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Dept. of Anesthesiology

TC e TIE no paciente com SARA

Marcelo B. P. Amato

University of São PauloBrazil

III Curso Nacional de Ventilação Mecânica da SBPT São Paulo, SP - 2008

Adapted from Adler. J Appl Physiol 1997

Patient thoraxPatient thorax

amplifiers

Imaging system

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Electrical Impedance TomographyElectrical Impedance Tomography

Acquisition

controller

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LIM 09

Hospital das Clínicas - FMUSP

Laboratório de Investigação Médica em Pneumologia – LIM 09

Laboratório de Investigação Médica em Pneumologia – LIM 09

Reg 1Reg 1

Reg 2Reg 2

Reg 3Reg 3

Reg 4Reg 4

URUR ULUL

LRLR LLLL

7.5

5.0

2.5

0

Z

(%)

Changes in Air content (mL)

Selective intubationSelective intubation

SPECT

PneumothoraxPneumothorax

Costa 2006. Submetido à publicação.

Costa 2006. Submetido à publicação

Costa 2006. Submetido à publicação

Mapa de mudança de aeração local

BasalBasal 100 mL100 mL

Mapa de mudança de aeração local

Mapa de mudança de aeração local

20mL

40mL

60mL

80mL

100mL

150mL

200mL

250mL

300mL

350mL

400mL

450mL

500mL

550mL

600mL

Costa et al. 2006 - submitted

100

mL

100

mL

Bas

alB

asal

Costa et al. 2006 - submitted

100

mL

100

mL

Bas

alB

asal

Pneumothorax detector

• sensitivity 100%sensitivity 100%• specificity 95%specificity 95%

Costa 2006. Submetido à publicação

DETECTING CLOSING PRESSURES

TIME

AIR

WA

Y P

RE

SS

UR

E (

cmH 2O

)

0

10

20

30

40

50

60

70

Blo

od G

as

Blo

od G

as

Blo

od G

as

Blo

od G

as

26 24 22 20

PEEP = 26

"Totally Open Lung "

SHUNT < 10%

Till detecting 10% fall in PaO2B

lood

Gas

18

4 min Steps

Collapse:

55.6 %55.6 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 55 cmHcmH22OO

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 25 25 cmHcmH22OO( after recruitment maneuver )( after recruitment maneuver )

Collapse:

0.9 %0.9 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 25 25 cmHcmH22OO

Collapse:

0.9 %0.9 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 23 23 cmHcmH22OO

Collapse:

0.6 %0.6 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 21 21 cmHcmH22OO

Collapse:

0.6 %0.6 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 19 19 cmHcmH22OO

Collapse:

1.0 %1.0 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 17 17 cmHcmH22OO

Collapse:

5.5 %5.5 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 15 15 cmHcmH22OO

Collapse:

12.4 %12.4 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 13 13 cmHcmH22OO

Collapse:

22.3 %22.3 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

FFIIOO22 = = 100 100 %%; V; VTT = = 44 mL/kgmL/kg; PEEP = ; PEEP = 5 5 cmHcmH22OO

Collapse:

55.6 %55.6 %

PatientPatient # 9 # 9PneumocystisPneumocystiscarinii carinii pneumoniapneumonia

Laboratório de Investigação Médica em Pneumologia – LIM 09

PEEP = 19 cmH2O

PEEP = 13 cmH2O

EIT func. imageEIT func. image

PEEP = 10PEEP = 10 PEEP = 0PEEP = 0

Titulação da PEEP

DETECTING CLOSING PRESSURES

TIME

AIR

WA

Y P

RE

SS

UR

E (

cmH 2O

)

0

10

20

30

40

50

60

70

Blo

od G

as

Blo

od G

as

Blo

od G

as

Blo

od G

as

26 24 22 20

PEEP = 26

"Totally Open Lung "

SHUNT < 10%

Till detecting 10% fall in PaO2B

lood

Gas

18

4 min Steps

PEEP = 23.5PEEP = 23.5

PEEP = 23.5PEEP = 23.5

PEEP = 21.5PEEP = 21.5

PEEP = 23.5PEEP = 23.5

PEEP = 21.5PEEP = 21.5

PEEP = 19.4PEEP = 19.4

PEEP = 23.5PEEP = 23.5

PEEP = 21.5PEEP = 21.5

PEEP = 19.4PEEP = 19.4

PEEP = 17.2PEEP = 17.2

PEEP = 23.5PEEP = 23.5

PEEP = 21.5PEEP = 21.5

PEEP = 19.4PEEP = 19.4

PEEP = 17.2PEEP = 17.2

PEEP = 13.6PEEP = 13.6

PEEP = 11.5PEEP = 11.5

PEEP = 11.5PEEP = 11.5

PEEP = 9.5PEEP = 9.5

PEEP = 7.5PEEP = 7.5

PEEP = 11.5PEEP = 11.5

PEEP = 9.5PEEP = 9.5

PEEP = 7.5PEEP = 7.5

PEEP = 11.5PEEP = 11.5

PEEP = 9.5PEEP = 9.5

PEEP = 7.5PEEP = 7.5

PEEP = 5.5PEEP = 5.5

PEEP = 11.5PEEP = 11.5

PEEP = 9.5PEEP = 9.5

PEEP = 7.5PEEP = 7.5

PEEP = 5.5PEEP = 5.5

PEEP = 3.5PEEP = 3.5

SUPINE

PRONE

Model Summary

.796a .634 .623 90.48631 .634 60.499 1 35 .000Model1

R R SquareAdjustedR Square

Std. Error ofthe Estimate

R SquareChange F Change df1 df2 Sig. F Change

Change Statistics

Predictors: (Constant), supinoa.

ARTE

RIAL

PO

2

(mm

Hg)

% COLAPSED TISSUE

Model Summary

.851a .725 .717 65.60886 .725 99.966 1 38 .000Model1

R R SquareAdjustedR Square

Std. Error ofthe Estimate

R SquareChange F Change df1 df2 Sig. F Change

Change Statistics

Predictors: (Constant), pronaa.

ARTE

RIAL

PO

2

(mm

Hg)

% COLAPSED TISSUE

BronchoscopyBronchoscopy

Diffuse injury

PEEP: 13 Cdyn: - 3.6

PEEP: 15 Cdyn: - 6.0

PEEP: 17 Cdyn: - 6.7

PEEP: 19 Cdyn: - 8.1

-8.1%

PaO2

Focal injury

PEEP: 13 Cdyn: - 4.7

PEEP: 15 Cdyn: - -13.8

PEEP: 17 Cdyn: - 17.0

PEEP: 19 Cdyn: - 27.4

-27.4%

PaO2

Diffuse

Localized

CT: - 200 HU to 100 HU

510152025

0

10

20

30

40

50

60

-10

% o

f col

laps

ed u

nits

EIT

CT

Adj

uste

d A

rter

ial P

O2 (

mm

Hg)

R2=0.72

0 20 40 600

100

200

300

400

500

600

700

800

Percent of collapsed units (EIT analysis)