Ventilación / Ventilation

Diciembre 9, 2017. No. 2927

Ventilación protectora y maniobras de reclutamiento pulmonar en cirugía mayor María Camila Arango-Granados, Fredy Ariza Rev Argent Anestesiol 2016;74:1-9 - DOI: 10.1016/j.raa.2016.05.002 Resumen La ventilación mecánica es una intervención frecuente en el escenario quirúrgico, especialmente para procedimientos de alta complejidad y en pacientes críticamente enfermos, pero no está exenta de complicaciones. Los estudios durante los últimos años han estado encaminados a definir cuál es la estrategia ventilatoria que ofrece el mejor perfil de seguridad durante cirugía mayor. Esta revisión busca exponer cuál es la evidencia disponible sobre estrategias ventilatorias y maniobras de reclutamiento pulmonar en el paciente llevado a cirugía mayor. Para esto se realizó una búsqueda estructurada de la literatura incluida en las bases de datos MEDLINE y SciELO. Las publicaciones disponibles parecen coincidir en que el uso de volúmenes corrientes bajos reduce las complicaciones pulmonares postoperatorias en pacientes que serán sometidos a cirugía mayor. Sin embargo, existe evidencia contradictoria sobre este beneficio en cirugía de tórax. Los hallazgos sobre el uso de presión positiva al final de la espiración aún son heterogéneos. La literatura disponible indica que en cirugía de tórax, cirugía cardiovascular y cirugía traumatológica esta estrategia parece tener potenciales beneficios. En cambio, en cirugía abdominal mayor y neurocirugía existen datos contradictorios que indican la necesidad de futuras investigaciones. Aun es necesario estudiar si las maniobras de reclutamiento ofrecen reales beneficios para los pacientes que se llevan a cirugía mayor, independiente del tipo de cirugía. Finalmente, aún no es posible establecer si tanto la ventilación protectora como las maniobras de reclutamiento pulmonar realizadas en el intraoperatorio impactan en los desenlaces a largo plazo o la mortalidad. PDF Posición prona en pacientes con síndrome de dificultad respiratoria aguda Prone positioning acute respiratory distress syndrome patients. Guérin C1,2,3. Author information Ann Transl Med. 2017 Jul;5(14):289. doi: 10.21037/atm.2017.06.63. Abstract Prone position has been used in acute respiratory distress syndrome (ARDS) patients for more than 40 years in ICU. After having demonstrated its capability to significantly improve oxygenation in a large number of patients, sometimes dramatically, this procedure has been found to prevent ventilator-induced lung injury, the primary concern for the intensivists managing ARDS patients. Over the time, several trials have been done, which regularly improved and refined from each other. At the end, significant improvement in survival has been demonstrated in the most severe ARDS patients, at a threshold of 100-150 mmHg PaO2/FiO2 ratio. The effect of proning on survival cannot be predicted and seems unrelated with both severity of oxygenation impairment and oxygenation response to proning. The rate of complication is declining with the increase in centers expertise. The pressure sores are more frequent in prone and require a special attention. Prone position is a key component of lung protective mechanical ventilation and should be used as a first line therapy in association with low tidal volume and neuromuscular blocking agents in patients with severe ARDS. KEYWORDS: Acute respiratory distress syndrome (ARDS); hypoxemia; mechanical ventilation; prone position; ventilator induced lung injury PDF Volumen corriente en síndrome de falla respiratoria aguda. Como mejor seleccionarlo Tidal volume in acute respiratory distress syndrome: how best to select it. Umbrello M1, Marino A2, Chiumello D1,2. Author information Ann Transl Med. 2017 Jul;5(14):287. doi: 10.21037/atm.2017.06.51. Abstract Mechanical ventilation is the type of organ support most widely provided in the intensive care unit. However, this form of support does not constitute a cure for acute respiratory distress syndrome (ARDS), as it mainly works by buying time for the lungs to heal while contributing to the maintenance of vital gas exchange. Moreover, it can further damage the lung, leading to the development of a particular form of lunginjury named ventilator-induced lung injury (VILI). Experimental evidence accumulated over the last 30 years highlighted the factors associated with an injurious form of mechanical ventilation. The present paper illustrates the physiological effects of delivering a tidal volume to the lungs of patients with ARDS, and suggests an approach to tidal volume selection. The relationship between tidal volume and the development of VILI, the so called volotrauma, will be reviewed. The still actual suggestion of a lung-protective ventilatory strategy based on the use of low tidal volumes scaled to the predicted body weight (PBW) will be presented, together with newer strategies such as the use of airway driving pressure as a surrogate for the amount of ventilatable lung tissue or the concept of strain, i.e., the ratio between the tidal volume delivered relative to the resting condition, that is the functional residual capacity (FRC). An ultra-low tidal volume strategy with the use of extracorporeal carbon dioxide removal (ECCO2R) will be presented and discussed. Eventually, the role of other ventilator-related parameters in the generation of VILI will be considered (namely, plateau pressure, airway driving pressure, respiratory rate (RR), inspiratory flow), and the promising unifying framework of mechanical power will be presented. KEYWORDS: Acute respiratory distress syndrome (ARDS); mechanical ventilation; tidal volume; ventilator-induced lung injury (VILI) PDF International Anesthesia Research Society Annuals Meetings USA Informes / Information

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