Your SlideShare is downloading. ×
0
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
The management of acute respiratory distress syndrome
Upcoming SlideShare
Loading in...5
×

Thanks for flagging this SlideShare!

Oops! An error has occurred.

×
Saving this for later? Get the SlideShare app to save on your phone or tablet. Read anywhere, anytime – even offline.
Text the download link to your phone
Standard text messaging rates apply

The management of acute respiratory distress syndrome

6,552

Published on

Published in: Health & Medicine
1 Comment
2 Likes
Statistics
Notes
  • wonderfull...perfect ......awsome....
       Reply 
    Are you sure you want to  Yes  No
    Your message goes here
No Downloads
Views
Total Views
6,552
On Slideshare
0
From Embeds
0
Number of Embeds
1
Actions
Shares
0
Downloads
391
Comments
1
Likes
2
Embeds 0
No embeds

Report content
Flagged as inappropriate Flag as inappropriate
Flag as inappropriate

Select your reason for flagging this presentation as inappropriate.

Cancel
No notes for slide
  • 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
  • Transcript

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

    ×