ARDS

Question 1

Qual é o objetivo principal ?

Answer 1

evitar secondary lung damage

LUNG PROTECTIVE VENTILATION

Question 2

Quais medidas principais nessa estratégia ?

Answer 2

VC baixo ( 4-8ml/kg )

Pressão de plato baixa ( <30)

e manter a VENT-MINUTO

Tidal Volume 4-8 ml/kg PBW, starting with 6 ml/kg

Respiratory Rate Higher, often > 20 breaths per minute

PEEP ≥ 8 cmH2O, avoiding overdistention

FiO2 Decrease as tolerated, SpO2 ≥ 92%

Question 3

Qual é a definição de MINUTE VENTILATION ?

Answer 3

min vent = volume corrente x FR

Question 4

Como manter a ventilação -minuto em paciente com ARDS se acharmos necessa’rio ?

Answer 4

ventilação- minuto OU minute -ventilation =

VCorrenteX FR

se temos de diminuir o VC

aumentamos a frequência respiratoria

Question 5

Quais seriam os 4 critérios diagnósticos da ARDS?

Answer 5

A: aguda ( < 7 dias )

D: dois pulmões acometidos ao Rx

R: responsável n é o EAP ( edema agudo de pulmao )

S: PaO2/FiO2 < 300 mesmo numa Peep >= 5

Question 6

Qual é a relação entre escolha de Pplatô e Peep?

Answer 6

a P de platô pode ser melhrada por um ajuste otimo da PEEP -»> a PEEP otima aumenta o compliance complacencia

mas a PEEP também pode elevar demais a P platô

Question 7

Qual é o conceito de driving pressure ?

Answer 7

P plateau - Peep = driving pressure

pressao necessaria p expandir

Studies have shown that a driving pressure of < 15 cmH2O is associated with better outcomes in patients with ARDS.

Question 8

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Answer 8

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Question 9

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Answer 9

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Question 10

Quando existe dissincronia , o que fazer ?

Answer 10

A recent trial, published in 2019, did not find improved mortality with neuromuscular blockade use in ARDS.

However, neuromuscular blockade was also not associated with increased harm.

As such, it can be considered in patients who remain dyssynchronous with the ventilator despite appropriate sedation.

Question 11

Derecruitment é uma causa comum de hipoxemia!

O que fazer ?

Answer 11

manobras de recrutamento

Question 12

Quais sao os possiveis efeitos adversos das manobras de recrutamento ?

Answer 12

temporario -> aumento pos carga do VD

diminuição da pre carga VD

Question 13

Depois de estabilizado , deve-se realizar um compliance pep trial : “recruitment maneuver and the best PEEP can be determined, using a decremental compliance PEEP trial”

Como deve ser feito ?

Answer 13

1) ( bloqueio nm)
2) FiO2 should be set at 1.0 and

3 ) sedaçao

4) modo Pressao Controlado ; FR 10 ; t insp 3seg ; PC= 15
5) Then, increase PEEP 3 cmH2O every 5 breaths until the applied PEEP is between 25 to 35 cmH2O and the maximum PIP is between 40 to 50 cmH2O.
6) Ventilate at this level for 1 min. If the patient desaturates or becomes hypotensive at any point, stop, and return to the prior PEEP.
7) From here, the best compliance decremental PEEP trial should be performed. The next step is to change to volume control ventilation (VCV) at 4-6 ml/kg PBW and set PEEP at 20 to 25 dependent on patient severity of lung injury. The respiratory rate should be set to a rate that does not result in autoPEEP, usually 20 to 30 breaths/minute.
8) Measure dynamic compliance, then decrease the PEEP by 2 cmH2O, holding for 30 seconds at a time, and reassessing dynamic compliance each time. Initially the compliance will increase as PEEP is decreased, but with derecruitment, compliance will decrease.

Question 14

Quando a PRONA é recomendada ?

Answer 14

ARDS grave PaO2 / Fio2 < 150