Management of lung problems

Management of

Management of

lung problems

lung problems

during Cardiac

during Cardiac

Surgery

Surgery

Ospedale Papa Giovanni XXIII di Bergamo

Dipartimento di Anestesia e Rianimazione : Direttore F.L.Lorini

Ospedale Papa Giovanni XXIII di Bergamo

•

_{Size of the problem and Factors}

causing pulmonary dysfunction

•

_{Definition of diseases}

•

_{Therapeutic implications}

Objectives

4

Volume 25(11) November1999 pp 1831-1839

Early onset of acute pulmonary dysfunction after cardiovascular

surgery: Risk factors and clinical outcome

Rady, Mohamed Y. MD, PhD, FRCS, MRCP; Ryan, Thomas MB, MRCPI, FFARCSI; Starr, Norman J. MD

A total of 3,122 patients were evaluated and 1,461 patients satisfied the entry

criteria of the study. Early postoperative pulmonary dysfunction was present in

180 (12%)

Conclusions: The incidence of early postoperative pulmonary dysfunction is

uncommon; however, once developed, it is associated with increased morbidity

and mortality after cardiovascular surgery.

Is There a Pulmonary Problem?

• _{Volume 25(11) November 1999 pp 1831-1839} Early onset of acute

pulmonary dysfunction after cardiovascular surgery: Risk factors and clinical outcome

• Rady, Mohamed Y. MD, PhD, FRCS, MRCP; Ryan, Thomas MB, MRCPI, FFARCSI; Starr, Norman J. MD •



_{Advanced age}



_{large body mass index}



_{preoperative increased pulmonary arterial}

pressure



_{low stroke volume index, hypoalbuminemia}



_{history of cerebral vascular disease}



_{emergency surgery, and prolonged CPB time}

risk factors for early onset

of severe pulmonary

dysfunction after surgery.

Postoperative systemic hemodynamics suggest that early postoperative

pulmonary dysfunction can be a component of a generalized inflammatory

CPB

CPB

1

1

.

.

2

2

Cellular

Cellular

activation

activation

Oxygen free radicals

Oxygen free radicals PAFPAF No

No Arachidonic acid metabolitesArachidonic acid metabolites Endothelins

Endothelins ProteasesProteases

Inflammatory response to CPB

Tissue injury

7

Ischemia/Reperfusion

Ischemia/Reperfusion

7

Representative light microscopic images of lung tissue

Alveolar septal thickness (A) and alveolar surface area (B) before CPB and at the end of reperfusion after CPB with or without controlled PA perfusion.

Is There a Pulmonary Problem?

Is There a Pulmonary Problem?

Do we think about lung protection?



Ventilation – stop

 Perfusion – stop

3% Total lung Bl. Flow (Bronchial Artery)

LEAST PROTECTED ORGAN DURING CPB

Do we think about lung protection?



Ventilation – stop

 Perfusion – stop

3% Total lung Bl. Flow (Bronchial Artery)



_{PCWP < 18 mmHg}



_{PaO2/FiO2 < 300 (ALI)}



_{PaO2/FiO2 < 200 (ARDS)}



_{Bilateral infiltrates on chest radiographs}

TRALI

TRALI = Transfusion

Related Acute Lung Injury



_{Acute onset}



_{Within 6 hours after}

transfusion

TRALI

Causes:

 _{Packed RBC, FFP, Platelets, granulocytes, cryoprecipitate, IV}

immunoglobulin ,bone marrow stem cells

 _{No Association with washed red cells, albumin,clotting factor}

concentrates

Pathogenesis

 _{Ab- mediated TRALI}

 _{Non Ab mediated TRALI}  _{Two hits}

TRALI

Journal of Intensive Care Medicine Volume 23 Number 2 March/April 2008

TRALI



_{Resolution usually in 96h after transfusion}



_{Mortality between 5-10%}

TRALI

Ann Thorac Surg 2009;88:1410–8)

TRALI

Monitoring

Echography

Heart

:

• Biventricular funtion

( RV failure)

• Pulmonary

hypertension

•Valve function

•Septal defects

Lung

:

• Effusion

• Consolidation

•PNX

Echography

Baseline

Recruitment

Critical Care 2009, 13:R59

Right Ventricular Function

Variation of RV function after CABG in 250 elective patients

Lung-Heart interaction

Afterload of RV increase for :



_{Compression of intralveolar vessel by positive pressure}

ventilation



_{Increasing of vasomotor tone}



_{Reduction of vessel tree by reduction of lung parenchyma}



_{Fluid overload ( prexisting and caused by fluid resuscitation)}

Ventilation

Lung protective

ventilation

Permissive

hypercapnia

Recruitment

Ventilation



_{TV ≤ 6 ml/Kg IBW}

(men weight in kg= 50+ 0.91 *(height in cm-152) (women weight in kg= 45.5+ 0.91 *(height in cm-152)



_{Plateu pressure ≤ 30 cmH20}



_{RF ≤ 35 b/min}

PEEP



ALVEOLI,LOVs, EXPRESS ) there is an evidence of using high

PEEP in patients with ARDS. May be harmful in patient with ALI



Titration of PEEP is not univocal



Less time to unassisted breath in ARDS patients

JAMA, March 3, 2010—Vol 303, No. 9

PEEP

PEEP

PEEP

Fio2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1

PEEP 8-12 12-18 18-20 20 20 20-22 22 22-24

ALVEOLI –LOVS high PEEP

•Sp02 between 88%-95%.

