ARDS Acute onset lt7 days Bilateral opacities not fully explained by heart failure Acute Respiratory Distress Syndrome Moderate ARDS PF 100200 Mild ARDS PF 201300 Berlin Definition 2012 ID: 935384
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Slide1
Mechanical Ventilation in ARDS
Slide2Slide3Acute onset (<7 days)
Bilateral opacities
“not fully explained by heart failure.”
Acute Respiratory Distress Syndrome
Moderate ARDS:
P/F 100-200
Mild ARDS:
P/F 201-300
Berlin Definition - 2012
Severe ARDS:
P/F <100
Severity
PaO
2
/FiO
2
Ratio
Mortality
Mild
200-300
27%
Moderate
100-200
32%
Severe
<100
45%
Slide4PhysiologyInsult or Injury directly to lungs or result of systemic inflammation
Microcirculation is damaged
Increase permeability leading to increase edema
Alveolar filling leads to stiff lung, shunting of blood, and increased dead spaceIncreased work of breathing
Slide5ARDS – EtiologiesCommon
Sepsis
Pneumonia
– viral & bacterialAspirationTrauma
Less Common
DrowningPancreatitisTransfusions (TRALI
)Emboli – Fat or AirCardiopulmonary BypassBurns/Inhalational injuryDiffuse Alveolar HemorrhageAcute drug toxicity -
Amio
Slide6ARDSnet ProtocolAKA lung protective ventilation or low tidal volume ventilation
Goal is to reduce injury from barotrauma and atelectrauma
O2 Sats of 87% are acceptable
Permissive hypercapniaSedation is usually an issue
Slide7The Acute Respiratory Distress Syndrome Network, N Engl J Med 2000;342:1301-1308
Probability of Survival and of Being Discharged Home and Breathing without Assistance during the First 180 Days after Randomization in Patients with Acute Lung Injury and the Acute Respiratory Distress Syndrome
Slide8Videos of ventilator
Slide9Potential Interventions for Severe ARDS
Ventilator-related:
Higher PEEP strategies
Recruitment maneuversNon-ventilator related:ProningParalysis
iNO/FlolanECMO
Slide10Rotoprone Bed
Slide11Prone positioningBetter matching of ventilation and perfusion
Opening of dependent collapsed lung segments
Improves oxygenation in about 70% of patients
Does it improve outcomes?
Slide12RCT Prone vs Supine Ventilation
Guerin, JAMA, 2004
Gattinoni et al, NEJM 2001
Slide13ARDS for 12 – 24 hrs
Prone position for at least 16 hrs
ARDSnet protocol ventilation in all groups
Manual proning
Outcome was mortality at 28 days
Slide14Slide15What about ParalysisAllows better ventilation by taking the patient’s efforts out of the equation
Decreased oxygen uptake in skeletal muscle
Requires deep sedation
Increases risk of critical care induced neuropathy (??)
Slide16Slide17Kaplan-Meyer survival curve
Slide18Paralytics – Bottom lineProbably help some patients
Not ready to be used for all patients
Still does not take the place of low lung volume ventilation
Outstanding issuesDuration of NMBA Type of agent to useMechanism