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What Is New in ARDS ?

11 th Annual Congress Turkish Thoracic Society. What Is New in ARDS ?. Lluis Blanch MD PhD Senior Critical Care Center Scientific Director Corporació Parc Taulí Universitat Autónoma de Barcelona Sabadell, Spain. Belek-Antalya. April 23 – 27, 2008. What Is New in ARDS ?. Definition

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What Is New in ARDS ?

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  1. 11th Annual Congress Turkish Thoracic Society What Is New in ARDS ? Lluis Blanch MD PhD Senior Critical Care Center Scientific Director Corporació Parc Taulí Universitat Autónoma de Barcelona Sabadell, Spain Belek-Antalya. April 23 – 27, 2008

  2. What Is New in ARDS ? • Definition • Types • Therapy • Mechanical Ventilation • Practice & Organization Aim of the talk: To reveal novel solutions for problems during mechanical ventilation and supportive therapy in ARDS.

  3. What Is New in ARDS ? • Definition • Types • Therapy • Mechanical Ventilation • Practice & Organization

  4. Diagnostic Criteria for ARDS Fan E, et al. JAMA 2005;294:2889-96

  5. PaO2/FiO2 156 mmHg PaO2/FiO2 247 mmHg In 170 pts meeting ARDS criteria (PaO2/FiO2 < 200 mmHg) diferent combinations of FiO2 & PEEP at VT 7 ml/kg were obtained in Day 0 and in Day 1. PaO2/FiO2 370 mmHg The definitions of ARDS and ALI require the use of standard ventilator settings to ensure that patients with consistent levels of lung injury are properly classified as having ARDS or ALI

  6. Observed Mortality According to the Quintile of Dead-Space Fraction in 179 Patients with ARDS Mechanisms: 1- Injury of pulmonary capillaries by thrombotic and inflammatory factors. 2- Obstruction of pulmonary blood flow in pulmonary circulation. 3- Lung areas with high V/Q ratio (impaired CO2 excretion) Nuckton TJ et al. N Engl J Med 2002; 346:1281.

  7. VAE/VT S D 0.7 ns 0.6 PCO2 0.5 PaCO2 * 0.4 Phase III * PetCO2 0.3 p<0.05 0.2 Adm 24 h 48 h Phase II Effective Alveolar Ventilation Phase I Exhaled Volume SS 73% SP 93%

  8. What Is New in ARDS ? • Definition • Types • Therapy • Mechanical Ventilation • Practice & Organization

  9. Models of ARDS LPS inhaled OAI i.v. CLP sepsis Human ARDS Severe intra-alveolar infiltrates, deposition of hyaline membranes, vascular congestion and microthrombi. Matute-Bello G, et al. http://www.thoracic.org

  10. American–European Consensus Conference Definition and Sensitivity, Specificity, and Likelihood Ratios Assessed in Patients Who Died in the Intensive Care Unit Reference Standard: Diffuse Alveolar Damage at Autopsy The accuracy of the American–European Consensus Conference definition of ARDS was only moderate. The definition was more accurate for patients with extrapulmonary risk factors than for patients with pulmonary risk factors.

  11. Mortality in Relation to the Percentage of Potentially Recruitable Lung PRL: difference between non-aerated tissue between 5 and 45 cmH2O PEEP

  12. Human ARDS Direct Indirect Pulmonary Extrapulmonary Medical Surgical Primary Secondary ?

  13. What Is New in ARDS ? • Definition • Types • Therapy • Mechanical Ventilation • Practice & Organization

  14. Effects of NO on Mortality

  15. Effects of NO on PaO2/FiO2 Effects of NO on Renal Dysfunction

  16. Low dose PLV group 7  9* 26 High dose PLV group 10  9* 19 CMV 13  9 15 Day 28 Ventilator-free days Mortality % 311 pts with ARDS At Randomization: VT 9 ml/kg, PEEP 14 cmH2O Pplat 30 cmH2O

  17. Rationale: Persistent ARDS is characterized by ongoing inflammation, parenchymal-cell proliferation and disordered deposition of collagen all of which may be responsive to corticosteroid therapy.

