Fisiologia das alteraes

respiratrias relacionadas a
anestesia.

Joao Alexandre Dias e Santos

Medico anestesiologista titulado pela SBA/MEC
Medico intensivista titulado pela AMIB/MEC
Efeitos da postura na
oxigenao

3.5
3.5

3.0
3.0

2.5
2.5

2.0
2.0

1.5
1.5

Nunn JF
 Deslocamento Ceflico do Diafragma
DISTANCIA DO APICE PULMONAR (cm)

DISTANCIA DA PAREDE TORCICA POSTERIOR (cm)

Posio supina 18
20 18 16 14 12 10 8 6 4 2 0

Froese et al. Anesthesiology 41: 242-54, 1974

16
14
Sedao e
12
curarizao 10
Froese et al Anesthesiology 41: 242-54, 1974
8
6
Presso 4
intrabdominal 2
(Peso das vsceras 0
abdominais)
Ranieri et al. AJRCCM 156: 1082-91, 1997
10 VOLUNTRIOS VE
21 PATIENTES
SOB VCM
Puybasset et al, Am J Respir Crit Care Med, 158:1544-55, 1998
 Ventilao Ventilao Delta
Espontnea Mecnica (cmH2O)

Expirao
(cmH2O) -5 5 10

Inspirao
(cmH2O) -10 24 34
CUFF
Fotomicroscopia
 Incidncia de complicaes
respiratrias ps-operatrias

5% a 10% de todos os pacientes cirrgicos

Wong et al. Anesth Analg 1995; 80:276 284

9% a 40% dos pacientes submetidos cirurgia abdmonial

Wong et al. Anesth Analg 1995; 80:276 284

40 90% dos pacientes submetidos cirurgia cadaca

Gale GD et al. Can Anaesth Soc J 26: 15-21; 1979
Hachenberg T et al. Acta Anesthiol Scand 36: 800-805; 1992
 Fisiologia da leso
pulmonar intra-operatrio
 Colapso pulmonar
Incidncia elevada em pacientes submetidos
cirurgia sob anestesia geral
Reduo da CRF
durante anestesia
(20%)

Hedenstierna et al, Anesthesiology 1985

Brismar et al, Anesthesiology 1985
Desacoplamento ventilao-perfuso

Prof. Hedenstierna
Compresso dos lobos
inferiores pelo corao

Malbouisson et al, Am J Respir Crit Care Med 161: 2005-12, 2000

Compresso dos lobos
inferiores pelo corao

7 2 g.cm-2
5 2 g.cm-2 62 g.cm-2 83 g.cm-2

Voluntrio normal Insuficincia respiratria

Malbouisson et al, Am J Respir Crit Care Med 161: 2005-12, 2000

Frao de parenquima pulmonar colaspsado no segmentos
dos lobos inferiores abaixo e fora dos limites cardacos
Resposta inflamatria sistmica

Wheeler AP, Bernard GR. N Engl J Med. 1999;340:207-14.

BAL cellularity evaluation before CPB in
patients undergoing CABG

0.6 x 106 cel.dL-1

Machado LB et al. Rev Bras Anestesiol 2006; 56: 3: 263-272

BAL celularity evaluation after CPB in patients undergoing CABG

6.8 x 106 cel.dL-1

Machado LB et al. Rev Bras Anestesiol 2006; 56: 3: 263-272
Superimposed pressure induced by
edematous lung parenchyma

Pelosi et al, Am J Respir Crit Care Med 149: 8-13, 1994

Influence of Gas Composition on Recurrence of Atelectasis after
a Reexpansion Maneuver during General Anesthesia

RR = 10 BPM
ZEEP

FiO2 = 0.4
FiO2 = 1

Rothen H et al. Anesthesiology 82: 832-84; 1995

Intrathoracic surgical manipulation
Colapso pulmonar induzido por
aspirao de vias areas
 Collapsing affect of tracheal aspiration

Before aspiration After 15 sec aspiration

Courtesy of Dr. Strang

Alveolar recruitment maneuver is able to completely reverse
lung collapse in patients undergoing cardiac surgery
 A manobra de recrutamento
alveolar melhor a oxigenao
sangunea durante o
intraoperatrio
PaO2/FiO2 relationship behavior in control
and in recruitment group during cardiac
surgery

RM

RM

*
*
*
*

* p < 0.05
before after chest end of ICU ICU ICU
anesthesia intubation opening CPB admission 3H 6H
PaO2 behavior in control and in recruitment patient groups
during cardiac surgery

extubation

*
*
* * p < 0.05

FiO2 0,6 0,4 0,4 0,3 0,3

ICU ICU ICU ICU ICU

admission 6H 12H 18H 24H
Utilizao da manobra de recrutamento alveolar para reverso de
atelectasias em cirurgia abdominal de obesos mrbidos
Rodrigo Snchez, Maria J. C. Carmona, Vanessa Oliveira, Luiz M Malbouisson

IMC > 35
N controle = 8
N recrut = 11

FiO2 21% 60% 60% 60% 21% 21%

final da cirurgia
Pr-induo

aps 1 hora

1 hora aps

6 hora aps
Aps MRA

extubao

extubao
 The Effects of the Alveolar Recruitment Maneuver and
Positive End-Expiratory Pressure on Arterial Oxygenation
During Laparoscopic Bariatric Surgery
Noninvasive alveolar recruitment maneuver induces cytokine release in healthy volunteers
L Malbouisson1 , T Szeles1 , C Carvalho1 , P Pelosi2 , M Carmona1 and J Auler1
1So Paulo University Medical School, So Paulo, Brazil
2University of Insubria, Varese, Italy

Critical Care 2007, 11(Suppl 2):P194

 Left ventricle Left ventricle

10 s LRM 40 cmH2O 20 s LRM 40 cmH2O

Effect of alveolar recruitment maneuver on lung
Effects of alveolar recruitment maneuvers on lung
collapse and oxygenation
collapse and oxygenation
Short term (make-up) effects ?
BAROTRAUMA APS MANOBRA DE
RECRUTAMENTO ALVEOLAR
 Em que pacientes no-indicar
manobra de recrutamento ?

Oxigenao mantida com FiO2 e PEEP baixa

Hipoxmicos com:
Hipertenso intracraniana
Choque circulatrio no controlado
Leso pulmonar com fuga area
Hipertenso pulmonar grave
Falncia ventricular direita
40
Collapse Inflation
O que fazer ?
Ventilao convencional

Hiperdisteno
alveolar

Ventilao no traumtica

Psup

Pinf

segundos Presso (cmH2O) segundos

Colapso
alveolar

M Tobin. N Engl J Med 344: 1986-1996, 2001

Effect of low tidal volume ventilation on atelectasis in patients
during general anesthesia: a computed tomographic scan

16 pacientes submetidos exrese de tumor cerebral

G1 = Vc 10 ml/kg G2 = 6 ml/kg
TC de trax no POI ( Seo da base do pulmo)

p = ns

Cai H et al, J Clin Anesth. 2007 Mar;19(2):125-9

Presso Positiva Expiratria Final

Preveno do colapso alveolar

formao de atelectasias
CRF

Distribuio mais homognea da ventilao

leses de abertura e fechamento alveolar

produo de mediadores inflamatrios
OBRIGADO

drjas@hotmail.com