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The Management of Acute Respiratory Distress Syndrome
The Management of Acute Respiratory Distress Syndrome
Acute Respiratory
Distress Syndrome
Outlines
Introduction
Ventilator strategy
Adjunctive therapy
Case demonstration
Definition
Acute onset
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
Differential Diagnosis
Hypersensitivity pneumonitis
Acute eosinophilic pneumonia
Bronchiolitis obliterans with organising pneumonia
Lancet 2007; 369:1553-65
Pathophysiology
Exudative phase
Cytokines inflammation surfactant
dysfunction atelectasis
Elastase epithelial barrier damage edema
Procoagulant tendency capillary thrombosis
Fibroproliferative phase
Chronic inflammation
Fibrosis
neovascularisation
NEJM 2000;342:1334-1349
NEJM 2000;342:1334-1349
NEJM 2000;342:1334-1349
Treatment
No specific treatment
Mainstay of treatment: supportive care
Avoid iatrogenic complications
Treat the underlying cause
Maintain adequate oxygenation
Supportive Care
Ventilator Strategy
Barotrauma
Volutrauma
Atelectrauma
Biotrauma
Collapse
Over
Distension
Volutrauma
Increased alveolar
wall stress (stretch)
by high tidal volume
Parenchymal injury
Gross physical
disruption
Stretch-responsive
inflammatory
pathways
Atelectrauma
PEEP
PEEP
PEEP
NEJM 2006;354:1839-1841
Upper
Deflection point
Lower
Inflection point
Lung-Protective Ventilation
ARDS Network, 2000: Multicenter, randomized 861 patients
Lung-protective
ventilation
Tidal Volume (ml/kg)
Pplateau
PEEP
Actual PEEP
Conventional
ventilation
12
<30
<50
Protocol
8.1
Protocol
9.1
Result (p<0.001)
31.0%
39.8%
Principle for FiO2 and PEEP Adjustment
FiO2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
PEEP
5-8
8-10
10
10-14
14
14-18
18-24
Lung-Protective Ventilation
Result:
Lower 22% mortality (31% vs 39.8%)
Increase ventilator-free days
Heterogeneous distribution
Hypercapnia
Auto-PEEP
Sedation and paralysis
Patient-ventilator dyssynchrony
Increased intrathoracic pressure
Maintenance of PEEP
Lung Recruitment
Ex.: PCV, Pi = 45
cmH2O, PEEP = 5
cmH2O, RR = 10 /min,
I : E = 1:1, for 2
minutes
NEJM 2007; 354: 1775-1786
Lung Recruitment
Lung Recruitment
Lung Recruitment
Sensitivity : 71%
Specificity : 59%
Lung Recruitment
Prone Position
Prone Position
Mechanisms to
improve oxygenation:
Prone Position
NEJM 2001;345:568-573
Prone Position
NEJM 2001;345:568-573
Prone Position
High-Frequency Oscillatory
Ventilation (HFOV)
HFOV
HFOV
Complications:
Recognition of a
pneumothorax
Desiccation of secretions
Sedation and paralysis
Lack of expiratory filter
Adjunctive Therapy
Steroid treatment
Fluid management
Extracorporeal membrane oxygenation
(ECMO)
Nitric oxide
Others
Steroid therapy
NEJM 2006;354:1671-1684
Steroid therapy
Fluid Management
NEJM 2006;354:2564-2575
Fluid Management
NEJM 2006;354:2564-2575
Fluid Management
NEJM 2006;354:2213-24
Fluid Management
Extracorporeal Membrane
Oxygenation (ECMO)
Nitric Oxide
Vasodilator
Improve oxygenation and pulmonary
vascular resistance
No improvement on survival
Routine use is not recommended
Unproven Treatments
Ketoconazole
Pentoxyfilline and lisofylline
Nutritional modification
Antioxidants
Neutrophil elastase inhibition
Surfactant
Liquid ventilation
Lancet 2007; 369:1553-65
Conclusions