  18. Main Outcome Variables

  19. Steroid Treatment in ARDS Prolonged methylprednisolone treatment of greater than 1 week’s duration after removing patients randomized after day 14. Meduri GU Intensive Care Med 2008; 34:61-69 • Correct use of prolonged glucocorticoid treatment is associated • with a substantial and significant improvement in meaningful • patient-centered outcome variables. • Surveillance measures: • intensive infection vigilance • avoidance of paralytic agents • avoidance of rebound inflammation with premature discontinuation of treatment

  20. Pulmonary Edema Formation in Congestive Heart Failure & ARDS Piantadosi CA, Schwartz DA. Ann Intern Med 2004; 141:460-470.

  21. B-agonists can enhance alveolar fluid clearance through the up-regulation of sodium transport mechanisms located on the alveolar epithelial cells. Objective & Methods: manipulation of alveolar fluid clearance with B-agonists can accelerate the resolution of alveolar edema. 40 pts.with ALI/ARDS were randomized to treatment with intravenous salbutamol (15 g kg-1 h-1) or placebo for 7 d. Results: Patients in the salbutamol group had lower extravascular lung water, plateau pressure and LIS at day 7 compared with placebo group.

  22. Main Outcome Variables

  23. Prone Positioning in Critically Ill Patients

  24. Am J Resp Crit Care Med 2006;173:1233-39 ARDS patients FiO2 0.85, VT 8 ml/kg, PEEP 12 SAPS 38 – 42 & Diffuse Infiltrates Enrolled 48 h Prone 20 h/day A total of 718 turning procedures were done and PP was applied for a mean of 17 h/day. A total of 28 complications were reported, most rapidly reversible.

  25. 100 80 PRONE 60 p= 0.27 Probability of Survival 40 SUPINE 20 0 10 20 30 40 50 60 Days After Randomization Spanish Trial: Kaplan-Meier Estimates of ICU Survival (up to 60 days) 25% ↓ Mortality in Prone

  26. What Is New in ARDS ? • Definition • Types • Therapy • Mechanical Ventilation • Practice & Organization

  27. More Protected (n=20) Less Protected (n=10) ARDSNet: VT 6 ml/kg & Pplat < 30 cm H2O

  28. JAMA, Feb.13, 2008;209:646-55 ALI pts. (n=767) Minimal Distension (n=382): - VT 6 ml/kg PBW - PEEP 5 – 9 cmH2O Increased Recruitment (n=385) - VT 6 ml/kg PBW - PEEP to reach Pplat 28-30 cmH2O Mortality: MD 31.2%, IR 27.8 %, p=.31 Vent. Free Days: MD 3, IR 7, p=.04 Organ Failure Free Days: MD 2, IR 6, p=.04 IR assocaited with better PaO2, Crs, less adjunctive therapies and larger fluid requir.

  29. JAMA, Feb.13, 2008;209:637-45 ALI pts. & PaO2 < 250 mmHg (n=983) Control Ventilation (n=508): - VT 6 ml/kg PBW, Pplat < 30 cmH2O, - PEEP mean 9.8 cmH2O -Table- Lung Open Ventilation (n=475) - VT 6 ml/kg PBW, Pplat < 40 cmH2O - PEEP mean 14.6 cmH2O -Table- & RMs. Mortality: CV 40.4%, LOV 36.4%, p=.19 Refractory Hipoxemia: CV 10%, LOV 5% p=.01 Rescue Therapies: CV 13%, LOV 8%, p=.05 RM associated with a complication in 22.1% of p.

  30. What Is New in ARDS ? • Definition • Types • Therapy • Mechanical Ventilation • Practice & Organization

  31. Assessing practice changes 1998 (1.383 p.) 2004 (1.675 p.)

  32. Thank You lblanch@tauli.cat

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