The Management of Acute Respiratory Distress Syndrome 署立桃園醫院 胸腔內科 林倬睿醫師
Outlines  <ul><li>Introduction </li></ul><ul><li>Ventilator strategy </li></ul><ul><li>Adjunctive therapy </li></ul><ul><l...
定義  Definition <ul><li>急性  Acute onset </li></ul><ul><li>缺氧  PaO2/FiO2 < 200 mmHg </li></ul><ul><li>CXR: bilateral infiltr...
致病原因 <ul><li>Direct injury </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Gastric aspiration </li></ul></ul><u...
Differential Diagnosis <ul><li>Left ventricular failure </li></ul><ul><li>Intravascular volume overload </li></ul><ul><li>...
Prognosis & Outcome <ul><li>Predictive of death: advanced age, shock, hepatic failure </li></ul><ul><li>Overall 28-day mor...
Pathophysiology  <ul><li>Exudative phase </li></ul><ul><ul><li>Cytokines    inflammation    surfactant dysfunction    a...
NEJM 2000;342:1334-1349
NEJM 2000;342:1334-1349
NEJM 2000;342:1334-1349
Treatment  <ul><li>No specific treatment </li></ul><ul><li>Mainstay of treatment:  supportive care </li></ul><ul><ul><li>A...
Supportive Care <ul><li>Prevention of deep vein thrombosis, gastrointestinal bleeding, and pressure ulcers </li></ul><ul><...
Ventilator Strategy
Ventilator-induced Lung Injury (VILI) <ul><li>Barotrauma </li></ul><ul><li>Volutrauma </li></ul><ul><li>Atelectrauma </li>...
Volutrauma  <ul><li>Increased alveolar wall stress (stretch) by high tidal volume </li></ul><ul><li>Parenchymal injury </l...
Atelectrauma  <ul><li>Cyclic closing and reopening of alveoli </li></ul><ul><li>Alveolar shear stress-related injury </li>...
The PEEP Effect NEJM 2006;354:1839-1841
Ventilator-induced Lung Injury (VILI) Upper Deflection point Lower Inflection point
<ul><li>ARDS Network, 2000:  Multicenter, randomized 861 patients </li></ul>Lung-Protective Ventilation NEJM 2000; 342: 13...
<ul><li>Result: </li></ul><ul><ul><li>Lower 22% mortality (31% vs 39.8%) </li></ul></ul><ul><ul><li>Increase ventilator-fr...
Concerns when using lung-protective strategy… <ul><li>Heterogeneous  distribution </li></ul><ul><li>Hypercapnia  </li></ul...
Other Ventilator Strategies <ul><li>Lung recruitment maneuvers </li></ul><ul><li>Prone positioning </li></ul><ul><li>High-...
Lung Recruitment <ul><li>To open the collapsed alveoli </li></ul><ul><li>A sustained inflation of the lungs to higher airw...
Lung Recruitment NEJM 2007; 354: 1775-1786
Lung Recruitment NEJM 2007; 354: 1775-1786
<ul><li>Potentially recruitable (PEEP 5    15 cmH2O) </li></ul><ul><ul><li>Increase in PaO2:FiO2 </li></ul></ul><ul><ul><...
<ul><li>The percentage of potentially recruitable lung: </li></ul><ul><ul><li>Extremely variable, </li></ul></ul><ul><ul><...
Prone Position
Prone Position <ul><li>Mechanisms to improve oxygenation: </li></ul><ul><ul><li>Increase in end-expiratory lung volume </l...
Prone Position NEJM 2001;345:568-573
Prone Position NEJM 2001;345:568-573
<ul><li>Improve oxygenation in about 2/3 of all treated patients </li></ul><ul><li>No improvement on survival, time on ven...
