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Rob Mac Sweeney
SMACCgold 2014
rob@criticalcarereviews.com / @critcarereviews
ARDS
An Evidence Based Update
Disclosure
• Research funding from Northern Ireland Health and Social Care
Research and Development Board
• Research into ...
Rob Mac Sweeney
SMACCgold 2014
rob@criticalcarereviews.com / @critcarereviews
ARDS
An Evidence Based Update
A Condition That….
1. can’t diagnose
2. of limited use
3. no specific treatment for
4. people don’t die from
……….. doesn’t...
Wikimedia Commons
Wikimedia Commons
Wikimedia Commons
Causes
Pulmonary
• Pneumonia
• Pulmonary contusion
• Inhalational injury
• Aspiration
• Fat embolism
• Near Drowning
Extra...
Acute Respiratory Distress Syndrome
Acute Respiratory Distress Syndrome
Original
Description
• Case Series of 12
Original
Description
• Syndrome of
• Severe Dyspnoea
• Tachypnoea
• Cyanosis refractory to oxygen therapy
• Loss of lung c...
Acute Lung Injury
ALI ARDS
300 – 200 mmHg < 200 mmHg
40 – 26.6 kPa < 40 kPa
Acute Respiratory Distress Syndrome
mild moderate severe
< 300 mmHg < 200 mmHg
< 40 kPa < kPa 26.6
< 100 mmHg
< kPa 13.3
Wikimedia Commons
Definition
Prediction
Clinical Utility
Autopsy Timing
Definition
Prediction
Clinical Utility
Autopsy
Timing Oedema
Timing
Definition
Prediction
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2
Radiograph
Infiltrates
Oedema
Origin
Definition
Prediction
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2
OxygenationOxygenation
Definition
Prediction
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2
Infiltrates
Infiltrates
Infiltrates
Definition
Utility
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2
Infiltrates
Infiltrates
Definition
Utility
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporality
Temporary
Temporality
Definition
Utility
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Clinical Use
Temporary Reality
Clinical
Re...
Definition
Utility
Clinical Utility
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporary
Clinical
Consequence
Recognition...
Definition
Utility
Mortality
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporary RecognitionReality
Definition
Utility
Mortality
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporary
Severity
Cause
Recognition
Cause
Reality
Definition
Utility
Mortality
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporary
Severity
Cause Prediction
Recognition
P...
Definition
Utility
Mortality
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporary
Severity
Cause Prediction
RecognitionRe...
Definition
Utility
Mortality
Autopsy
Timing Oedema PaO2/FiO2 Infiltrates
Temporary
Diffuse
Alveolar
Damage
Cause Predictio...
Source: Wikimedia Commons
50%
One in Two
DAD
ARDS
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD Cancer
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD Cancer
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD Cancer
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD Cancer
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD Cancer
DAD
ARDS
Pneumonia
No Lesion
Abscess
COPD Cancer
DAD
PE
Bleeding
Fibrosis
PO
TB
ARDS
DAD
ARDS
DAD
NON - DAD
ARDS
ARDS
NON - ARDS
ARDS
NON - ARDS
Therapy
General
ARDS
NON - ARDS
Therapy
DAD
Specific
ARDS – A Condition That….
1. can’t diagnose (we can’t agree to diagnose)
2. of limited use (doesn’t change management)
3. ...
ARDS – A Condition That….
1. can’t diagnose (we can’t agree to diagnose)
2. of limited use (doesn’t change management)
3. ...
ARDS – A Condition That….
1. can’t diagnose (we can’t agree to diagnose)
2. of limited use (doesn’t change management)
3. ...
ARDS – A Condition That….
1. can’t diagnose (we can’t agree to diagnose)
2. of limited use (doesn’t change management)
3. ...
ARDS – A Condition That….
1. can’t diagnose (we can’t agree to diagnose)
2. of limited use (doesn’t change management)
3. ...
ARDS – A Condition That….
1. can’t diagnose (we can’t agree to diagnose)
2. of limited use (doesn’t change management)
3. ...
Therapeutic
Evidence-
Base
Timing InfiltratesOedema PaO2/FiO2
Temporary Function Clinical
Severity Mortality
DAD
?
Ventilatory Adjuncts
Haemodynamics
Drugs
ECMO
Ventilation
Tidal
Volume
• 861 ARDS patients (P/F < 300 cm H20)
• 6 ml/kg & Pplt ≤ 30 cm H20
versus
• 12 ml/kg & Pplt ≤ 50 cm H20
• 9%...
Tidal
Volume
• 150 critically ill mechanically
ventilated patients
• 6 ml/kg vs 10 ml/kg
Development of ARDS
• 2.6% versus...
