Ventilacion mecanica no invasiva en falla respiratoria hipoxemica
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Transcript of Ventilacion mecanica no invasiva en falla respiratoria hipoxemica
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VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA
EDWARD GARCIA
MEDICINA CRITICA Y CUIDADO INTENSIVO UPB
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MARCO HISTORICO
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MARCO HISTORICO
• 1918 Haldane
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MARCO HISTORICO
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• 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
MARCO HISTORICO
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SDRA
VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA
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SDRA
• Falla 50%
• Mortalidad 35%
• Alta heterogeneidad
• Se necesitan protocolos
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SDRA
• NIV
– Disminuyó FR y mejoró PaFi
– Menor requerimiento de intubacion
– No impacto en mortalidad
– Sugiere inicio en estadios tempranos.
– Se requieren mas estudios.
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NEUMONIA SEVERA
VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA
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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
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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
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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
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• Disminuye necesidad de intubación
• Disminuye estancia en UCI
• Efecto en mortalidad?
• Mortalidad disminuye en hipercapnicos
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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
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PACIENTES INMUNOSUPRIMIDOS
VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA
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INMUNOSUPRIMIDOS
• Causas de ingreso
– Infecciones relacionadas a inmunosupresión
– Compromiso pulmonar directo por malignidad
– Toxicidad orgánica relacionada a quimioterapia
– Comorbilidades pulmonares pre existentes
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INMUNOSUPRIMIDOS
• OBJETIVOS
– Evitar complicaciones asociadas con IOT
– Mejorar comodidad del paciente
– Preservar mecanismos de defensa de la vía aérea
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N Engl J Med, Vol. 344, No. 7 · February 15, 2001
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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
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TRAUMA DE TORAX
VENTILACION MECANICA NO INVASIVA EN FALLA RESPIRATORIA HIPOXEMICA
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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
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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
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Trauma de tórax
• SDRA
– Entre 8 y 37%
– Tercer día
– Mortalidad entre 16 y 29%
– Mayor estancia hospitalaria
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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
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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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