la#ven'la'on#du#pa'ent#en#sdra# - smurbmpm.fr
TRANSCRIPT
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La#ven'la'on#du#pa'ent#en#SDRA#
Pr#Antoine#Roch#
Service#d’Accueil#des#urgences#
Réanima'on#DRIS#
CHU#Nord##
Marseille#
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SDRA ##
• Hypoxémie#sévère##
• Baisse#de#compliance#pulmonaire#par#œdème#
lésionnel##
• Pas#d’œdème#cardiogénique#
• Principales#causes#de#SDRA:#– Sepsis#sévère/choc#sep'que#– Pneumopathies#
– Polytrauma,#pancrea'te,#sepsis#abdominaux##
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IOT#en#réanima'on:#geste#délicat#
Cri$cal(Care(Med(2006(
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Mort(T.,(Proxygéna$on(in(cri$cally(ill(pa$ents(requiring(emergency(tracheal((((((((intuba$on.(Crit(Care(Med,(2005(
Rendement#de#la#préoxygéna'on#
en#réanima'on#
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PaO2#<#100#mmHg#sous#masque#HC#10#l/min.##
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98±2#
93±6#
93±8#
#
81±15#
98±2#
94±6#
P<0.05# P<0.01# P<0.05#
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En#pra'que#
• Disponibilité#VNI#• Expérience#VNI#• Estomac#plein#
• Poursuivre#VNI#si#déjà#en#place#!##• Pour#le#transport#du#pa'ent#très#hypoxemique#?#
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FiO2#21a100%#
Débit#10a50#l/min##
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• FiO2#plus##élevée#• Effet#PEP#• Humidifica'on##
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Préserva'on#du#parenchyme#pulmonaire#
Correc'on#de#l’hypoxémie#
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Réglages#du#respirateur#
– Vt#:#5a7#ml/kg#de#poids#idéal#
– Op'misa'on#de#la#PEP,#plutôt#haute#
– Op'misa'on#Pplat#(24a28#cmH20)#
– Manœuvres#de#recrutement##
# # ##
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NEJM#2000#
6#vs#12#ml/kg##
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Taille PBW h PBW f 155 52 48 160 57 52 165 61 57 170 66 62 175 71 66 180 75 71 185 80 75 190 84 80 195 89 84
PBW#=#X#+#0,91#(taille#en#cm#–#152,4),#avec#X#=#50#pour#les#hommes#et#45,5#
pour#les#femmes##
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Paw
Temps
Débit
Temps
Les#4#phases#du#cycle#ven'latoire#en#VCaVAC#
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Paw
Temps
Débit
Temps
Les#4#phases#du#cycle#ven'latoire#en#VC#
Déclenchement##
de#l’inspira'on:#
a Fréquence#a Trigger#(VAC)#
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Paw
Temps
Débit
Temps
Les#4#phases#du#cycle#ven'latoire#en#VC#
Délivrance#du#volume#
#
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Paw
Temps
Débit
Temps
Les#4#phases#du#cycle#ven'latoire#en#VC#
Déclenchement#de##
l’expira'on:#
a Débit#a temps#plateau#
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Paw
Temps
Débit
Temps
Les#4#phases#du#cycle#ven'latoire#en#VC#
Expira'on##
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SURVEILLANCE DE LA PRESSION DE PLATEAU
SURVEILLANCE DU BAROTRAUMATISME
ET DU VOLOTRAUMATISME
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Ven'la'on#protectrice:#Vt#bas#et#PEP#
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VT 6 ml / kg (PBW)
RR ≤ 35 / mn ; 7.30 < pH < 7.45
55 mmHg < PaO2 < 80 mmHg
88% < SpO2 < 95%
Minimal
alveolar distension
PEEP set for
5 ≤ PEEPtot ≤ 9
Maximal
alveolar recruitment
PEEP set for
28 ≤ Pplat ≤ 30
ExPress
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Mercat et al. JAMA 2008
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ALVEOLI#ARDSnet NEJM 2004
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O’Meade et al. JAMA 2008
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PEP
PATIENT AVEC DES HYPERDENSITÉS DIFFUSES
PATIENT AVEC DES HYPERDENSITÉS LOBAIRES
Rouby et al. ICM 2000
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Day#1:##
PEP#15#vs#10#
Pplat#30#vs#25#
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• Op'misa'on#du#réglage#du#respirateur#
