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MANAGEMENT OF ARDS

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MANAGEMENT OF ARDS

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  1. MANAGEMENT OFARDS Carl W. Peters, MD Clinical Associate Professor Division of Critical Care Medicine Department of Anesthesiology University of Florida College of Medicine Gainesville, Florida, USA

  2. ARDS--OUTLINE • HISTORY • FEATURES OF THE SYNDROME • PATHOPHYSIOLOGY • MANAGEMENT • VENTILATORY • NON-VENTILATORY

  3. ARDS MANAGEMENT • 85 YEAR FEMALE • 10% BURN TO LOWER BACK • ONE OPERATION FOR SKIN GRAFTING • RECEIVING WOUND CARE

  4. ARDS MANAGEMENT • TWO WEEKS IN BURN ICU • SUDDENLY HAS A SEIZURE • UNRESPONSIVE • INTUBATED • ASPIRATING • Gastric Contents at Time of Intubation

  5. ARDS MANAGEMENT • FIVE DAYS--MUCH WORSE • HYPOXEMIC • PaO2 = 65, FiO2 = .95 • Pa02/Fi02 = 68 • HYPOTENSIVE • SBP = 75 • VASOPRESSIN, PHENYLEPHRINE, MILRINONE • NO URINE OUTPUT

  6. ARDS--HISTORY • 12 PATIENTS: • ACUTE RESPIRATORY DISTRESS • CYANOSIS DESPITE OXYGEN SUPPLEMENT • DECREASED LUNG COMPLIANCE • DIFFUSE PULMONARY INFILTRATES Ashbaugh, Petty et al, Lancet 1967; 12:319-323

  7. ARDS--HISTORY • 4-POINT LUNG-INJURY SCORE • LEVEL OF PEEP • PaO2 / FiO2 RATIO • STATIC LUNG COMPLIANCE • DEGREE OF INFILTRATION ON CHEST XRAY • NATURE OF INCITING DISORDER • INCLUDES POSSIBILITY OF NON-PULMONARY ORGAN DYSFUNCTION MURRAY, MATTHAY, LUCE AM REV RESPIR DIS 1988:138:720

  8. ARDS--DEFINITION • BERNARD, ARTIGAS, BRIGHAM, 1994: • ACUTE ONSET • BILATERAL PULMONARY INFILTRATES • PCWP < 18, NO L.A. HTN • PaO2 / FiO2 RATIO < 200 = ARDS • PaO2 / FiO2 RATIO < 300 = A.L.I., “LESS SEVERE” FORM OF LUNG INJURY AM J RESPIR CRIT CARE MED 1994 149:818-24

  9. WARE L, MATTHEY M; NEJM 2000 342(18);1334-1349

  10. ARDS—1994 DEFINITION • ADVANTAGES • REGOGNIZES VARIABILITY OF CLINICAL LUNG INJURY • SIMPLE TO APPLY • DISADVANTAGES • TOO SIMPLE ? • UNDERLYING CAUSE & INVOLVEMENT OF OTHER ORGAN SYSTEMS NOT ASSESSED • RADIOLOGIC CRITERION FOR PRESENCE OF BILATERAL PULMONARY INFILTRATES • INCONSISTENTLY APPLIED

  11. ARDS-THE PROCESS • MEMBRANE INJURY • ENDOTHELIAL OR EPITHELIAL • EITHER MEMBRANE INJURED • MANY CAUSES, SAME RESULT • MEMBRANE LEAKAGE • NON-HYDROSTATIC • PROTEIN-RICH FLUID LEAKAGE • ALVEOLI FLOODED

  12. ARDS-THE PROCESS • MEMBRANE DAMAGE • CONTINUING • INFLAMATION • “RIDE-ALONG” NEUTROPHILS • CYTOKINES • V.I.L.I. • OLD IDEA: LARGE TIDAL VOLUME • OVERDISTEND/INJURY/DEADSPACE • COLLAPSED ALVEOLI

  13. ARDS-THE PROCESS • ALVEOLAR DAMAGE • PERMEABILITY • SURFACTANT • HYPOXEMIA • SEVERE V-Q MISMATCH • FIBROBLASTS • RESOLUTION????