Tidal
Volume
• 400 patients undergoing major
abdominal surgery
• 10-12 ml/kg & ZEEP & no recruitment
versus
• 6-8 ml/kg & ...
Oscillate
• 548 ARDS patients
• PaO2/FiO2 < 200 cmH20
• Fi02 > 0.5
In-hospital mortality
• HFOV 47% vs Control 35%
(RR 1.3...
Oscar
• 548 ARDS patients
• PaO2/FiO2 < 200 cmH20
• PEEP > 5 cmH20
30 day mortality
• HFOV 41.7% vs Control 41.1%
• Differ...
Haemodynamics
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Haemodynamics
Drugs
ECMO
Ventilation
ACURASYS Study
• 340 ARDS patients
• PaO2/FiO2 < 150 mmHg
Adjusted Mortality at Day 90
• NMB: 31.6% vs placebo: 40.7%
• HR...
PROSEVA
Study
• 466 ARDS patients
• PaO2/FiO2 < 150 cmH20
28 day mortality
• Prone: 16% vs Control 32.8%
Unadjusted 90-day...
Prone
Ventilation
• 4 RCTS
• 1,573 patients
In the most hypoxaemic
• 486 patients
• PaO2/FiO2 < 100 mmHg
• absolute mortal...
Ventilatory Adjuncts
NMBs
Drugs
ECMO
Ventilation
Prone
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
FACTT
Study
• 1000 patients with ALI
• 0 ml vs 7000 ml fluid balance at day 7
60 Day Mortality
• Conservative: 25.5% vs li...
FACTT
Study
• 1000 patients with ALI
• 0 ml vs 7000 ml fluid balance at day 7
60 Day Mortality
• Conservative: 25.5% vs li...
FACTT
Study
• 1000 patients with ALI
• 0 ml vs 7000 ml fluid balance at day 7
60 Day Mortality
• Conservative: 25.5% vs li...
Ventilatory Adjuncts
Fluids
Fluids CVC
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Drugs
Drugs
Clinically Tested
1. NMBs √
2. Steroids ?
3. Surfactant X
4. β2 agonists X
5. Diuretics ?
6. Ketoconazole X
7. Activ...
Drugs
Clinically Tested
1. NMBs √
2. Steroids ?
3. Surfactant X
4. β2 agonists X
5. Diuretics ?
6. Ketoconazole X
7. Activ...
Drugs
Clinically Tested
1. NMBs √
2. Steroids ?
3. Surfactant X
4. β2 agonists X
5. Diuretics ?
6. Ketoconazole X
7. Activ...
Drugs
Clinically Tested
1. NMBs √
2. Steroids ?
3. Surfactant X
4. β2 agonists X
5. Diuretics ?
6. Ketoconazole X
7. Activ...
ALTA
Study
• 282 patients with ALI
• Aerosolized albuterol vs saline
Ventilator-free days
• albuterol 14.4 vs control 16.6...
BALTI 2
Study
• 326 ARDS patients
• PaO2/FiO2 < 200 mmHg
• IV salbutamol vs placebo
28 day mortality
• salbutamol: 34% vs ...
Nitric Oxide
Severe ARDS
• n = 329, six trials
• RR 1.01; 95% CI 0.78 to 1.32; p = 0.93
Mild to Moderate ARDS
• n = 740, s...
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
ECMO
CESAR STUDY
• 170 patients with severe respiratory
failure
6 month mortality outcome
• ECMO centre 63% vs referral 47...
ECMO
ANZICS H1N1 ECMO Case Series
• 2009 influenza A(H1N1) - associated
ARDS
• 68 patients
• Median PaO2/FiO2 56 (48-63) m...
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
Ventilatory Adjuncts
Fluids
Drugs
ECMO
Ventilation
To Summarise
1. The positive studies would likely be positive in
any critical care condition
2. The negative studies are p...
To Summarise
1. The positive studies would likely be positive in
any critical care condition
2. The negative studies may b...
To Summarise
1. The positive studies would likely be positive in
any critical care condition
2. The negative studies may b...
To Summarise
1. The positive studies would likely be positive in
any critical care condition
2. The negative studies may b...
ARDS – A Condition That….
1. can’t diagnose
2. of limited use
3. no specific treatment for
4. people don’t die from
…….doe...