High-Frequency Oscillatory Ventilation (HFOV)
HFOV Frequency: 180-600 breaths/min (3-10Hz)
Effect of HFOV on gas exchange in ARDS patients AJRCCM 2002; 166:801-8
Survival difference of ARDS patients treated with HFOV or CMV 30-day: P=0.057 90-day: P=0.078 AJRCCM 2002; 166:801-8
HFOV <ul><li>Complications: </li></ul><ul><ul><li>Recognition of a pneumothorax </li></ul></ul><ul><ul><li>Desiccation of ...
Adjunctive Therapy <ul><li>Steroid treatment </li></ul><ul><li>Fluid management </li></ul><ul><li>Extracorporeal membrane ...
Steroid therapy NEJM 2006;354:1671-1684
<ul><li>Increase the number of ventilator-free and shock-free days during the first 28 day </li></ul><ul><li>Improve oxyge...
Fluid Management NEJM 2006;354:2564-2575
Fluid Management NEJM 2006;354:2564-2575
Fluid Management NEJM 2006;354:2213-24
<ul><li>Conservative strategy improves lung function and shortens the duration of ventilator use and ICU stay </li></ul><u...
Extracorporeal Membrane Oxygenation (ECMO) <ul><li>No improvement on survival or time on ventilation </li></ul><ul><li>Sub...
Nitric Oxide <ul><li>Vasodilator  </li></ul><ul><li>Improve oxygenation and pulmonary vascular resistance </li></ul><ul><l...
Unproven Treatments <ul><li>Ketoconazole  </li></ul><ul><li>Pentoxyfilline and lisofylline </li></ul><ul><li>Nutritional m...
Conclusions  <ul><li>The only treatment that shows mortality benefit:  </li></ul><ul><ul><li>lung-protective ventilation s...
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The management of acute respiratory distress syndrome

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  • Limitations: 生理定義不需要標準呼吸器治療 , 醫師判讀有差異
  • Predisposing: alcoholism, severe sepsis, genetic predisposition Direct or indirect, outcome is similar
  • 不一定想到 , 想到不一定判斷的出
  • 一開始的缺氧不是好的預測指標 , 但 severe hypoxia for days 則是
  • TNF, IL1,IL8 Tissue factor, plasminogen activator inhibitor 1
  • 近年重要觀念 : 不均勻 , 體重大於預期 ( 可能大於 20%), 呼吸器會導致傷害 , 雖然一開始不明顯
  • taken at the end of inspiration. A=0, B=15, C=15 x3, D= 15*5 F=0*1, G = 0*3, H =0*5
  • 用的是預期體重
  • 目前唯一對 mortality 有效的方法
  • 高低的分界是 9%
  • 不論哪一組 , 都大約有 24% 的肺無法打開
  • The management of acute respiratory distress syndrome

    1. 1. The Management of Acute Respiratory Distress Syndrome 署立桃園醫院 胸腔內科 林倬睿醫師
    2. 2. Outlines <ul><li>Introduction </li></ul><ul><li>Ventilator strategy </li></ul><ul><li>Adjunctive therapy </li></ul><ul><li>Case demonstration </li></ul>
    3. 3. 定義 Definition <ul><li>急性 Acute onset </li></ul><ul><li>缺氧 PaO2/FiO2 < 200 mmHg </li></ul><ul><li>CXR: bilateral infiltrates 雙側浸潤 </li></ul><ul><li>排除心因性呼吸衰竭 PAWP < 18 mmHg, no clinical evidence of LA HTN </li></ul>
    4. 4. 致病原因 <ul><li>Direct injury </li></ul><ul><ul><li>Pneumonia </li></ul></ul><ul><ul><li>Gastric aspiration </li></ul></ul><ul><ul><li>Drowning </li></ul></ul><ul><ul><li>Fat and amniotic fluid embolism </li></ul></ul><ul><ul><li>Pulmonary contusion </li></ul></ul><ul><ul><li>Alveolar hemorrhage </li></ul></ul><ul><ul><li>Toxic inhalation </li></ul></ul><ul><ul><li>Reperfusion </li></ul></ul><ul><li>Indirect injury </li></ul><ul><ul><li>Severe sepsis </li></ul></ul><ul><ul><li>Transfusions </li></ul></ul><ul><ul><li>Shock </li></ul></ul><ul><ul><li>Salicylate or narcotic overdose </li></ul></ul><ul><ul><li>Pancreatitis </li></ul></ul>