#
– réduire#le#volume#courant#(6a8#ml/kg…)#donc#
choisir#plutôt#VAC#
– limiter#les#pressions#(Pplat#<#32#cmH2O)#
– u'liser#une#PEEP#suffisamment#élevée#(≥#10#
cmH2O,#max#?)#
– Cas#de#l’obèse#ou#si#Pabdo#élevée#– limiter#les#objec'fs#de#PaO2#60a75#mmHg#(donc#
u'liser#le#niveau#le#plus#bas#de#FiO2)#
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• #CPAP#4O#cmH2O#pdt#40#sec,##
• #PEP#2#CmH2O>#PI#inferieur#PV#curve#
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Adjuvants##
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Time Inclusion 24 h 48 h 72 h 96 h 120 H
PaO
2/FI
O2
(mm
Hg)
75
100
125
150
175
200
225
250
275Control group (n = 18)NMBA group (n = 18)
Study drug administration
p = .002p = .006
p = .002
p = .013
***
*
*
* *
Forel,(Roch,(Crit(Care(Med(2006(
PaO2/FiO2#iden'ques#entre#les#groupes#à#H24#dans#accurasys#
n = 56
Temps (Heures) H0 H24 H48 H72 H96 H120 100
150
200
250 Curares Contrôle
*
*
*
* p < 0.05
Curarisa'on#précoce#de#48#h#au#cours#du#SDRA#sévère#
Gainnier,(Roch,(Crit(Care(Med(2004(
N#=#56# N#=#36#
PaO2#/#FiO2#
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Curarisa'on#
NMBA#
placebo#
Cox#mul'variate#propor'onal#hazards#model#
a#Plateau#pressure#(predefined)#
a #SAPS#II#(predefined)#a #PaO2:FiO2#
#NMBA#0.68#(0.48a0.98),#p#=#0.04#
#Plateau#pressure,#P=0.04#
#SAPS#II,#P=0.004#
#PaO2:FiO2,#P=0.78#
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• #PAFI#<#150#persistant,#en#moyenne#100#
• #4±4#séances#de#DV#de#17±3#h#
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supine' prone' p'
ECMO# 2.6%# 0.8%# 0.14#
INO# 15.7# 9.7# 0.05#
almitrine# 6.6# 2.5# 0.04#
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Dellinger(RP(Crit(Care(Med(1998(
50#%#de#répondeurs#au#NO#inhalé##
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BMJ#2007#
Augmenta'on#moyenne#PAFI#=#13%#a#Pas#d’effet#sur#la#PAP#
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NO#en#pra'que##
• #En#awendant#mieux##
• #Tester#la#réponse#(<1h)#
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p < 0.05
PaO
2 / F
iO2
NO NO + NO + Alm 5 Alm 16
p < 0.05
Posologies#élevées#d’almitrine#u'les#chez#les#pa'ents##
sous#noradrénaline#et#répondeurs#au#NO#
Roch((Intensive(Care(Med(2001(
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Michard(Crit(Care(Med(2001(
Risque#pour#le#cœur#droit## Risque#pour#le#foie##
B’Chir(Anesthesiology(1998(
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Quand#en#arriver#à#l’ECMO#?#
Ou#ne#pas#aller#jusqu’à#l’ECMO#
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Pompe#
Arrivée#Air#
et#O2#
Oxygénateur##
CO2#
ECMO##
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Décès#ou#handicap#majeur#à#6#mois#
Peek#et#al.#Lancet#2009#
P/F#<#100#
VM#<#7j##
P#=#0.03#
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! Équipe#chirurgie#cardiaque##disponible##24/24h##
#
#
Collaboration*multidisciplinaire*ECMO''
Chirurgien# Perfusioniste##IBODE#
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#
##
##
#
#
#
##
#
UMAC5UMAREC*Unité*Mobile*d’Assistance*
Respiratoire*Extra5Corporelle#
Transport'inter1hospitalier'sous'
ECMO''
SAMU'Chirurgie'cardiaque'
Réanima>on'médicale'
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Lancet(2009(
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95#UMAC#en#4#ans#a#3#régions#
85#UMAC#en#4#ans#a#PACA#
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Conception : 10 Laveran :1 St Joseph : 2 Vert coteau : 1
Arles : 2
Salon : 3
Aix : 3
Martigues : 3
Toulon : 4
Hyères : 2
Draguignan : 3
Fréjus : 2
Cannes : 2
Nice : 5
Brignoles : 1
Avignon : 4
Alès : 2
Carpentras : 1
Grasse : 1
Aubagne : 1
Apt : 1
Briançon : 1
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• Hypoxémie#profonde##– PaO2/FiO2#<#70###sous#FiO2#1#depuis#2h#au#moins##
– avec#une#PEEP#d'au#moins#10#cmH2O#
• Une#ven'la'on#protec've#impossible:#– PaO2/FiO2#entre#70#et#100#(à#FiO2#=#1)##
• avec#une#Pplat#>#35#cmH2O##
• ou#la#présence#d'une#acidose#respiratoire#sévère#(pH#<#7,15#malgré#une#fréquence#respiratoire#à#35/min).#