Final Thoughts
1. ARDS studies need to be able to identify
alveolar injury
2. Did the AECCC prevent us from adequately
inv...
http://www.flickr.com/photos/furlined/6744550629
References at:
www.criticalcarereviews.com/SMACC
Autopsy
Case Series
• 712 Autopsies
• 356 ARDS patients
• 159 had DAD (45%)
• 75% of severe ARDS had DAD
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
ARDS -    An Evidence Based Update by Rob Mac Sweeney
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ARDS - An Evidence Based Update by Rob Mac Sweeney

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A talk given by Rob Mac Sweeney from criticalcarereviews.com at the SMACCgold conference March 2014 in Australia

Published in: Health & Medicine

Transcript of "ARDS - An Evidence Based Update by Rob Mac Sweeney"

  1. 1. Rob Mac Sweeney SMACCgold 2014 rob@criticalcarereviews.com / @critcarereviews ARDS An Evidence Based Update
  2. 2. Disclosure • Research funding from Northern Ireland Health and Social Care Research and Development Board • Research into ARDS biomarkers • http://www.criticalcarereviews.com/index.php/smacc-2014 References
  3. 3. Rob Mac Sweeney SMACCgold 2014 rob@criticalcarereviews.com / @critcarereviews ARDS An Evidence Based Update
  4. 4. A Condition That…. 1. can’t diagnose 2. of limited use 3. no specific treatment for 4. people don’t die from ……….. doesn’t actually exist
  5. 5. Wikimedia Commons
  6. 6. Wikimedia Commons
  7. 7. Wikimedia Commons
  8. 8. Causes Pulmonary • Pneumonia • Pulmonary contusion • Inhalational injury • Aspiration • Fat embolism • Near Drowning Extra-Pulmonary • Extra-pulmonary sepsis • Trauma • Burns • Acute Pancreatitis • Massive Transfusion • Drug overdose
  9. 9. Acute Respiratory Distress Syndrome
  10. 10. Acute Respiratory Distress Syndrome
  11. 11. Original Description • Case Series of 12
  12. 12. Original Description • Syndrome of • Severe Dyspnoea • Tachypnoea • Cyanosis refractory to oxygen therapy • Loss of lung compliance • Benefit with PEEP • Possible benefit with steroids • Diffuse alveolar infiltration
  13. 13. Acute Lung Injury ALI ARDS 300 – 200 mmHg < 200 mmHg 40 – 26.6 kPa < 40 kPa
  14. 14. Acute Respiratory Distress Syndrome mild moderate severe < 300 mmHg < 200 mmHg < 40 kPa < kPa 26.6 < 100 mmHg < kPa 13.3
  15. 15. Wikimedia Commons
  16. 16. Definition Prediction Clinical Utility Autopsy Timing
  17. 17. Definition Prediction Clinical Utility Autopsy Timing Oedema Timing
  18. 18. Definition Prediction Clinical Utility Autopsy Timing Oedema PaO2/FiO2 Radiograph Infiltrates Oedema Origin
  19. 19. Definition Prediction Clinical Utility Autopsy Timing Oedema PaO2/FiO2 OxygenationOxygenation
  20. 20. Definition Prediction Clinical Utility Autopsy Timing Oedema PaO2/FiO2 Infiltrates Infiltrates Infiltrates
  21. 21. Definition Utility Clinical Utility Autopsy Timing Oedema PaO2/FiO2 Infiltrates Infiltrates
  22. 22. Definition Utility Clinical Utility Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporality Temporary Temporality
  23. 23. Definition Utility Clinical Utility Autopsy Timing Oedema PaO2/FiO2 Infiltrates Clinical Use Temporary Reality Clinical Reality
  24. 24. Definition Utility Clinical Utility Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporary Clinical Consequence Recognition Recognition Reality
  25. 25. Definition Utility Mortality Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporary RecognitionReality
  26. 26. Definition Utility Mortality Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporary Severity Cause Recognition Cause Reality
  27. 27. Definition Utility Mortality Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporary Severity Cause Prediction Recognition Prediction Reality
  28. 28. Definition Utility Mortality Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporary Severity Cause Prediction RecognitionReality
  29. 29. Definition Utility Mortality Autopsy Timing Oedema PaO2/FiO2 Infiltrates Temporary Diffuse Alveolar Damage Cause Prediction DAD RecognitionReality
  30. 30. Source: Wikimedia Commons
  31. 31. 50%
  32. 32. One in Two
  33. 33. DAD ARDS
  34. 34. DAD ARDS
  35. 35. Pneumonia No Lesion Abscess COPD DAD ARDS
  36. 36. Pneumonia No Lesion Abscess COPD Cancer DAD ARDS
  37. 37. Pneumonia No Lesion Abscess COPD Cancer DAD ARDS
  38. 38. Pneumonia No Lesion Abscess COPD Cancer DAD ARDS
  39. 39. Pneumonia No Lesion Abscess COPD Cancer DAD ARDS
  40. 40. Pneumonia No Lesion Abscess COPD Cancer DAD ARDS
  41. 41. Pneumonia No Lesion Abscess COPD Cancer DAD PE Bleeding Fibrosis PO TB ARDS
  42. 42. DAD ARDS
  43. 43. DAD NON - DAD ARDS
  44. 44. ARDS NON - ARDS
  45. 45. ARDS NON - ARDS Therapy General
  46. 46. ARDS NON - ARDS Therapy DAD Specific
  47. 47. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
  48. 48. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
  49. 49. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
  50. 50. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
  51. 51. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
  52. 52. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) …….doesn’t actually exist (half the time)
  53. 53. Therapeutic Evidence- Base Timing InfiltratesOedema PaO2/FiO2 Temporary Function Clinical Severity Mortality DAD ?
