Enseignement Post-Universitaire Anesthésie-Réanimation 2006

LESIONS ALVEOLAIRES INDUITES PAR LA VENTILATIONVentilator-Induced Lung Injury (VILI)

Eric Kipnis

Service de Réanimation Chirurgicale, Clinique d’Anesthésie-Réanimation, Hôpital Claude Huriez, CHRU Lille

LÉSIONS

Barotrauma

Oinhu Lancet 2003

Barotrauma

Oinhu Lancet 2003

ARDS: 5.34-5.66 [2.56-12.63] p<0.001

De Lassence Anesthesiology 2006

Lésions induites par la VM

14 cm H2O 30 cm H2O 45 cm H2O

Barotrauma ? / Volotrauma ?Mais…Vt?

Webb HH, Tierney DF Am Rev Respir Dis 1974

Lésions induites par la VM

Dès 5 min!Dreyfuss D, Am Rev Respir Dis 1985

Dès 5 min / 45 cmH2O décollement endothélial

oedème interstitiel

Dreyfuss D, Am Rev Respir Dis 1985

destruction epithelium

Membranes hyalines

Dreyfuss D, Am Rev Respir Dis 1985

Diffuse Alveolar Damage

Rich, PB, Journal of Trauma 2000

VOLOTRAUMA

Volotrauma

• Brebis en VS• Injection intra V4 de salicylate de Na: hyperventilation• Témoins: idem mais paralysés/ventilés

Hyperventilation en VS!

entraîne des lésions histologiques d’ALI

Mais effets non individualisés de Vt par rapport a FR…

Mascheroni, Intensive Care Med. 1988

Volotrauma

Dreyfuss, D, Am Rev Respir Dis 1988

STRESS FAILURE

Stress circonferentiel (PTM)

Tension linéaire

West JB, AJP Lung, 2003.

Stress failure

West JB, J Appl Physiol 1991

Mechanismes de stress failure

• Pcap élévées

• Matrice extracellulaire anormale (Ex: Sd de Goodpasture)

• Hyperinflation pulmonaire / VILI

STRESS FAILURE DU VILI=

VOLOTRAUMA

Stress failure / VILI

Vt-dépendant, quelle que soit la PtmWest JB, AJP - Lung, 2003.

West JB, AJP - Lung, 2003.

PERMEABILITE

Egan, JAP 1982

Frank AJRCCM 2002

Frank AJRCCM 2002

ATELECTRAUMA

Zone de surdistension

Zone d’atelectasie

Zone de contrainte

Oinhu Lancet 2003

Interdependance alveolaire

Ptm > 140 cmH2O

Mead J, J Appl Physiol 1970

Forces de cisaillement / shear stress

Bilek, A. M. et al. J Appl Physiol 2002

Repetitive Alveolar Collapse And Expansion

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Di Rocco Intensive Care Med. 2006

Repetitive Alveolar Collapse And Expansion

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Halter, Am J Respir Crit Care Med. 2003

Repetitive Alveolar Collapse And Expansion

Steinberg Am J Respir Crit Care Med. 2004

BIOTRAUMA

Inflammation

Tremblay, L. et al. J. Clin. Invest. 1997

Inflammation

0

0,05

0,1

0,15

0,2

0,25

0,3

-60 -30 0 30 60 90 120 150

NPV lowNPV highPPV lowPPV high

TNFα (ng/ml)

t (min)t

Nepomuk et al, AJRCCM 1998

Coagulation intrapulmonaire

Dahlem et al, Intens Care Med 1998

Coagulation intrapulmonaire

Fibrinolysis inhibition(PAI1)

Fibrin-formation(TAT complexes)

Fibrinolysis(tPA, uPA)

Fibrin deposit persistence(histology)

time

Coagulationmarkers

Kipnis et al, Shcok 2004

Mechanotransduction

Gattinoni et al. Eur Resp J 2004

Mechanotransduction

Parker, J. C. et al. J Appl Physiol 1998

Mechanotransduction

Vlahakis et al. AJRCCM 2005

Ventilator Induced Lung Injury

Ventilator Induced Extrapulmonary Injury

Lésions Extrapulmonaires

Imai JAMA 2003

Lésions Extrapulmonaires

Imai JAMA 2003

0

5

10

15

20

25

30

35

40

Cardiaq

ue

Rna

leH

matolog

ique

Neurol

ogiqu

eH

patiq

ue Total

10-12 ml/kg6-8 ml/kg

Grasso ATS 2003

n patients developping organ failure at 72h of admission

*

*

GENOMIQUE

• Vt bas vs. Vt élevé 30’ poursuivie 90’

• Expression génomique a 30’

– Alors que les lésions histo n’apparaissent qu’a 90’– à 30’:

• Upregulation de 10 genes– Facteurs de transcription– Proteines de stress– Médiateurs inflammatoires

• Suppression de 12 genes– Genes de régulation du métabolisme

Copland et al, AJRCCM 2003

PROTEOMIQUE

Kipnis et al, communication ATS 2004

VILI sur poumon lésé (ALI / ARDS)“adding insult to injury”

Niall Curr Op Crit Care 2005

Brun-Buisson Intens Care Med 2004

Kipnis Med Mal Inf 2005

Frank AJRCCM 2002

Frank AJRCCM 2002

ConclusionsLE VILI =• Barotrauma• Volotrauma / Stress-failure• Shear-stress• Atelectrauma / RACE• Biotrauma / Méchanotransduction

-Troubles de la perméabilité alvéolocapillaire-Troubles de la fonction épithéliale-Inflammation / coagulation-Apoptose

TOUS INTRIQUES A DIVERS DEGRES

Conclusions

Beaucoup de preuves expérimentales du VILI

Et évidence de l’aggravation de lésions par VM

Mais….

EXISTE-T-IL UN VILI CLINIQUE?

VILI Clinique

Gajic, Critical Care Medicine. 2004

VILI Clinique

Gajic, Critical Care Medicine. 2004

Conclusions

Aucun traitement des lésions de ALI/ARDS/VILI n’existe

Traiter les étiologies des pathologies aggravées par le VILI

Prévenir le VILI = ventilation protectrice

ARDSNet NEJM 2004

Tschumperlin, D. J. et al. Am J Physiol Lung Cell Mol Physiol 275: L1173-L1183

Tschumperlin, AJRCCM 2000

Copyright ©1998 American Physiological Society

Débit Inspiratoire

Maeda, Y, 2004. Anesthesiology 101(3):722-8

Berg Am J Respir Crit Care Med. 1998

REPETITIVE ALVEOLAR COLLAPSE AND EXPANSION

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Schiller Crit Care Med. 2001

Steinberg Crit Care Med. 2002

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Steinberg Crit Care Med. 2002

Tween

VILI

OA

Di Rocco Intensive Care Med. 2006

Jammes Y, Auran Y, Gouvernet J, Delpierrre S, and Grimaud C.The ventilatory pattern of conscious man according to age and morphology. Bull Eur Physiopath Respir 15: 527–540, 1979

Tremblay JCI 1997

Tremblay, L. et al. J. Clin. Invest. 1997;99:944-952

Copyright ©1997 American Society for Clinical Investigation

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Halter, Am J Respir Crit Care Med. 2003