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Manejo AnestesicoCx IntratoracicaDr. Raul Fernando VasquezSpringer 2011Manejo Anestesico Cx IntratoracicaAislamiento Pulmonar1Posicion Intraoperatoria2Monitoria33Estrategias de Ventilacion44Tenica Anestesica35Principles and Practice of Anesthesia for Thoracic SurgerySpringer 20111. Aislamiento PulmonarTubos Doble LumenCarlens y BjorkMallinckrodt Broncho cathSherindan Sher-I-BronchRushPortexAislamientoPulmonarBloqueadores BronquialesUniventARNDCohenFuji Uni-blockerC. Fogarty1. Aislamiento PulmonarIndicaciones

Principles and Practice of Anesthesia for Thoracic SurgerySpringer 2011

Javier H. Campos, M.D.Clinical Professor

1. Aislamiento PulmonarProfundidad Fijacin 1.70 mtsPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011Incisivos superiores a Cuerdas vocales15 cmCuerdas vocales a Carina traqueal12 cm27 cm

1. Aislamiento PulmonarProfundidad - FijacinPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011 Thoracic-anesthesia.comInsercinMujerHombreBronquio lobulo superior derecho

Bifurcacion sec.Izquierda

Diametro traqueal1,5 cm

4.5 cm

19 mm2 cm

5 cm

22 mm

1/250 Arriba de la carina traquealSimulador Broncoscopia

www.Thoracic-anesthesia.com

Principles and Practice of Anesthesia for Thoracic SurgeryThe optimal position of a left-sided DLT. (a) View from the tracheal lumen of the unobstructed entrance of the right mainstem bronchus. (b) View from the tracheal lumen of the right-upper bronchus. (c) View from thebronchial lumen of the left-upper (above) and left-lower (below) lobe bronchi [29].71. Aislamiento PulmonarSeleccin de TamaoCurrent Techniques for Perioperative Lung Isolation in AdultsAdultsAnesthesiology, V 97, No 5, Nov 2002 - Anesth Analg 1996, 82:861-4

Mujer 1.65, peso 72Hombre 1.77 peso 87The tracheais located in the midline position, but often can be deviated tothe right at the level of the aortic arch, with a greater degreeof displacement in the setting of an atherosclerotic aorta,advanced age, or in the presence of severe chronic obstructivepulmonary disease (COPD). With COPD or aging, thelateral diameter of the trachea may decrease with an increasein the anteroposterior diameter. Conversely, COPD may alsolead to softening of the tracheal rings with a decrease in theanteroposterior diameter of the trachea. The cricoid cartilageis the narrowest part of the trachea with an average diameterof 17 mm in men and 13 mm in women.82. PosicionSupino

LateralEvitar Lesiones Evitar desplazamiento lineas, tubos, monitoreoPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 20112. PosicionPositioning Techniques in Surgical ApplicationsSpringer 2006

Patient in the lateral position on avacuum mat. Note both arms are supported onarmrests which are fixed to the operating table.This position of the arms allows good access tothe head for monitoring and airway managementafter surgical draping. The dependentleg is straight and the nondependent leg flexed

