Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP

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The 6 P's of ARDS Management

• Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC,
  CEN, CNRN, CMSRN, NP
• Education Specialist
• LRM Consulting
• Nashville, TN

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The 6 P's of ARDS Management

• Objectives
• Identify the 5 criteria for the diagnosis of
  ARDS.
• Discuss the common etiologies that lead to ARDS.
• Describe the priorities in the management of
  patients with ARDS.

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The 6 P's of ARDS Management

• diffuse lung injury resulting in noncardiogenic
  pulmonary edema due to increase in capillary
  permeability

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The 6 P's of ARDS Management
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The 6 P's of ARDS Management
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The 6 P's of ARDS Management

• refractory hypoxemia
• diminished compliance
• diffuse infiltrates on chest x-ray
• normal PAOP
• PaO2 / FiO2 ratio lt 200

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The 6 P's of ARDS Management
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The 6 P's of ARDS Management
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The 6 P's of ARDS Management

• Etiology
• shock
• trauma
• infections
• inhaled toxins

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The 6 P's of ARDS Management

• Etiology
• aspiration
• near-drowning
• massive blood transfusions
• fat or amniotic fluid emboli
• pancreatitis

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The 6 P's of ARDS Management

• Phase I II
• subclinical respiratory distress
• ABGs (respiratory alkalosis)
• hyperventilating

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The 6 P's of ARDS Management

• Phase III
• established respiratory distress
• pulmonary shunt gt 10 above baseline
• chest x-ray shows infiltrates
• crackles in lung bases

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The 6 P's of ARDS Management

• Phase IV
• severe respiratory failure
• rising pCO2
• rising physiologic shunt
• white-out on chest x-ray

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The 6 P's of ARDS Management

• Diagnosis
• history
• signs/symptoms
• labs (ABGs)
• x-ray
• hemodynamics

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The 6 P's of ARDS Management

• Treatment
• establish patent airway
• restore arterial O2 level

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The 6 P's of ARDS Management
Add PEEP

• Mechanical Ventilation
• conventional with PEEP
• PC / IRV
• HFJV
• APRV

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The 6 P's of ARDS Management

• Goals of mechanical ventilation in ARDS are to
• maintain oxygenation
• avoiding oxygen toxicity and the complications of
  mechanical ventilation

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The 6 P's of ARDS Management

• maintain oxygen saturation in the range of 85-90
• aim of reducing the fraction of inspired oxygen
  (FIO2) to less than 60 within the first 24-48
  hours
• usually requires the use of moderate-to-high
  levels of PEEP

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The 6 P's of ARDS Management

• experimental studies have shown that mechanical
  ventilation may promote a type of acute lung
  injury (ALI) termed ventilator-associated lung
  injury
• protective ventilation strategies using low tidal
  volumes and limited plateau pressures improves
  survival when compared with conventional tidal
  volumes and pressures

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The 6 P's of ARDS Management

• ARDS Network study
• patients with ALI and ARDS were randomized to
  mechanical ventilation
• tidal volume of 12 mL/kg of predicted body weight
  and an inspiratory pressure of 50 cm water or
  less
• tidal volume of 6 mL/kg and an inspiratory
  pressure of 30 cm water or less

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The 6 P's of ARDS Management

• the study was stopped early after interim
  analysis of 861 patients demonstrated that
  subjects in the low-tidal-volume group had a
  significantly lower mortality rate (31 versus
  39.8)

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The 6 P's of ARDS Management

• mechanical ventilation with a tidal volume of 6
  mL/kg predicted body weight is recommended, with
  adjustment of the tidal volume to as low as 4
  mL/kg if needed to limit the inspiratory plateau
  pressure to 30 cm water or less

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The 6 P's of ARDS Management

• increase the ventilator rate and administer
  bicarbonate as needed to maintain the pH at a
  near normal level (7.3)

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The 6 P's of ARDS Management

• High-frequency ventilation uses low tidal volumes
  and high respiratory rates.
• diminishes alveolar distention
• compared to conventional ventilation in adults
  demonstrates early improvement in oxygenation but
  no improvement in survival.

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The 6 P's of ARDS Management

• Fluid Management
• maintain adequate perfusion
• isotonic solutions
• fluid restriction
• consider diuretics

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The 6 P's of ARDS Management

• primary ARDS due to aspiration, pneumonia, or
  inhalational injury ? treated with fluid
  restriction
• secondary ARDS due to remote infection or
  inflammation ? requires initial fluid and
  potential vasoactive drug therapy
• essential in directing initial treatments to
  stabilize the patient

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The 6 P's of ARDS Management

• Improve systemic O2Delivery
• modest volume expansion
• vasopressors/vasodilators

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The 6 P's of ARDS Management

• Sedation
• control anxiety physical activity
• may require addition of neuromuscular blocker
• suggestions
• propofol
• versed

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The 6 P's of ARDS Management

• Positioning
• good lung in dependent position
• both lungs are equally injured
• beneficial positions include
• prone
• right lung down

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The 6 P's of ARDS Management

• 60-75 of patients with ARDS have significantly
  improved oxygenation when turned from the supine
  to the prone position
• improvement in oxygenation is rapid and often
  substantial enough to allow reductions in FiO2 or
  level of CPAP