    5. 5. Differential Diagnosis <ul><li>Left ventricular failure </li></ul><ul><li>Intravascular volume overload </li></ul><ul><li>Mitral stenosis </li></ul><ul><li>Veno-occlusive disease </li></ul><ul><li>Lymphangitic carcinoma </li></ul><ul><li>Interstitial and airway diseases </li></ul><ul><ul><li>Hypersensitivity pneumonitis </li></ul></ul><ul><ul><li>Acute eosinophilic pneumonia </li></ul></ul><ul><ul><li>Bronchiolitis obliterans with organising pneumonia </li></ul></ul>Lancet 2007; 369:1553-65
    6. 6. Prognosis & Outcome <ul><li>Predictive of death: advanced age, shock, hepatic failure </li></ul><ul><li>Overall 28-day mortality: 20-40% </li></ul><ul><li>Lung function: returns to normal over 6-12 months </li></ul><ul><li>Common complications: neuropsychiatric problems, neuromuscular weakness </li></ul>Lancet 2007; 369:1553-65
    7. 7. Pathophysiology <ul><li>Exudative phase </li></ul><ul><ul><li>Cytokines  inflammation  surfactant dysfunction  atelectasis </li></ul></ul><ul><ul><li>Elastase  epithelial barrier damage  edema </li></ul></ul><ul><ul><li>Procoagulant tendency  capillary thrombosis </li></ul></ul><ul><li>Fibroproliferative phase </li></ul><ul><ul><li>Chronic inflammation </li></ul></ul><ul><ul><li>Fibrosis </li></ul></ul><ul><ul><li>neovascularisation </li></ul></ul>Lancet 2007; 369:1553-65
    8. 8. NEJM 2000;342:1334-1349
    9. 9. NEJM 2000;342:1334-1349
    10. 10. NEJM 2000;342:1334-1349
    11. 11. Treatment <ul><li>No specific treatment </li></ul><ul><li>Mainstay of treatment: supportive care </li></ul><ul><ul><li>Avoid iatrogenic complications </li></ul></ul><ul><ul><li>Treat the underlying cause </li></ul></ul><ul><ul><li>Maintain adequate oxygenation </li></ul></ul>
    12. 12. Supportive Care <ul><li>Prevention of deep vein thrombosis, gastrointestinal bleeding, and pressure ulcers </li></ul><ul><li>Semi-recumbent position </li></ul><ul><li>Enteral nutrition </li></ul><ul><li>Infection control </li></ul><ul><li>Goal-directed sedation practice </li></ul><ul><li>Glucose control </li></ul>
    13. 13. Ventilator Strategy
    14. 14. Ventilator-induced Lung Injury (VILI) <ul><li>Barotrauma </li></ul><ul><li>Volutrauma </li></ul><ul><li>Atelectrauma </li></ul><ul><li>Biotrauma </li></ul>Over Distension Collapse
    15. 15. Volutrauma <ul><li>Increased alveolar wall stress (stretch) by high tidal volume </li></ul><ul><li>Parenchymal injury </li></ul><ul><ul><li>Gross physical disruption </li></ul></ul><ul><ul><li>Stretch-responsive inflammatory pathways </li></ul></ul>AJRCCM 1998; 157: 294-323
    16. 16. Atelectrauma <ul><li>Cyclic closing and reopening of alveoli </li></ul><ul><li>Alveolar shear stress-related injury </li></ul><ul><li>Heterogeneous nature of lung aeration in ALI/ARDS </li></ul>PEEP PEEP PEEP Lung edema
    17. 17. The PEEP Effect NEJM 2006;354:1839-1841
    18. 18. Ventilator-induced Lung Injury (VILI) Upper Deflection point Lower Inflection point
