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The Management of Acute Respiratory Distress Syndrome

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Title: The Management of Acute Respiratory Distress Syndrome


1
The Management of Acute Respiratory Distress
Syndrome
  • ?????? ????
  • ?????

2
Outlines
  • Introduction
  • Ventilator strategy
  • Adjunctive therapy
  • Case demonstration

3
?? Definition
  • ?? Acute onset
  • ?? PaO2/FiO2 lt 200 mmHg
  • CXR bilateral infiltrates????
  • ????????? PAWP lt 18 mmHg, no clinical evidence of
    LA HTN

4
????
  • Direct injury
  • Pneumonia
  • Gastric aspiration
  • Drowning
  • Fat and amniotic fluid embolism
  • Pulmonary contusion
  • Alveolar hemorrhage
  • Toxic inhalation
  • Reperfusion
  • Indirect injury
  • Severe sepsis
  • Transfusions
  • Shock
  • Salicylate or narcotic overdose
  • Pancreatitis

5
Differential Diagnosis
  • Left ventricular failure
  • Intravascular volume overload
  • Mitral stenosis
  • Veno-occlusive disease
  • Lymphangitic carcinoma
  • Interstitial and airway diseases
  • Hypersensitivity pneumonitis
  • Acute eosinophilic pneumonia
  • Bronchiolitis obliterans with organising pneumonia

Lancet 2007 3691553-65
6
Prognosis Outcome
  • Predictive of death advanced age, shock, hepatic
    failure
  • Overall 28-day mortality 20-40
  • Lung function returns to normal over 6-12
    months
  • Common complications neuropsychiatric problems,
    neuromuscular weakness

Lancet 2007 3691553-65
7
Pathophysiology
  • Exudative phase
  • Cytokines ? inflammation ? surfactant dysfunction
    ? atelectasis
  • Elastase ?epithelial barrier damage ? edema
  • Procoagulant tendency ? capillary thrombosis
  • Fibroproliferative phase
  • Chronic inflammation
  • Fibrosis
  • neovascularisation

Lancet 2007 3691553-65
8
NEJM 20003421334-1349
9
NEJM 20003421334-1349
10
NEJM 20003421334-1349
11
Treatment
  • No specific treatment
  • Mainstay of treatment supportive care
  • Avoid iatrogenic complications
  • Treat the underlying cause
  • Maintain adequate oxygenation

12
Supportive Care
  • Prevention of deep vein thrombosis,
    gastrointestinal bleeding, and pressure ulcers
  • Semi-recumbent position
  • Enteral nutrition
  • Infection control
  • Goal-directed sedation practice
  • Glucose control

13
Ventilator Strategy
14
Ventilator-induced Lung Injury (VILI)
  • Barotrauma
  • Volutrauma
  • Atelectrauma
  • Biotrauma

Over Distension
Collapse
15
Volutrauma
  • Increased alveolar wall stress (stretch) by high
    tidal volume
  • Parenchymal injury
  • Gross physical disruption
  • Stretch-responsive inflammatory pathways

AJRCCM 1998 157 294-323
16
Atelectrauma
  • Cyclic closing and reopening of alveoli
  • Alveolar shear stress-related injury
  • Heterogeneous nature of lung aeration in ALI/ARDS

17
The PEEP Effect
NEJM 20063541839-1841
18
Ventilator-induced Lung Injury (VILI)
Upper Deflection point
Lower Inflection point
19
Lung-Protective Ventilation
  • ARDS Network, 2000 Multicenter, randomized 861
    patients

Lung-protective ventilation Lung-protective ventilation Conventional ventilation
Tidal Volume (ml/kg) Tidal Volume (ml/kg) 6 12
Pplateau Pplateau lt30 lt50
PEEP PEEP Protocol Protocol
Actual PEEP Actual PEEP 8.1 9.1
Result (plt0.001) Result (plt0.001) 31.0 39.8
Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment Principle for FiO2 and PEEP Adjustment
FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
PEEP 5 5-8 8-10 10 10-14 14 14-18 18-24
NEJM 2000 342 1301-1308
20
Lung-Protective Ventilation
  • Result
  • Lower 22 mortality (31 vs 39.8)
  • Increase ventilator-free days

NEJM 2000 342 1301-1308
21
Concerns when using lung-protective strategy
  • Heterogeneous distribution
  • Hypercapnia
  • Auto-PEEP
  • Sedation and paralysis
  • Patient-ventilator dyssynchrony
  • Increased intrathoracic pressure
  • Maintenance of PEEP