  14. ARDS CAUSES WARE L, MATTHEY M. NEJM 2000 342(18) 1334-1349

  15. WARE L, MATTHEY M; NEJM 2000; 342(18) 1334-1349

  16. WARE L, MATTHEY M. NEJM 2000 352(18), 1334-1349

  17. ARDS MANAGEMENT • GENERAL ISSUES: • SEARCH FOR CAUSE • TREAT INFECTIONS • PROVIDE ADEQUATE NUTRITION • ENTERALLY WHENEVER POSSIBLE • PREVENT GI BLEEDING AND DVTs • REMEMBER • ARDS IS PART OF A SEVERE SYSTEMIC CONDITION • TREAT THE WHOLE ILLNESS

  18. ARDS MANAGEMENT • GOALS: • BEST OXYGENATION • LOWEST FiO2 • LIMIT SIDE EFFECTS OF TREATMENT • SUPPORT THE PATIENT • WHILE THE LUNGS & OTHER SYSTEMS HEAL

  19. ARDS MANAGEMENT MODALITIES • VENTILATORY TECHNIQUES • LUNG PROTECTIVE VENTILATION STRATEGIES • OTHER TECHNIQUES / MODALITIES • NITRIC OXIDE • PRONE POSITIONING • SURFACTANT REPLACEMENT • PARTIAL LIQUID VENTILATION • HIGH-FREQUENCY OSCILLATORY VENTILATION • PHARMACOLGIC THERAPY • FLUID MANAGEMENT • NUTRITION

  20. WARE L, MATTHEY M; NEJM 2000 342(18) 1334-1349

  21. ARDS MANAGEMENTVENTILATORY ISSUES • TWO GOALS: • OPTIMAL • OXYGENATION & VENTILATION • AVOID • INJURIOUS EFFECTS OF MV ON LUNGS • “VENTILATOR-INDUCED LUNG INJURY”

  22. ARDS MANAGEMENTVENTILATORY ISSUES • LUNG PROTECTIVE VENTILATION: • PEEP / CPAP • RECRUIT COLLAPSED ALVEOLI • MINIMIZE SHUNT • LOWER SUPPLEMENTAL OXYGEN • USE LOW TIDAL VOLUMES • MINIMIZE • ALVEOLAR OVERDISTENTION • CYCLIC AIRWAY OPENING / CLOSING • Alveolar “Shear Forces”

  23. PIANTADOSI C, SCHWARTZ D; ANN INTERN MED 2004:141;460-470

  24. BARBAS C, deMATOS G, PINCELLI M, ET AL CUR OPIN CRIT CARE 2005; 11:18-28

  25. ARDS MANAGEMENTVENTILATORY ISSUES • HOW MUCH PEEP IS ENOUGH • 5 to 20 CM H20 • HOW MUCH VOLUME IS ENOUGH • UNKNOWN • PROBABLY 6 to 8 ML / KG • MUCH LESS THAN “TRADITIONAL” VOLUMES • 10 to 12 ML / KG • HOW MUCH PEAK PRESSURE IS TOO MUCH • APPROX 35 CM H2O PLATEAU PRESSURE LIMIT

  26. MOLONEY E, GRIFFITHS M. BR J ANAESTH 2004:92:261-270

  27. ARDS MANAGEMENTVENTILATORY ISSUES • PRESSURE-VOLUME CURVES • USEFUL ? • AT OR SLIGHTLY ABOVE LIP: • RECRUIT COLLAPSED ALVEOLI • DECREASE SHUNT • ABOVE UIP • ALVEOLI OVER-DISTEND • WORSEN V.I.L.I

  28. BARBAS C, deMATOS G, PINCELLI M, ET AL CUR OPIN CRIT CARE 2005;11:18-28

  29. TOBIN M. NEJM 2001;344(26) 1986-1996

  30. ARDS MANAGEMENTVENTILATORY ISSUES • “PROTECTIVE” (LOW VOLUME) VENTILATION • 5 STUDIES • LARGEST SHOWED BENEFIT; 3--NONE • ARDS NET STUDY, 861 PTS, • 6 ML/KG, PLAT<30CM H20 vs 12 ML/KG & PLAT<50CM H2O • START WITH HIGHER PEEP • 25% FEWER DEATHS LOW VOLUME 1. MALONEY E, GRIFFITHS M. BR J ANAESTH 2004:92: 261-270 2. ARDSNET. NEJM 2000:342:1301-1308

  31. ARDS MANAGEMENT • OTHER TECHNIQUES / MODALITIES • NITRIC OXIDE • PRONE POSITIONING • SURFACTANT REPLACEMENT • PARTIAL LIQUID VENTILATION • HIGH-FREQUENCY OSCILLATORY VENTILATION • PHARMACOLGIC THERAPY • FLUID MANAGEMENT • NUTRITION

  32. LOS ANGELES

  33. CALIFORNIA SURFERS

  34. HOLLYWOOD BIG SHOTS

  35. LOS ANGELES TRAFFIC

  36. LOS ANGELES TRAFFIC

  37. LOS ANGELES TRAFFIC