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MANAGEMENT OF ARDS

MANAGEMENT OF ARDS. Carl W. Peters, MD Clinical Associate Professor Division of Critical Care Medicine Department of Anesthesiology University of Florida College of Medicine Gainesville, Florida, USA. ARDS--OUTLINE. HISTORY FEATURES OF THE SYNDROME PATHOPHYSIOLOGY MANAGEMENT

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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

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