slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn PowerPoint Presentation
Download Presentation
Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn

Loading in 2 Seconds...

play fullscreen
1 / 37

Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn - PowerPoint PPT Presentation


  • 121 Views
  • Uploaded on

Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn The Department of Critical Care Medicine, The Hospital for Sick Children, Toronto. Paediatric BMT and Critical Care. Sepsis Respiratory Airway obstruction Pneumonia/pneumonitis Pulmonary haemorrhage

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn' - jenna-gamble


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient

Desmond Bohn

The Department of Critical Care Medicine, The Hospital for Sick Children, Toronto

slide2

Paediatric BMT and Critical Care

Sepsis

Respiratory

Airway obstruction

Pneumonia/pneumonitis

Pulmonary haemorrhage

Interstitial pneumonitis

ARDS

Neurological

Seizures

Intracranial haemorrhage

slide3

Paediatric BMT and Critical Care

Hepatic failure

Venocclusive disease

GVHD

Renal failure

Drug nephrotoxicity

Cardiac failure

Drug toxicity

slide4

ICU outcomes in paediatric BMT patients

Diaz de Heredia C Bone Marrow Transplantation 1999; 24:163-168

31/176 patients admitted to ICU post BMT - 18%

n BMT BMT

allogenic autologous

ARF 15 10 5

Septic shock 5 3 2

Neurological disorders 5 5

Heart failure 2 2

Others 4 2 2

26 patients underwent mechanical ventilation - survival 46%

slide5

BAL in ventilated and non-ventilated in children after BMT

Ben-Ari J Bone Marrow Transplantation 2001; 27:191

non-ventilated

ventilated

slide8

Diffuse alveolar haemorrhage in BMT patients

  • Presents with cough and tachypneoa
  • No underlying infective aetiology
  • Pulmonary haemorrhage on BAL
  • Usually occurs following engraftment
  • Incidence 5 - 10%
  • Characterised by thrombocytopoenia but normal coagulation
  • Treated with high dose steroids and PEEP
  • High mortality
slide10

Markers of oxygenation defect

PaO2/FiO2

< 200 = ARDS

Oxygenation

Index

MAP x FiO2 x 100

>15 = severe ARDS

PaO2

slide12

Goals:

1. Avoid Overdistention

2. Avoid Underinflation

3. Keep the lung open

4. Reduce FiO2

Froese AB, Crit Care Med 1997; 25:906

slide13

Responses of baboons to prolonged hyperoxia

Fracica PJ J Appl Physiol 1991; 71:2352

normal

lethal toxicity - FiO2 1.0 for 110 h

alveolus

PMN

interstitial matrix

PMN

alveolus

PMN

interstitial matrix

alveolus

alveolus

slide14

Pulmonary oxygen toxicity

Davis WB N Engl J Med 1983; 309:878

FiO2 0.9 for 17 hrs in healthy humans

slide15

VOLUME 342 MAY 4, 2000 NUMBER 18

VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH TRADITIONAL TIDAL VOLUMES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROME

THE ACUTE RESPIRATORY DISTRESS SYNDROME NETWORK

slide17

Surfactant in ARDS

Willson D Crit Care Med 1999; 27:188

Infasurf

Surfactant proteins B & C

42 children with ARDS

slide18

Control

iNO

Nitric oxide in ARDS

Dobyns EL J Pediatr 1999;134:406

60

10

50

5

*

4 hours 12 hrs

0

40

*

Change in P/F ratio from baseline

Change in OI from baseline

30

-5

20

-10

*

*

-15

10

0

-20

4 hours 12 hrs

slide19

Nitric oxide in ARDS

n=40

n=177

n=30

Michael JR

Am J Respir Crit Care Med

1999; 157:1372

Dellinger RP

Crit Care Med 1998; 26:15

Troncy E

Am J Respir Crit Care Med

1997; 157:1483

slide20

Nitric oxide in ARDS

5 RCTs in adults

3 case series and 2 RCTs in pediatrics

Physiological endpoints - improved oxygenation & reduction in PAP

40 - 60% of patients are “responders”

No data suggests any improvement in outcome

slide21

Steroids in ARDS

MeduriGU JAMA 1998; 280:159

MODS Score Outcome

slide23

Effect of prone position on survival in ARDS

Gattinoni L N Engl J Med 2001; 345:568

slide24

Effect of prone position on survival in ARDS

Gattinoni L N Engl J Med 2001; 345:568

slide25

RCT of prone vs supine ventilation in ARDS/ALI

Gattinoni L N Engl J Med 2001; 345:568

304 patients randomised in 3 yrs

Mortality (%) Supine Prone

Intention to treat

End of study 25 21

ICU discharge 48 50.7

Prone vs supine protocol

End of study 27 22

ICU discharge 49.3 52.2

*Patients with P/F <88 40 20

slide27

HFOV in Paediatric ARDS

Arnold J. Crit Care Med 1994; 22:1530

CMV HFOV

No. of patients 29 29

Duration of CMV 80 ± 81 143 ± 240

FiO2 0.83 ± 0.18 0.84 ± 0.15

PEEP 21 ± 5 22 ± 3

OI 29 ± 14 26 ± 10

slide28

Algorithm for the use of HFOV

MAP >5 cmH2O above CMV setting (25-30 cmH2O)

High FiO2 (>0.8)

Maintain MAP for 10-15 mins

Attempt to decrease FiO2

yes

no

Decrease FiO2

in increments to <0.6

Increase the MAP

in increments of 2 cmH2O

Response usually at 30-35 cmH20

slide29

Oxygen extraction ratio = (CaO2 - CvO2)/CaO2

.

VO2 = Q x (CaO2 - CvO2)

Oxygen delivery/consumption

DO2 = Q x CaO2

.

As DO2 decreases VO2 maintained by increased extraction

slide30

Published outcomes in paediatric BMT patients admitted to ICU

Number of Number Survival

BMTs ventilated ventilated patients

Lamas 1991-2000 151 34 5(23%)

Hagen 1990-99 - 86 32(37%)

Jacobe 1994-98 210 36 15 (41%)

Keenan 1983-96 1080 121 19(16%)

Rossi 1986-95 355 39 17(44%)

Warwick 1976-92 869 196 79(40%)

Diaz de Heredia 1991-95 176 26 12(46%)

Hayes 1987-97 367 33 5(15%)

Nichols 1978-88 23 2(9%)

Bojko 1986-93 43 5(12%)

Todd 1973-90 54 6(11%)

slide31

AHRF: an integrated approach

Pressure control ventilation (PIP <35 cmH2O)

Negative fluid balance (furosimide)

HFOV

Prone position ventilation

iNO 5 -20 ppm

?ECMO

slide32

Prognosis of paediatric BMT patients requiring ventilation

Rossi R Crit Care Med 1999; 27:1181

n = 41

slide33

Prognosis of paediatric BMT patients requiring PPV

Rossi R Crit Care Med 1999; 27:1181

slide34

Ventilation in paediatric BMT patients

Hagen SA Pediatric Crit Care Med 2003; 4:206

slide35

Ventilation in paediatric BMT patients

Hagen SA Pediatric Crit Care Med 2003; 4:206

slide36

Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient

Acute respiratory failure requiring PPV in the BMT patient is associated with a high mortality

Therapy should be focused on minimising ventilation induced lung injury

Ventilation strategies that improve oxygenation may not improve O2 delivery

The development of hepato-renal failure is almost universally fatal