Posterior view of a patient in theLateral view with cushions. It is very importantto survey the patient from this perspectiveto ascertain that the cervico-thoracic spine is inalignment prior to draping. After turning fromthe supine position, it is very easy to accidentallyreposition the patient with a degree of lateralcervical flexion that is difficult to appreciatefrom the head of the table. Note the extra paddingunder the upper thorax below the axilla. Alsonote the gel ring preventing compression of thedependent ear pinna and the cushioning betweenthe legsIt is very easy afterrepositioning the patient in the lateral position to cause excessivelateral flexion of the cervical spine because of improperpositioning of the patients head. This malpositioning, whichexacerbates brachial plexus traction, can cause a whiplashsyndrome and is difficult to appreciate from the head of theoperating table, particularly after the surgical drapes havebeen placed.102. PosicionLesiones neurovasculares especificas de la posicion lateral. Revision rutinaria cabeza - pieOjo dependientePinna oreja dependienteColumna cervical alineada con columna toracicaBrazo dependientePlejo braquialCirculacionBrazo no dependientePlejo braquialCirculacionNervios supraescapulares dependiente y no dependienteLesion del nervio ciatico no dependientePierna dependienteNervio peronealCirculacionPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011CompresionEstiramientoFijacion Plejo AxilarPrinciples and Practice of Anesthesia for Thoracic SurgeryProximal: Procesos transversos vertebras cervicalesDistal: Fascia axilarFactores que contribuyen a lesion de plejo braquial en la posicion lateralBrazo dependiente (Lesiones por compresion)Brazo bajo el toraxPresion en el espacio retroclavicularCostilla cervicalMigracion caudal del mal llamado rollo axilarBrazo no dependiente (Lesiones por estiramiento)Flexion lateral de la columna cervicalABDuccion excesiva del brazo (>90)Reposicionamiento semiprono semisupino una vez se ha fijado el brazoSpringer 2011

Thoracic outlet syndromeThoracic outlet syndrome (TOS) is a term used to denote a variety of upper extremity syndromes, with only a small number having a neurologic basis [25]. TOS is generally divided into true neurogenic TOS, true vascular TOS (with arterial vascular and venous vascular subtypes), and disputed neurogenic TOS.

True neurogenic TOS is rare, with an estimated incidence of 1:1,000,000, and occurs most commonly in women, with a female to male ratio of 9:1 [26]. Symptoms of true TOS include slowly progressive unilateral atrophic weakness of intrinsic hand muscles and numbness in the distribution of the ulnar nerve, with occasional numbness of the ulnar aspect of the forearm. The syndrome may be caused by a taut congenital band from the first rib to the tip of an elongated C7 transverse process or to a rudimentary cervical rib. The lower portion of the plexus is stretched over this band, and chronic traction injury results. This explains why true TOS has the clinical features of a lower trunk plexopathy [26].

The incidence of the nonneurogenic forms of TOS is less clear. True vascular TOS is caused by compression of the subclavian or axillary artery or vein [27,28]. Patients may present with arm ischemia (claudication and/or acute embolic events) or venous thrombosis. (See "Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome)".)

Disputed neurogenic TOS (also called nonspecific neurogenic TOS) is the most controversial form [26,29,30]. Proponents of this entity believe that pathologic processes in the thoracic outlet, such as soft tissue anomalies that can only be appreciated at time of surgery, are the cause of a myriad of symptoms affecting the neck, shoulder, and arm, including involvement of upper trunk nerves [29]12Paralisis PostoracotomiaPrinciples and Practice of Anesthesia for Thoracic SurgeryParaplejia incidencia 0.08%Hematoma epidural

Cuerpo extrao o ligadura arteria medular*Regional Anesthesia and Pain Medicine Volume 35, Number 1 2010 - Springer 2011Factores de Riesgo e Incidencia Estimada de Hematoma Espinal y Anestesia Central Neuroaxial*Riesgo Relativo de Hematoma EspinalIncidencia Estimada Anestesia EpiduralIncidencia Estimada Anestesia EspinalNo Heparina Atraumatico Traumtico Con AspirinaAnticoagulacin HNF Atraumatico Traumtico Heparina 1 hr PL Heparina 1 hr PL +Aspirina1.0011.22.543.161122.1825.2261:2200001:200001:1500001:700001:20001:1000001:87001:85001:3200001:290001:2200001:1000001:29001:1500001:130001:12000Thoracic outlet syndromeThoracic outlet syndrome (TOS) is a term used to denote a variety of upper extremity syndromes, with only a small number having a neurologic basis [25]. TOS is generally divided into true neurogenic TOS, true vascular TOS (with arterial vascular and venous vascular subtypes), and disputed neurogenic TOS.