•Po2 between 55 mmHg-80 mmHg.

•Ventilation strategies included a protocol for reducing PEEP levels when plateau pressure exceeded 30-35 cmH2O or when mean arterial pressure decreased to less than 60 mmHg.

EXPRESS

•In the higher PEEP group levels were set to maintain the plateau

airway pressure between 28 cmH2O and 30 cm H2O.

• When the plateau pressure was

less than 28 cm H2O despite a PEEP level producing a total PEEP of 20 cm H2O, PEEP was not increased further

•When oxygenation targets were not met despite an FiO2 of 1 and a PEEP level producing a plateau of 30 cm H2O, PEEP was increased, provided the plateau pressure remained no greater than 32 cm H2O

Recruitment

Recruitment

Recruitment



Sure effect on oxygenation



Outstanding improving of

oxygenation may indicate that PEEP is

too low



Hypotension and desaturation are self-limited and without

serious risk



_{Few side effect ( barotrauma 1%)}



At the moment there is no evidence to use recruitment

maneuvers as a routine, reserve it to patients with severe

refractory hypoxemia

Recruitment

28 days mortality

ICU mortality

Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006667

Recruitment

In Hospital Mortality

Cochrane Database of Systematic Reviews 2009, Issue 2. Art. No.: CD006667

There is no available evidence to determine whether recruitment manoeuvres alter mortality, duration of mechanical ventilation, or hospital stay.

Further research is required to determine if recruitment in isolation increase oxygen partial pressure for a longer period of time and whether this has any impact on

Prone Position



Better recruitment of dorsal region



Heart on sternum



Better distribution of ventilation and ventilation /perfusion ratio



Improving on arterial saturation



Advantage in severe hypoxiemic ARDS ( P/F<100)

CHEST 2010; 137( 5 ): 1203 – 1216

Prone Position

Minerva Anestesiol. 2010 Jun;76(6):448-54

In Gattinoni’s review were take in account 4 studies (Prono-Supine

I e II, Mancebo 2006, Guerin 2003 )

Prone Position

Crit Care Med 2008 Vol. 36, No. 2 Alsaghir’s review take in account 5 studies with different timing and

ECMO V-V

1

. In hypoxic respiratory

failure due to any cause (primary

or secondary) ECLS should be considered when the risk

of mortality is 50% or greater, and is

indicated when the

risk of 80% or greater

.

a. 50% mortality risk can be identified by a PaO2/FiO2 <

150 on FiO2 > 90% and/or Murray score 2-3

b. 80% mortality risk can be identified by a PaO2/FiO2 <

80 on FiO2> 90% and Murray score 3-4

2.

CO2 retention

due to asthma or permissive hypercapnia

with a PaCO2 > 80 or inability to achieve safe inflation

pressures (Pplat ≤ 30 cm HO) is an indication for ECLS.

36

1. PaO2/FIO2 FIO2 at 1 for at least 20 minutes. 2. PEEP in CMH2O

3. Lung Compliance in ml/CMH2O

4. Number of quadrants with infiltration seen on chest X- ray

Score values

• PaO2/FIO2: ≥ 300 = 0, 225–299 = 1, 175–224 = 2, 100– 174 = 3, <100 = 4 • CXR: normal = 0, 1 point per quadrant infiltrated.

• PEEP: ≤ 5 = 0, 6–8 = 1, 9–11 = 2, 12–14 = 3, ≥ 15 = 4.

• Compliance : ≥ 80 = 0, 60–79 = 1, 40–59 = 2, 20–39 = 3, and ≤ 19 = 4

The Murray score

grading system for ARDS (0-4)

ECMO V-V

Considered relative contraindication because of expected poor outcome:

1.

Mechanical ventilation at high settings (FiO2 > .9,

P-plat > 30) for 7 days or more

2. Major pharmacologic immunosuppression (absolute

neutrophil count <400/ml3

ECMO V-V

Criteri per ECMO VV:

• PaO2/FiO2<100 con FiO2 100% • P (A-a)>600 mmHg

• Murray Score > 3

• Not buffered hypercania pH < 7,2

• Respiratory condition with a reversible possibilty • Age < 65 y

• No controindication to herapin

CESAR

CESAR Trial

CESAR Trial

Murray score

PaO2/FIO2

: ≥ 300 = 0, 225–299 = 1, 175–224 = 2, 100–

174 = 3, <100 = 4

CXR

: normal = 0, 1 point per quadrant infiltrated.

PEEP

: ≤ 5 = 0, 6–8 = 1, 9–11 = 2, 12–14 = 3, ≥ 15 = 4.

Compliance

(ml/cmH2O): ≥ 80 = 0, 60–79 = 1, 40–59 =

2, 20–39 = 3, and ≤ 19 = 4

Lancet Vol 374 Oct 17,2009

Sum of the components divided for the number of the components used

Steroids

Ventilator free days at day 28

Mortality patients with steroids before 14 days