Critères'UMAREC'
Hotline:#06#32#36#48#22###(24/7)#
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Complica'ons#
• CESAR:#1#perfora'on#veineuse#(n=68)#• ANZICS:#6#hémorragies#intracrâniennes#(n=61)#
• Pi'é:#6#chocs#hémorragiques,#4#HIC#(n=140)#
• Thromboses#veineuses#
• Thrombopénie#
• Hémolyse#
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ICM#2014#
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UMAC#en#France#
• Sur#28#CHU,#23#ont#une#ac'vité#d’UMAC#
• Jamais#iden'fiée#en#tant#qu’unité#fonc'onnelle#avec#des#moyens#
spécifiques#
• Indica'ons##cardiaques#et#respiratoires#pour#22#CHU#• Nombre#médian#=#10#par#an#,#range#[1a300]#
0#
2#
4#
6#
8#
10#
12#
<10# 10# >10#
300#
50#
21#
17#
12#
#
Nb#CHU#
Nb#UMAC#
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Conf#consensus#
• Il'est'nécessaire'que,'dans'chaque'région,'soit'iden>fié'au'minimum'un'centre'référent'possédant'tous'les'moyens'humains'et'matériels'indispensables'à'la'prise'en'charge'd’un'pa>ent'aHeint'de'SDRA'et'à'l’implanta>on'et'la'conduite'des'techniques'd’assistance'extra1corporelle':''réanima>on,''chirurgie'cardiaque'et'Unité'Mobile'd’Assistance'Circulatoire'
• Les'centres'référents'doivent'disposer'd’une'Unité'Mobile'd’Assistance'Circulatoire'disponible'24h/24,'à'même'd’intervenir'dans'tous'les'établissements'de'santé'de'la'région'concernée'
• Le'main>en'de'la'compétence'en'ECMO'd’un'service'de'réanima>on'risque'de'ne'pas'être'assuré'en'deçà'de'dix'indica>ons'annuelles'd’ECMO#
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œdème pulmonaire
↓ Compliance pulm ↑ Résistance VA Compression
vasculaire
Ventilation mécanique
Inflammation, Subst. vasoactives
remodeling
HTAP
Shunt hypoxémie
Défaillance VD
↑ travail respi VPH
épuisement
Baisse#drainage#
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Richard#JC#ICM#2013#
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Richard#JC#ICM#2013#
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BIPAP#Cycles#contrôlés#en#pression#
Cycle#en#aide#VS#sur#cycle#contrôlé#
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• More#protec've#ven'la'on#vs#CMV:#
– Lower#'dal#volume#
– Safe#use#of#higher#mean#airway#pressures#
#
• Treatment#of#oxygena'on#failure#and/or#
ven'la'on#failure##
Buts#de#l’HFO#
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n=190#
Adhikari#CCM#2011#
Change#in#PaO2#to#FiO2#ra'o#(%)# Change#in#PaCO2#(%)#
2/3#of#pa'ents#exhibited#an#increase#in#PF#ra'o##
55%#exhibited#a#decrease#in#PaCO2##
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• 12 centers in UK
• PF ratio < 200 with PEEP > 5 cmH20 and MV < 7 d
• MAP up to 50 cmH2O if PF ratio < 60
• Decrease MAP when FiO2 0.4 by 2 cmH20 every 6h
• Weaning if MAP = 24 cmH2O
• Frequency 10 Hz decreased if pH < 7.25
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41%#
5#j#d’HFO#en#moyenne#
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• Target#recruitment:#1200#pa'ents#
• 37#centers#across#the#world#
• PF#ra'o#<#200#with#FiO2#>#0.5#and#<#72h#MV#
• start#mPAW#30;#keep#∆P#90;#maximal#frequency#
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34#crossaover#du#groupe#contrôle#vers#HFO#
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PP#followed#byHFO#
PP#followed#by#CMV#
Mean#Paw#=#25#
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Fat#embolism,#day#2#of#ECMO# Day#3#of#ECMO#and#HFO#
ECMO#+#HFO#
ECMO#weaned#on#day#9#
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ECMO+HFO+PP#
Burn#+#VAP#–#day#15#of#ECMO##
Fi02#0.9#–#PEP#17a#compliance#4#ml/cmH20##
AÇer#2#days#of#HFO+PP#
Fi02#0.4#–#FDO2#1amean#Paw#25#
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DV#sous#ECMO#
• Nos#indica'ons#actuelles:#– Hypoxémie#profonde#sous#ECMO#
– Pplat#>#32##– Sevrage#ECMO#impossible#vers#J10#
• 15#pa'ents#traités,#21#séances#
PaO
2 / F
iO2 (m
mH
g)
Supine' Prone'+1H'''''''+6H''''''''''+12H'''''Supine+1H''''+6H''''''''''Under#revision##