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The 6 P's of ARDS Management

• Possible mechanisms for improvement are
• recruitment of dependent lung zones
• increased functional residual capacity (FRC)
• improved diaphragmatic excursion
• increased cardiac output
• improved ventilation-perfusion matching

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The 6 P's of ARDS Management

• despite improved oxygenation with the prone
  position, randomized controlled trials of the
  prone position in ARDS have not demonstrated
  improved survival

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The 6 P's of ARDS Management

• Pharmacologic Therapy
• corticosteroids
• antimicrobials
• non - steroidal anti - inflammatory
  agents
• anti pyretic
• Star Trek Meds

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The 6 P's of ARDS Management

• No drug has proved beneficial in the prevention
  or management of acute respiratory distress
  syndrome (ARDS).

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The 6 P's of ARDS Management

• Hemoglobin
• 12 to 15 gm / dL
• factors decreasing offloading
• hypophosphatemia
• alkalosis
• hypothermia

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The 6 P's of ARDS Management

• Nutritional Support
• often overlooked in ARDS
• ingredients required
• stress amino acid
• trace elements
• omega 3 / omega 6
• Oxepa or Impact

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The 6 P's of ARDS Management

• patients who required mechanical ventilation
  within 48 hours of developing acute lung injury
  received either trophic or full enteral feeding
  for the first 6 days

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The 6 P's of ARDS Management

• Initial lower-volume trophic enteral feeding did
  not improve
• ventilator-free days
• 60-day mortality
• infectious complications
• it was associated with less gastrointestinal
  intolerance

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The 6 P's of ARDS Management

• Other Therapeutics
• nitric oxide
• surfactant
• ECMO
• partial liquid ventilation

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Extracorporeal Membrane Oxygenation (ECMO)
The 6 P's of ARDS Management

• Description
• type of cardiopulmonary bypass
• CO2 removal O2 replacement
• ventilated (lower VT, FiO2, PEEP)

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Extracorporeal Membrane Oxygenation (ECMO)
The 6 P's of ARDS Management

• Complications
• technical difficulties
• cannula malposition
• hemorrhage
• sepsis

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The 6 P's of ARDS Management

• ECMO appeared to improve survival in patients
  with H1N1-associated ARDS who could not be
  oxygenated with conventional mechanical
  ventilation

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The 6 P's of ARDS Management

• randomized controlled trial that compared partial
  liquid with conventional mechanical ventilation
• partial liquid ventilation resulted in increased
  morbidity
• pneumothoraces
• hypotension
• hypoxemic episodes
• trend toward higher mortality

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The 6 P's of ARDS Management

• Case Study
• 48 - year old alcoholic with GI bleed
  pancreatitis
• severe epigastric pain, acute abdomen
• ultrasound confirms enlarged, edematous pancreas
• hemodynamically unstable
• refractory hypoxemia

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The 6 P's of ARDS Management

• Case Study
• HR 130
• BP 80 / 50 / 62

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The 6 P's of ARDS Management

• Case Study
• HR 130
• BP 80 / 50 / 62
• CI 2.2
• PAP 15 / 8 / 10
• PAOP / CVP 2 / 1

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The 6 P's of ARDS Management

• Case Study
• PVRI 290
• SVRI 2218
• SVI 28
• LVSWI/RVSWI 22.8 / 2.6

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The 6 P's of ARDS Management

• Case Study
• ABGs (.70 FiO2)
• pH 7.38
• pCO2 45
• pO2 50
• SaO2 .83
• HCO3 27
• SvO2 60

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The 6 P's of ARDS Management

• Case Study
• PaO2 / FiO2 Ratio (P/F)
• 50 / .70
• 71
• Normal gt 300
• ALI lt 250
• ARDS lt 200

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The 6 P's of ARDS Management

• Case Study
• Laboratory Values
• Na 150
• Cl 96
• Hgb / Hct 12.1 / 36.3
• CO2 26

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The 6 P's of ARDS Management

• Case Study
• Anion Gap
• Na (CO2 Cl)
• 150 (96 26)
• 28
• (Normal 12 15)

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The 6 P's of ARDS Management

• PEEP can ? DOI2
• WOB ? VOI2
• triggers inflammatory response
• maldistributed blood flow ? ? VOI2
• ideal Hgb is 12

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The 6 P's of ARDS Management

• ? DOI2 until VOI2 plateaus

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The 6 P's of ARDS Management

• Case Study
• DOI2 CI ( 1.38 x Hgb x SaO2) 10
• 2.2 X 1.38 X 12.1 X 0.83 x 10
• 305 mL/min/m2
• (normal 360 - 600 mL/min/m2)

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The 6 P's of ARDS Management

• Case Study
• VOI2 CI X 1.38 X Hgb X (SaO2 - SvO2) X 10
• 2.2 x 1.38 x 12.1 x (.83 - .60) x 10
• 84 mL/min/m2
• (Normal 220 - 290 mL/min/m2)

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The 6 P's of ARDS Management

• In Summary
• 6 Ps of ARDS Management
• Pathophysiology
• Prevention
• Positive Pressure Ventilation
• Perfusion
• Pharmacology
• Positioning

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The 6 P's of ARDS Management