOB), improve gas exchange (increase
PaO2and decrease PaCO2
), and unload the respiratory mus-
cles. Animal studies have demonstrated that insufficient
unloading may lead to considerable structural injury to the
respiratory muscles.1,2 Therefore, some degree of ventila-
tory support is essential, especially during the initial phases
of recovery from respiratory failure. Synchronization be-
tween ventilator and patient is virtually assured at times of
Scott K Epstein MD is affiliated with the Office of Educational Affairs,
and with the Division of Pulmonary, Critical Care and Sleep Medicine,
Tufts Medical Center, Tufts University School of Medicine, Boston,
Massachusetts.
The author has disclosed no conflicts of interest.
Dr Epstein presented a version of this paper at the 46th RESPIRATORY
CARE Journal Conference, “Patient-Ventilator Interaction,” held March 19-
21, 2010, in Cancun, Quintana Roo, Mexico.
Correspondence: Scott K Epstein MD, Office of Educational Affairs,
Tufts University School of Medicine, 136 Harrison Avenue, Sackler 317,
Boston MA 02111. E-mail: scott.epstein@tufts.edu.
RESPIRATORY CARE · JANUARY 2011 VOL 56 NO 1 25
How Often Does Patient-Ventilator Asynchrony Occurand What Are the Consequences?
Scott K Epstein MD
Introduction
Factors to Consider in Analyzing the Prevalence of Patient-Ventilator
Asynchrony
Detecting Patient-Ventilator Asynchrony
How Often Does Patient-Ventilator Asynchrony Occur?
Effect of Patient-Ventilator Asynchrony on Outcomes
Summary
Mechanical ventilation can belife-saving for patientswith acuterespiratory failure. In between the
2 extremesof complete and no ventilatory support, both patient and machine contribute to venti-
latory work. Ideally, ventilator gas delivery would perfectly match patient demand. This patient-
ventilator interaction dependson how the ventilator respondsto patient respiratory effort and, in
turn, how the patient respondsto the breath delivered by the ventilator. It isnow evident that the
interaction between patient and ventilator is frequently suboptimal and that patient-ventilator
asynchrony iscommon. Itsprevalencedependson numerousfactors, includingtimingand duration
of observation, technique used for detection, patient population, type of asynchrony, ventilation
mode and settings (eg, trigger, flow, and cycle criteria), and confounding factors (eg, state of
wakefulness, sedation). Patient-ventilator asynchrony is associated with adverse effects, including
higher/wasted work of breathing, patient discomfort, increased need for sedation, confusion during
the weaning process, prolonged mechanical ventilation, longer stay, and possibly higher mortality.
Whether asynchrony isa marker of poor prognosisor causestheseadverseoutcomesremainstobe
determined. Key words: patient-ventilator asynchrony; trigger asynchrony; mechanical ventilation;
weaning. [Respir Care 2011;56(1):25–35. © 2011 Daedalus Enterprises]
Introduction
Mechanical ventilation can be life-saving for patients
with acute respiratory failure. Once established, the objec-
tive of mechanical ventilation should be to assume the
work of breathing (WOB), improve gas exchange (increase
PaO2and decrease PaCO2
), and unload the respiratory mus-
cles. Animal studies have demonstrated that insufficient
unloading may lead to considerable structural injury to the
respiratory muscles.1,2 Therefore, some degree of ventila-
tory support is essential, especially during the initial phases
of recovery from respiratory failure. Synchronization be-
tween ventilator and patient is virtually assured at times of
Scott K Epstein MD is affiliated with the Office of Educational Affairs,
and with the Division of Pulmonary, Critical Care and Sleep Medicine,
Tufts Medical Center, Tufts University School of Medicine, Boston,
Massachusetts.
The author has disclosed no conflicts of interest.
Dr Epstein presented a version of this paper at the 46th RESPIRATORY
CARE Journal Conference, “Patient-Ventilator Interaction,” heldMarch19-
21, 2010, in Cancun, Quintana Roo, Mexico.
Correspondence: Scott K Epstein MD, Office of Educational Affairs,
Tufts University School of Medicine, 136 Harrison Avenue, Sackler 317,
Boston MA 02111. E-mail: scott.epstein@tufts.edu.
RESPIRATORY CARE · JANUARY 2011 VOL 56 NO 1 25
SIN CONFLICTOS DE
INTERÉS
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