True neurogenic TOS is rare, with an estimated incidence of 1:1,000,000, and occurs most commonly in women, with a female to male ratio of 9:1 [26]. Symptoms of true TOS include slowly progressive unilateral atrophic weakness of intrinsic hand muscles and numbness in the distribution of the ulnar nerve, with occasional numbness of the ulnar aspect of the forearm. The syndrome may be caused by a taut congenital band from the first rib to the tip of an elongated C7 transverse process or to a rudimentary cervical rib. The lower portion of the plexus is stretched over this band, and chronic traction injury results. This explains why true TOS has the clinical features of a lower trunk plexopathy [26].

The incidence of the nonneurogenic forms of TOS is less clear. True vascular TOS is caused by compression of the subclavian or axillary artery or vein [27,28]. Patients may present with arm ischemia (claudication and/or acute embolic events) or venous thrombosis. (See "Spontaneous upper extremity venous thrombosis (Paget-Schroetter syndrome)".)

Disputed neurogenic TOS (also called nonspecific neurogenic TOS) is the most controversial form [26,29,30]. Proponents of this entity believe that pathologic processes in the thoracic outlet, such as soft tissue anomalies that can only be appreciated at time of surgery, are the cause of a myriad of symptoms affecting the neck, shoulder, and arm, including involvement of upper trunk nerves [29]13Tres pacientes sufrieron lesion neurologica permanente despues de que celulosa oxidada regenerada migrara al canal espinal pop toracotomia. Estos casos reportados alertan al cirujano de la posible complicacion cuando se usa el compuesto para lograr hemostasia en el angulo posterior de la incision

Paralisis Postoracotomia

Ann Thorac Surg 1990;50:288-90Ann Thorac Surg 1990;50:288-90

14Paralisis Postoracotomia1 ASA 2/3 anteriores2 ASP 1/3 Posterior

Ramas Dorsales Art Intercostales PosterioresC7 T9 Dos ramas radicularesArteria radicular magna (Arteria de Adamkiewics) 80% Izquierda, 75% T9-T12Ann Thorac Surg 2003;76:31521

ContinuoDependencia alta suministro segmentarioHipoperfusion medularIsquemia - Infarto Clampeo Aorta, retraccion costal, interrupcion de flujo Intercostal y sangrado costovertebral

Ann Thorac Surg 2003;76:31521Tratando de sistematizar, la mdula es irrigada por la arteria espinal anterior formada por dos ramas que emergen de ambas arterias vertebrales a nivel intracraneal, y recorre toda la mdula por el surco medio anterior, y por un par de arterias espinales posteriores originadas igualmente de ramas de ambas vertebrales.Sin embargo estas 3 arterias tienen la peculiaridad en nuestro organismo de ser discontinuas: la arteria espinal anterior llega a estrecharse de tal modo que no sirve de anastamosis en diferentes segmentos medulares fundamentalmente D4 y D11, que constituyen territorios limtrofes y por tanto ms vulnerables a hipoperfusin y a oclusin de una arteria nica. Mientras que las espinales posteriores llegan a formar un plexo tambin discontinuo. Por lo que ms aferentes alcanzan este sistema a diferentes niveles supliendo el flujo sanguneo. Adems vasos circunflejos conectan ambos sistemas.Por tanto la irrigacin de la mdula espinal es segmentaria: arterias generalmente pares emergen metamricamente para terminar dando afluentes al sistema espinal, se originan bilateralmente en la aorta o sus principales ramas. Tras el nacimiento solo llegan a ser prominentes un nmero muy variable de estas arterias segmentarias de 5 a 10. A nivel de la mdula cervical, donde la irrigacin es ms abundante, entre 0 y 6 pares de arterias terminan dando ramas a las espinales, siendo las ms habituales las procedentes de las arterias cervical ascendente y cervical profunda. A nivel de la mdula torcica permanecen entre 2 y 4 arterias segmentarias, y a nivel torcico inferior y lumbar entre 1 y 2, aunque generalmente la mayor parte del flujo lumbar es aportado por una arteria segmentaria prominente que puede alcanzar la mdula entre los segmentos D8 y L4, denominada arteria radicular magna o de Adamkiewick.