    19. 19. <ul><li>ARDS Network, 2000: Multicenter, randomized 861 patients </li></ul>Lung-Protective Ventilation NEJM 2000; 342: 1301-1308 39.8% 31.0% Result (p<0.001) 9.1 8.1 Actual PEEP Protocol Protocol PEEP <50 <30 P plateau 12 6 Tidal Volume (ml/kg) Conventional ventilation Lung-protective ventilation 18-24 14-18 14 10-14 10 8-10 5-8 5 PEEP 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 FiO2 Principle for FiO2 and PEEP Adjustment
    20. 20. <ul><li>Result: </li></ul><ul><ul><li>Lower 22% mortality (31% vs 39.8%) </li></ul></ul><ul><ul><li>Increase ventilator-free days </li></ul></ul>Lung-Protective Ventilation NEJM 2000; 342: 1301-1308
    21. 21. Concerns when using lung-protective strategy… <ul><li>Heterogeneous distribution </li></ul><ul><li>Hypercapnia </li></ul><ul><li>Auto-PEEP </li></ul><ul><li>Sedation and paralysis </li></ul><ul><li>Patient-ventilator dyssynchrony </li></ul><ul><li>Increased intrathoracic pressure </li></ul><ul><li>Maintenance of PEEP </li></ul>
    22. 22. Other Ventilator Strategies <ul><li>Lung recruitment maneuvers </li></ul><ul><li>Prone positioning </li></ul><ul><li>High-frequency oscillatory ventilation (HFOV) </li></ul>
    23. 23. Lung Recruitment <ul><li>To open the collapsed alveoli </li></ul><ul><li>A sustained inflation of the lungs to higher airway pressure and volumes </li></ul><ul><ul><li>Ex.: PCV, Pi = 45 cmH2O, PEEP = 5 cmH2O, RR = 10 /min, I : E = 1:1, for 2 minutes </li></ul></ul>NEJM 2007; 354: 1775-1786
    24. 24. Lung Recruitment NEJM 2007; 354: 1775-1786
    25. 25. Lung Recruitment NEJM 2007; 354: 1775-1786
    26. 26. <ul><li>Potentially recruitable (PEEP 5  15 cmH2O) </li></ul><ul><ul><li>Increase in PaO2:FiO2 </li></ul></ul><ul><ul><li>Decrease in PaCO2 </li></ul></ul><ul><ul><li>Increase in compliance </li></ul></ul><ul><li>The effect of PEEP correlates with the percentage of potentially recruitalbe lung </li></ul><ul><li>The percentage of recruitable lung correlates with the overall severity of lung injury </li></ul>Lung Recruitment Sensitivity : 71% Specificity : 59% NEJM 2007; 354: 1775-1786
    27. 27. <ul><li>The percentage of potentially recruitable lung: </li></ul><ul><ul><li>Extremely variable, </li></ul></ul><ul><ul><li>Strongly associated with the response to PEEP </li></ul></ul><ul><li>Not routinely recommended </li></ul>Lung Recruitment
    28. 28. Prone Position
    29. 29. Prone Position <ul><li>Mechanisms to improve oxygenation: </li></ul><ul><ul><li>Increase in end-expiratory lung volume </li></ul></ul><ul><ul><li>Better ventilation-perfusion matching </li></ul></ul><ul><ul><li>More efficient drainage of secretions </li></ul></ul>
    30. 30. Prone Position NEJM 2001;345:568-573
    31. 31. Prone Position NEJM 2001;345:568-573
    32. 32. <ul><li>Improve oxygenation in about 2/3 of all treated patients </li></ul><ul><li>No improvement on survival, time on ventilation, or time in ICU </li></ul><ul><li>Might be useful to treat refractory hypoxemia </li></ul><ul><li>Optimum timing or duration ? </li></ul><ul><li>Routine use is not recommended </li></ul>Prone Position
    33. 33. High-Frequency Oscillatory Ventilation (HFOV)
    34. 34. HFOV Frequency: 180-600 breaths/min (3-10Hz)