22
Other Ventilator Strategies
  • Lung recruitment maneuvers
  • Prone positioning
  • High-frequency oscillatory ventilation (HFOV)

23
Lung Recruitment
  • To open the collapsed alveoli
  • A sustained inflation of the lungs to higher
    airway pressure and volumes
  • Ex. PCV, Pi 45 cmH2O, PEEP 5 cmH2O, RR 10
    /min, I E 11, for 2 minutes

NEJM 2007 354 1775-1786
24
Lung Recruitment
NEJM 2007 354 1775-1786
25
Lung Recruitment
NEJM 2007 354 1775-1786
26
Lung Recruitment
  • Potentially recruitable (PEEP 5 ? 15 cmH2O)
  • Increase in PaO2FiO2
  • Decrease in PaCO2
  • Increase in compliance
  • The effect of PEEP correlates with the percentage
    of potentially recruitalbe lung
  • The percentage of recruitable lung correlates
    with the overall severity of lung injury

Sensitivity 71 Specificity 59
NEJM 2007 354 1775-1786
27
Lung Recruitment
  • The percentage of potentially recruitable lung
  • Extremely variable,
  • Strongly associated with the response to PEEP
  • Not routinely recommended

28
Prone Position
29
Prone Position
  • Mechanisms to improve oxygenation
  • Increase in end-expiratory lung volume
  • Better ventilation-perfusion matching
  • More efficient drainage of secretions

30
Prone Position
NEJM 2001345568-573
31
Prone Position
NEJM 2001345568-573
32
Prone Position
  • Improve oxygenation in about 2/3 of all treated
    patients
  • No improvement on survival, time on ventilation,
    or time in ICU
  • Might be useful to treat refractory hypoxemia
  • Optimum timing or duration ?
  • Routine use is not recommended

33
High-Frequency Oscillatory Ventilation (HFOV)
34
HFOV
Frequency 180-600 breaths/min (3-10Hz)
35
Effect of HFOV on gas exchange in ARDS patients
AJRCCM 2002 166801-8
36
Survival difference of ARDS patients treated with
HFOV or CMV
30-day P0.057 90-day P0.078
AJRCCM 2002 166801-8
37
HFOV
  • Complications
  • Recognition of a pneumothorax
  • Desiccation of secretions
  • Sedation and paralysis
  • Lack of expiratory filter
  • Failed to show a mortality benefit
  • Combination with other interventions ?

Chest 2007 1311907-1916
38
Adjunctive Therapy
  • Steroid treatment
  • Fluid management
  • Extracorporeal membrane oxygenation (ECMO)
  • Nitric oxide
  • Others

39
Steroid therapy
NEJM 20063541671-1684
40
Steroid therapy
  • Increase the number of ventilator-free and
    shock-free days during the first 28 day
  • Improve oxygenation, compliance and blood
    pressure
  • No increase in the rate of infectious
    complications
  • Higher rate of neuromuscular weakness
  • Routine use of steroid is not supported
  • Starting steroid more than 14 days after the
    onset of ARDS may increase mortality

NEJM 20063541671-1684
41
Fluid Management
NEJM 20063542564-2575
42
Fluid Management
NEJM 20063542564-2575
43
Fluid Management
NEJM 20063542213-24
44
Fluid Management
  • Conservative strategy improves lung function and
    shortens the duration of ventilator use and ICU
    stay
  • No significant mortality benefit
  • The use of pulmonary artery catheter not
    routinely suggested

45
Extracorporeal Membrane Oxygenation (ECMO)
  • No improvement on survival or time on ventilation
  • Substantial risk of infection and bleeding
  • Not routinely recommended

46
Nitric Oxide
  • Vasodilator
  • Improve oxygenation and pulmonary vascular
    resistance
  • No improvement on survival
  • Routine use is not recommended

47
Unproven Treatments
  • Ketoconazole
  • Pentoxyfilline and lisofylline
  • Nutritional modification
  • Antioxidants
  • Neutrophil elastase inhibition
  • Surfactant
  • Liquid ventilation

Lancet 2007 3691553-65
48
Conclusions
  • The only treatment that shows mortality benefit
  • lung-protective ventilation strategy
  • Low tidal volume (6ml/Kg), high PEEP, adequate
    Pplat (lt30 cmH2O)
  • Modalities to improve oxygenation
  • Prone position, steroid, fluid treatment,
    steroid, HFOV, NO
  • Combining other treatments
  • Activated protein C, antibiotics, EGDTetc
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