Because the PSAs are continuous and have moreconsistent segmental supply [12], most vascular lesionswill cause anterior cord dysfunction.15Los principios generales de monitoria intraoperatoria para cirugia intratoracica son similares a los de cualquier cirugia mayor.3. MonitoreoPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011ECGUSA 30 millones de cirugia/ao1 millon EAC conocida2 a 3 millones riesgo EACIsquemia, infartoMuerte cardiacaMortalidad 10% 15%

Management of Perioperative Myocardial Infarction in Noncardiac Surgical PatientsChest 2006 UpToDate 19.2

HipoxemiaHipotensionArritmiasAnalisis continuo automatico del segmento STDII 90% sensibilidad para detectar arritmiasV5 75% Isquemia lateralV4 61% Isquemia lateralECGPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 201190%

?Hipokalemia18Uso rutinario fibrobroncoscopio - posicin TDLMejores tcnicas anestsicas halogenadoOximetra de PulsoManagement of One Lung Ventilationwww.thoracic-anesthesia.com1970201120% - 25%10%Hipoxemia Ventilacion Unipulmonarwww.thoracic-anesthesia.com19OMS vs COCHRANE

Tomado de Hipoxemia Perioperatoria 2011. RFVOximetra de PulsoParametros dinamicos son indicadores mas exactos que estaticos para predecir respuesta a fluidos en pacientes con VMPP respiratory variations in arterial pulse pressurePOP respiratory variations in the pulse oximeter plethysmographic waveform amplitudePleth variability index (PVI) 11.5% predice POP 13%

Anesth Analg 2008;106:1189 94

Dynamic indices (respiratory variations in arterialpulse pressure (PP),1 inferior vena cava diameter,2superior vena cava diameter,3 and stroke volume4) haveconsistently been shown to be more accurate than staticindicators for predicting fluid responsiveness in mechanicallyventilated patients under general anesthesia.5Pleth variability index (PVI) (Masimo Corp., Irvine,CA) measures the maximal and minimal plethysmographicwaveform amplitudes over a given period oftime and calculates the percentage difference betweenthe two. The goal of the PVI is to automaticallydetermine the POP and provide a numerical value tothe clinicianIn mechanically ventilated patients, dynamic indicatorshave consistently been shown to be more accuratepredictors of fluid responsiveness than staticindicators.5,15 These indices rely on the respiratoryinducedvariations in LV stroke volume or its surrogatesinduced by positive pressure ventilation. Themain limitations of these indicators are that they areinvasive, operator-dependent, or not widely available.There are several factors other than volume status thatcan affect plethysmography such as local temperature, site ofmeasurement, influence of venous pressures, etc. [11]. Thefuture application of this plethysmographic aspect of pulseoximetry is ripe for further investigation both during and afterthoracic surgery.21

Capnography.com

Indica de manera indirectaRelacion V/QCapnogramas en Anestesia Toracica

Capnograma NormalAumento Fase IIIFase III Reversa

www.capnography.com

Capnograma Bifasico

Phase I is the expiratory baseline and represents the exhalationof CO2-free gas from anatomic dead space. Phase II is theexpiratory upstroke or fast rise phase representing the mixingof dead space gas with alveolar gas containing CO2. Phase III or the alveolar expiratory plateau phase represents the exhalationof CO2-rich gas from the gas-exchanging alveoli. Theangle between phases II and III has been referred to as thea angle and is an indirect indication of ventilationperfusion(V/Q) matching. Finally, phase 0 is the inspiratory down-slopeduring which time fresh gases are inhaled. The nearly 90 anglebetween phases III and 0 has been referred to as the b angle[12]. This b angle may increase during rebreathing. Duringthoracic surgery these phases are affected by cardiopulmonaryconditions that need to be recognized by the anesthesiologist.A decrease in the slope of phase II may be seen in certainacute and chronic conditions that negatively impact expiratoryflow (such as bronchospasm or COPD). This reduction inthe slope is determined by the extent of mixing of parallel andseries dead space gases with ideally well-mixed alveolar gas.An increase in the a angle appears as a prominent up-slopingin phase III and signifies worsening V/Q matching. This maybe due to changes in cardiac output, CO2 production, airwayresistance, and/or functional residual capacity.In the lateral decubitus position, there are physiologicchanges in ventilation and perfusion for both the dependentand nondependent lungs. Phase III of the capnograph has acharacteristic biphasic appearance of the waveform. This isbelieved to occur because the nondependent lung will obtainsignificantly more ventilation relative to perfusion (high V/Qunits) and will contain more alveolar dead space contributingto the earlier and lower part of an up-sloping phase III.The dependent lung will receive more perfusion relative toventilation (lower V/Q units) and less alveolar dead spaceconsequently contributing to the later and higher part of thephase III plateau. During cross-field ventilation for proceduresinvolving resection of main stem or tracheal masses thatrequire jet ventilation or intermittent apnea, close monitoringand vigilance of the capnogram is pivotal because completeabsence of a waveform implies no ventilation, no circulation,or a disconnected capnometer. The end-tidal CO2 to arterialCO2 gradient (PaCO2PETCO2) is related to the extent of deadspace ventilation and tends to increase during OLV. Despiteoccasionally significant oxygen desaturation, the maintenanceof adequate ventilation or normocarbia during OLV is usuallynot problematic.