    35. 35. Effect of HFOV on gas exchange in ARDS patients AJRCCM 2002; 166:801-8
    36. 36. Survival difference of ARDS patients treated with HFOV or CMV 30-day: P=0.057 90-day: P=0.078 AJRCCM 2002; 166:801-8
    37. 37. HFOV <ul><li>Complications: </li></ul><ul><ul><li>Recognition of a pneumothorax </li></ul></ul><ul><ul><li>Desiccation of secretions </li></ul></ul><ul><ul><li>Sedation and paralysis </li></ul></ul><ul><ul><li>Lack of expiratory filter </li></ul></ul><ul><li>Failed to show a mortality benefit </li></ul><ul><li>Combination with other interventions ? </li></ul>Chest 2007; 131:1907-1916
    38. 38. Adjunctive Therapy <ul><li>Steroid treatment </li></ul><ul><li>Fluid management </li></ul><ul><li>Extracorporeal membrane oxygenation (ECMO) </li></ul><ul><li>Nitric oxide </li></ul><ul><li>Others </li></ul>
    39. 39. Steroid therapy NEJM 2006;354:1671-1684
    40. 40. <ul><li>Increase the number of ventilator-free and shock-free days during the first 28 day </li></ul><ul><li>Improve oxygenation, compliance and blood pressure </li></ul><ul><li>No increase in the rate of infectious complications </li></ul><ul><li>Higher rate of neuromuscular weakness </li></ul><ul><li>Routine use of steroid is not supported </li></ul><ul><li>Starting steroid more than 14 days after the onset of ARDS may increase mortality </li></ul>Steroid therapy NEJM 2006;354:1671-1684
    41. 41. Fluid Management NEJM 2006;354:2564-2575
    42. 42. Fluid Management NEJM 2006;354:2564-2575
    43. 43. Fluid Management NEJM 2006;354:2213-24
    44. 44. <ul><li>Conservative strategy improves lung function and shortens the duration of ventilator use and ICU stay </li></ul><ul><li>No significant mortality benefit </li></ul><ul><li>The use of pulmonary artery catheter not routinely suggested </li></ul>Fluid Management
    45. 45. Extracorporeal Membrane Oxygenation (ECMO) <ul><li>No improvement on survival or time on ventilation </li></ul><ul><li>Substantial risk of infection and bleeding </li></ul><ul><li>Not routinely recommended </li></ul>
    46. 46. Nitric Oxide <ul><li>Vasodilator </li></ul><ul><li>Improve oxygenation and pulmonary vascular resistance </li></ul><ul><li>No improvement on survival </li></ul><ul><li>Routine use is not recommended </li></ul>
    47. 47. Unproven Treatments <ul><li>Ketoconazole </li></ul><ul><li>Pentoxyfilline and lisofylline </li></ul><ul><li>Nutritional modification </li></ul><ul><li>Antioxidants </li></ul><ul><li>Neutrophil elastase inhibition </li></ul><ul><li>Surfactant </li></ul><ul><li>Liquid ventilation </li></ul>Lancet 2007; 369:1553-65
    48. 48. Conclusions <ul><li>The only treatment that shows mortality benefit: </li></ul><ul><ul><li>lung-protective ventilation strategy </li></ul></ul><ul><ul><li>Low tidal volume (6ml/Kg), high PEEP, adequate Pplat (<30 cmH2O) </li></ul></ul><ul><li>Modalities to improve oxygenation: </li></ul><ul><ul><li>Prone position, steroid, fluid treatment, steroid, HFOV, NO </li></ul></ul><ul><li>Combining other treatments: </li></ul><ul><ul><li>Activated protein C, antibiotics, EGDT…etc </li></ul></ul>
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