ARDS - trauma

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Lungs might be affected by trauma, chemicals, infections.
patients show in respiratory failure.

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ARDS - trauma

  1. 1. Acute Respiratory Distress Syndrome. Case presentation Dr. Adel Hassan Sen. Consult. Anesthesiologist HOD Anesthesia & ICU. Kalba Hospital, MOH. 31st March 2014
  2. 2. F. 35ys , 300 Kgs, Lt. TIBIA/FIBULA Fx (Impacted In place). 8th D -in pat. w.- after admission, sudden severe hypoxia PH 7.22 PaCO2 =72 mmhg PaO2=43 mmhg HCO36 , Unconscious. Anesthesia on duty was called to IPW. Supported ventilation shifted pt. to ICU. Management started as will be discussed later.
  3. 3. Acute Respiratory Failure • Failure in one or both gas exchange functions: oxygenation and carbon dioxide elimination • In practice: PaO2<60mmHg or PaCO2>46mmHg • Derangements in ABGs and acid-base status
  4. 4. Acute Respiratory Failure • Hypercapnic v Hypoxemic respiratory failure • ARDS and ALI
  5. 5. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Problem VCO2 V/Q Abnormality Hypermetabolism Overfeeding
  6. 6. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Problem VCO2 V/Q Abnormality Hypermetabolism Overfeeding
  7. 7. Hypercapnic Respiratory Failure Alveolar Hypoventilation Brainstem respiratory depression Drugs (opiates) Obesity-hypoventilation syndrome PI max Central Hypoventilation Neuromuscular Disorder nlPI max Critical illness polyneuropathy Critical illness myopathy Hypophosphatemia Magnesium depletion Myasthenia gravis Guillain-Barre syndrome
  8. 8. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Disorder VCO2 V/Q Abnormality Hypermetabolism Overfeeding
  9. 9. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding
  10. 10. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding • Increased dead space ventilation • advanced emphysema • PaCO2 when Vd/Vt >0.5 • Late feature of shunt-type • edema, infiltrates
  11. 11. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding • VCO2 only an issue in pts with ltd ability to eliminate CO2 • Overfeeding with carbohydrates generates more CO2
  12. 12. Hypoxemic Respiratory Failure Is PaCO2 increased? Hypoventilation (PAO2 - PaO2)? Hypoventilation alone Respiratory drive Neuromuscular dz Hypovent plus another mechanism Shunt Inspired PO2 High altitude FIO2 (PAO2 - PaO2) No NoYes Is low PO2 correctable with O2? V/Q mismatch No Yes Yes
  13. 13. The Case of Patient ES 77F s/p MVC. Injuries include multiple L rib fxs, L hemopneumothorax s/p chest tube placement, L iliac wing fx. PMH: atrial arrhythmia, on coumadin. INR>2 HD#1 RR 30s and shallow. Pain a/w breathing deeply. Placed on BiPAP overnight PID#1 BiPAP 80%: 7.45/48/66/32/+10
  14. 14. Hypoxemic Respiratory Failure Is PaCO2 increased? Hypoventilation (PAO2 - PaO2)? Hypoventilation alone Respiratory drive Neuromuscular dz Hypovent plus another mechanism Shunt Inspired PO2 High altitude FIO2 (PAO2 - PaO2) No NoYes Is low PO2 correctable with O2? V/Q mismatch No Yes Yes
  15. 15. Hypoxemic Respiratory Failure V/Q mismatch V/Q mismatch DO2/VO2 Imbalance PvO2>40mmHg PvO2<40mmHg DO2: anemia, low CO VO2: hypermetabolism
  16. 16. Hypoxemic Respiratory Failure V/Q mismatch SHUNT V/Q = 0 DEAD SPACE V/Q = ∞ Atelectasis Intraalveolar filling Pneumonia Pulmonary edema Pulmonary embolus Pulmonary vascular dz Airway dz (COPD, asthma) Intracardiac shunt Vascular shunt in lungs ARDS Interstitial lung dz Pulmonary contusion
  17. 17. Hypoxemic Respiratory Failure V/Q mismatch SHUNT V/Q = 0 DEAD SPACE V/Q = ∞ Atelectasis Intraalveolar filling Pneumonia Pulmonary edema Pulmonary embolus Pulmonary vascular dz Airway dz (COPD, asthma) Intracardiac shunt Vascular shunt in lungs ARDS Interstitial lung dz Pulmonary contusion
  18. 18. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • Severe ALI • B/L radiographic infiltrates • PaO2/FiO2 <200mmHg (ALI 201-300mmHg) • No e/o L Atrial P; PCWP<18
  19. 19. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • Develops ~4-48h • Persists days-wks • Diagnosis: – Distinguish from cardiogenic edema – History and risk factors
  20. 20. Inflammatory Alveolar Injury
  21. 21. Inflammatory Alveolar Injury Pro-inflmm cytokines (TNF, IL1,6,8)
  22. 22. Inflammatory Alveolar Injury Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
  23. 23. Inflammatory Alveolar Injury Fluid in interstitium and alveoli Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
  24. 24. Inflammatory Alveolar Injury Fluid in interstitium and alveoli • Impaired gas exchange •  Compliance •  PAP Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
  25. 25. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Exudative phase Fibrotic phaseProliferative phase Diffuse alveolar damage
  26. 26. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Direct Lung Injury • Infectious pneumonia • Aspiration, chemical pneumonitis • Pulmonary contusion, penetrating lung injury • Fat emboli • Near-drowning • Inhalation injury • Reperfusion pulmonary edema s/p lung transplant
  27. 27. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Indirect Lung Injury • Sepsis • Severe trauma with shock / hypoperfusion • Burns • Massive blood transfusion • Drug overdose: ASA, cocaine, opioids, phenothiazines, TCAs. • Cardiopulmonary bypass • Acute pancreatitis
  28. 28. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Complications • Barotrauma • Nosocomial pneumonia • Sedation and paralysis  persistent MS depression and neuromuscular weakness
  29. 29. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • 861 patients, 10 centers • Randomized • Tidal Vol 12mL/kg PDW, PlatP<50cmH2O • Tidal Vol 6mL/kg PDW, PlatP<30cmH2O • NNT 12 • 31% mortality v 39.8% • 65.7% breathing without assistance by day 28 v 55% • Significantly more ventilator-free days • Significantly more days without failure of nonpulmonary organs/systems

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