1). Capnogramswithincreased phase IIIslope due to a large spread V/Q ratios, as in lung disease. The initial part of the slope is represented by areas which are well ventilated with high V/Q ratios (i.e., decreased CO2concentration), while the latter part is represented by areas which are poorly ventilated and with low V/Q ratios (i.e., increased CO2concentration).2.)Biphasic capnogram:Phase III of the capnogram represents mixed alveolar gas at the CO2sampling site. Therefore, if the lungs have distinctly different V/Q ratios and exhalation time constants, then a Biphasic waveform can be seen, as in lateral decubitus position.1 The upper lung (non-dependent) has a low airway resistance, high V/Q ratio (secondary to gravity dependent blood flow) and a low CO2concentration compared with the lower, dependent lung. The earlier part of the biphasic CO2waveform is due to the expired gases from the upper lung containing lower PCO2and the later part of the biphasic waveform is predominantly due to the expired gases containing high PCO2from the lower lung.IA similar capnogram can occur following asingle lung transplantSome patients with COPD may also display a slight biphasic expiratory plateau if they have, throughout both lungs, two distinct populations of alveoli with very different time constants. In this situation, rapidly exchanging alveolar spaces are overinflated during inspiration (their compliance is high) so that their CO2concentration is low, whereas slower exchanging alveoli empty only during the later part of exhalation, releasing a higher CO2content.1,23.) Reverse phase III capnogram: Occasionally seen in patients with emphysema. The slope of phase III can be reversed in patients with emphysema where there is marked destruction of alveolar capillary membranes and reduced gas exchange.22CapnografiaJournal of Clinical Anesthesia 2010 22, 557559

Hipercapnia PermisivaEstrategia de ventilacion mecanica (VM) que acepta hipoventilacion alveolar deliverada. Proposito primario es permitir cambios en el ventilador que reduzcan presin alveolar y sus riegos asociadosVolutrauma - BarotraumaLesion pulmonar asociada a VentiladorHipotensionAcidosis hipercapnica - una consecuencia no una meta.Permissive Hypercapnic VentilationUpToDate 19.2There are reasons to believe that hypercapnia might actually be beneficial in the context of VILI [17,18]; forexample, acidosis attenuates a number of inflammatoryprocesses, inhibits xanthine oxidase (a key component inreperfusion injury), and attenuates the production of freeradicals [18]. However, there are also potential detrimental effects such as increased catecholamine release [19]that might mitigate the potential beneficial effects ofhypercapnia on lung injury24

Hipercapnia PermisivaActa Anaesthesiol Scand 1999; 43: 845849

Acta Anaesthesiol Scand 1999; 43: 84584925Tecnica anestesica Mixta 10 de 10Soporte Vasopresor - inotropico

