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Ard spresentation
 

Ard spresentation

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    Ard spresentation Ard spresentation Presentation Transcript

    • Acute Respiratory Distress SyndromeARDS
    • Overview • Previously called Adult Respiratory Distress Syndrome • Defined in 1994 American-European Consensus Conference on ARDS: • Most sever Acute Lung Injury • Diffuse alveolar damage • Severe hypoxemia (PaO2/FIO2 < 200) • Bilateral pulmonary infiltrates • Absence of cardiogenic pulmonary edema (PCWP <18 mmHg)
    • Epidemiology • 75 cases/ 100,000 population • Can occur at any age • Risks • advanced age • No sex preference • female sex (only in trauma) • cigarette smoking • alcohol use. • High APACHE score (any underlying cause)
    • Pathophysiology • Diffuse alveolar damage • Increased permeability • Damage to alveolar or capillary endothelium • Inflammation (cytokines, leukotrienes, TNF) • Increased neutrophils ? Reactive • Severe pulmonary shunting  hypoxemia • Pulmonary hypertension
    • Causative Insults • Sepsis • Aspiration • Trauma • Drug overdose • Fractures • Near drowning • Burns • Cardiopulmonary • Massive bypass transfusion • Pancreatitis • Pneumonia • Fat embolism
    • Presentation • Acute dyspnea and hypoxemia • within hours to days of an inciting event • Critically ill • Dyspnea, rapidly progressing • Tachypnea • Agitation • Increasing O2 demands • Often multisystem organ failure
    • Physical Exam • Unspecific • Tachypnea • Tachycardia • Cyanosis • Rales • Sepsis • Hypotension • Peripheral vasoconstriction • Manifestation of the underlying cause • i.e abdominal finding pancreatitis
    • Differential Diagnosis • Pulmonary hemorrhage • Transfusion-related • Near drowning acute lung injury (TRALI) • Drug reaction • Acute eosinophilic • Noncardiogenic pneumonia pulmonary edema • Reperfusion injury • Hamman-Rich • Leukemic infiltration syndrome • Fat embolism syndrome • Retinoic acid syndrome • Acute hypersensitivity pneumonitis
    • Workup • ABG • Hypoxemia • Respiratory alkalosis initially • Respiratory Acidosis ( late) • BNP- exclude cardiogenic pulmonary edema • CXR diffuse bilateral infiltrates • Echocardiogram • Possible CT
    • Treatment • Treatment is supportive + underlying cause • No effective drug for prevention nor management • Xigris • Nitric Oxide • Liquid surfactant • New hopes • Simvastatin • TNF and interleukin antibodies
    • Treatment • Fluid management • Resuscitation vs. maintenance • Negative fluid balance “dry side of normal” • Ventilation • Lung protective • High PEEP ( , low TV ( 6 mL/kg) • Neuromuscular block- improved 90 day survival • ECMO- no improved survival • Proning- no improve survival • Nutrition • Enteral, antioxidants, eicosapentaenoic acid, and gamma-linoleic acid
    • Prognosis • Mortality • Before 1990 , 40-70% • Recent 30-40% • Better understanding and treatment of sepsis. • Increased in older patients • Morbidity • VAP • Weight loss/muscle weakness • Only 49% survivors return to work