Permissive hypercapnia during thoracic anaesthesiaHipercapnia PermisivaDuracin e intensidadProduce AV3 de 10 THAMReduce VH4 de 10 CPAPDespertar TardioInstbldd HemodinamicaArritmia VentricularVasoconstriccion HipoxicaNo es clinicamente significativa en Acidosis respiratoriaHiperKalemiaActa Anaesthesiol Scand 1999; 43: 845849La acidosis metablica incrementa el pasaje del potasio al exterior celular y la alcalosis tiende a producir el efecto inverso (a travs del intercambio de K+ intracelular con protones del LEC).26Hipercapnia PermisivaCriterios ExclusionPMAP30mmHgSx Ht Endocraneana Ant Hemorragia CxArritmia cardaca LowenIIbHipercapnia PreviaAcidosis MetabolicaASAIIIActa Anaesthesiol Scand 2001; 45: 842847

41 - 6727Hipercapnia PermisivaAsumiendo una reserva cardiovascular rasonable y, particularmente VD, PaCO2 hasta 70 mmHg son probablemente bien toleradas a corto plazo y claramente beneficas ya que evitan o atenuan la lesion pulmonar asociada al ventilador Evidence-based Management of One-Lung VentilationAnesthesiology Clin 26 (2008) 241272Evidence-based Management of One-Lung VentilationAnesthesiology Clin 26 (2008) 24127228Invasiva?Transductor seno CoronarioNo diferencia arteria radial dependiente / no dependienteComorbilidades influencian trazado.No Invasiva.TA Brazo dependienteTA Brazo no dependientePresion ArterialPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011However, noninvasively measured blood pressure willbe higher in the dependent arm and lower in the nondependentarm. Such differences in noninvasive blood pressure measurementare determined by the positions of the arms aboveand below the level of the heart and are equal to the hydrostaticpressure differences between the level of the heart andthe respective arm.29Estima la presin de llenado ventricular derechoCVC Infusion vasoactivosPVC erroneaNeumotoraxMasa mediastinal comprimiento camara der.Posicion lateralTorax abierto

Presion Venosa CentralPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011

Receiver operating curve (ROC) for right atrial pressure (RAP), Pulmonary artery occlusion pressure (PAOP), delta systolic pressure (DSP) and delta pulse pressure (DPP) to predict a response to volume challenge. Only the dynamic parameters allow prediction beforehand if the patient will improve cardiac performance in response to a volume challenge. Using a cut-off value of 13% for DPP allowsalmost perfect prediction of which patients respond to a volume challenge (area under the ROC curve of 90%). Static parameters (CVP, PAOP) are no better than a coin toss with area under the ROC curve of approximately 50%.However, noninvasively measured blood pressure willbe higher in the dependent arm and lower in the nondependentarm. Such differences in noninvasive blood pressure measurementare determined by the positions of the arms aboveand below the level of the heart and are equal to the hydrostaticpressure differences between the level of the heart andthe respective arm.303. MonitoreoCateter arteria pulmonarEcocardiograma transesofagicoDispositivos de monitoreo hemodinamico no invasivo o minimamente invasivo y monitoreo de perfusion tisularDoppler esofagicoAnalisis continuo contorno pulso PiCCOGasto cardiaco GC termodilucionTecnologas deGC basado en lapresin arterial Vigileo/Flotrac, APCOPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011Intercambio Gaseoso AdecuadoColapso Pulmonar Contralateral Lesion Pulmonar POPVentilacionUni -Pulmonar4. Estrategias VentilacionPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 20114. Estrategias VentilacionAreas de controversiaVentilacion Presion vs VolumenVolumen corriente Alto vs BajoUso de PEEPPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011Efectos a corto plazo en oxigenacion durante VUP y en lesion pulmonar asociada al ventilador son controversialesPresion Control-PresionModosVMVolumen Control-Flujo4. Estrategias VentilacionPrinciples and Practice of Anesthesia for Thoracic SurgerySpringer 2011

Ventilacion UnipulmonarBarboza, Miguel Fisiologia de la ventilacion Unipulmonar

SobredistensionBaro - Volotrauma - LADVENTANA SEGURAAtelectasiasEstres por deslizamiento, alteracion por surfactanteVentilacion mecanica

Springer 20114. Estrategias VentilacionLesion Pulmonar asociada al ventiladorBaja incidencia alta mortalidadAdministracion de LEV intraoperatoriosPredisposicion geneticaVentilacion mecanica con altos volumenes corrientes

Principles and Practice of Anesthesia for Thoracic SurgerySpringer 2011tidal volume of 6 mL/kg andplateau pressure below 2530 cm H2O, with the respiratoryfrequency adjusted to maintain CO2 elimination (normocapniato mild hypercapnia) and PEEP as needed to improve oxygenationwithout increasing the plateau pressure above 30 cmH2O. This ventilation strategy is intended to prevent both thecyclic opening and closing of collapsed alveoli at the start ofinspiration (atelec-trauma) as well as the overdistension (barotrauma)of some alveoli at the end of inspiration374. Estrategias VentilacionCritical Care Vol 13 No 2 Licker et al. 2009

PEEPAumenta la CFRPreviene el cierre alveolar al final de la expiracionMejora oxigenacion Disminuye lesion pulmonar asociada al ventilador

Principles and Practice of Anesthesia for Thoracic SurgerySpringer 2011Cuanto PEEP?tidal volume of 6 mL/kg andplateau pressure below 2530 cm H2O, with the respiratoryfrequency adjusted to maintain CO2 elimination (normocapniato mild hypercapnia) and PEEP as needed to improve oxygenationwithout increasing the plateau pressure above 30 cmH2O. This ventilation strategy is intended to prevent both thecyclic opening and closing of collapsed alveoli at the start ofinspiration (atelec-trauma) as well as the overdistension (barotrauma)of some alveoli at the end of inspiration39Ventilacion UnipulmonarDI 55% 45%DI 45% 55%DI 35% 65%FisiologiaBarboza, Miguel Fisiologia de la ventilacion UnipulmonarVentilacion UnipulmonarDI 45% 55%DI 35% 65%Fisiologia 40% 60%

Barboza, Miguel Fisiologia de la ventilacion UnipulmonarVentilacion UnipulmonarFisiologia 35% 55%VHP?17%18%Barboza, Miguel Fisiologia de la ventilacion UnipulmonarPEEPPEEPiPacienteResistencia pulmonarComplianceVentilacion MecanicaTubo endotraquealTiempo exhalacionVolumen corriente

Principles and Practice of Anesthesia for Thoracic SurgerySpringer 2011

43PEEPMantener volumen al final de la expiracion tan cercano como sea posible de la CFRCRF: Volumen pulmonar al cual la resistencia vascular es minima

www.anesthesia.toronto.caCME Module 13: Management of One-Lung Ventilation

AtelectasiasAnesthesiology, V 102, No 4, Apr 2005Pulmon sano Hiperinflacin pasiva 3 sucesivas-20 cm H2O x 10 seg-30 cm H2O x 15 seg-40 cm H2O x 15 segNunn et al-40 cm H2O x 40 segTusmanReclutamiento alveolarPulmon Lesionado -Evitar; VC, presiones pico elevadas, atelectrauma-Usar PEEP

Depende del Pulmon!Prevencion - ReversionAnesthesiology, V 102, No 4, Apr 200545Schematic representation of the Alveolar Recruitment Strategy: PEEP is incremented in 3 steps of 5 cmH2O each. The vertical rectangles represent tidal breathing with a tidal volume of 7-9 mg/kg BW at a respiratory rate of 8 bpm. At a PEEP of 15 cmH2O tidal volumes are increased until a maximum tidal volume of 18 ml/kg or a peak airway pressure of 40 cmH2O is reached. These settings are applied for 10 breaths. Thereafter, tidal volumes are reduced to the previous values. Finally, PEEP is set to a level of 5 cmH2O in two steps.

Reclutamiento AlveolarTusman G et al. Alveolar Recruitment Strategy normalizes arterial oxygenation

Pulmn Sano465. Tcnica Anestesica

Dr. Raul VasquezGracias!Determinantes O2 Arterialwww.themegallery.comCompany Logo