  54. 54. Ventilatory Adjuncts Haemodynamics Drugs ECMO Ventilation
  55. 55. Tidal Volume • 861 ARDS patients (P/F < 300 cm H20) • 6 ml/kg & Pplt ≤ 30 cm H20 versus • 12 ml/kg & Pplt ≤ 50 cm H20 • 9% absolute risk reduction in 28 day mortality
  56. 56. Tidal Volume • 150 critically ill mechanically ventilated patients • 6 ml/kg vs 10 ml/kg Development of ARDS • 2.6% versus 13.5%; p = 0.01
  57. 57. Tidal Volume • 400 patients undergoing major abdominal surgery • 10-12 ml/kg & ZEEP & no recruitment versus • 6-8 ml/kg & PEEP 6-8 cm H20 & RM • Postoperative Respiratory Support • 5% vs 17% • RR 0.29 (95% CI 0.14 to 0.61)
  58. 58. Oscillate • 548 ARDS patients • PaO2/FiO2 < 200 cmH20 • Fi02 > 0.5 In-hospital mortality • HFOV 47% vs Control 35% (RR 1.33; 95% CI 1.09 to 1.64; P = 0.005)
  59. 59. Oscar • 548 ARDS patients • PaO2/FiO2 < 200 cmH20 • PEEP > 5 cmH20 30 day mortality • HFOV 41.7% vs Control 41.1% • Difference 0.6%, 95% CI −6.1 to 7.5
  60. 60. Haemodynamics Drugs ECMO Ventilation
  61. 61. Ventilatory Adjuncts Haemodynamics Drugs ECMO Ventilation
  62. 62. ACURASYS Study • 340 ARDS patients • PaO2/FiO2 < 150 mmHg Adjusted Mortality at Day 90 • NMB: 31.6% vs placebo: 40.7% • HR 0.68 (95% CI 0.48 to 0.98; P = 0.04)
  63. 63. PROSEVA Study • 466 ARDS patients • PaO2/FiO2 < 150 cmH20 28 day mortality • Prone: 16% vs Control 32.8% Unadjusted 90-day mortality • Prone: 23.6% vs supine 41.0%
  64. 64. Prone Ventilation • 4 RCTS • 1,573 patients In the most hypoxaemic • 486 patients • PaO2/FiO2 < 100 mmHg • absolute mortality reduction 10% (6% to 21%)
  65. 65. Ventilatory Adjuncts NMBs Drugs ECMO Ventilation Prone
  66. 66. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  67. 67. FACTT Study • 1000 patients with ALI • 0 ml vs 7000 ml fluid balance at day 7 60 Day Mortality • Conservative: 25.5% vs liberal 28.4% 95% CI difference −2.6 to 8.4 %, P=0.3
  68. 68. FACTT Study • 1000 patients with ALI • 0 ml vs 7000 ml fluid balance at day 7 60 Day Mortality • Conservative: 25.5% vs liberal 28.4% 95% CI difference −2.6 to 8.4 %, P=0.3
  69. 69. FACTT Study • 1000 patients with ALI • 0 ml vs 7000 ml fluid balance at day 7 60 Day Mortality • Conservative: 25.5% vs liberal 28.4% 95% CI difference −2.6 to 8.4 %, P=0.3
  70. 70. Ventilatory Adjuncts Fluids Fluids CVC ECMO Ventilation
  71. 71. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  72. 72. Drugs
  73. 73. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X
  74. 74. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X Clinically Untested 1. Prostacyclin 2. Almitrine 3. Ibuprofen 4. N-Acetylcysteine 5. Mucolytics 6. Albumin
  75. 75. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X Clinically Untested 1. Prostacyclin 2. Almitrine 3. Ibuprofen 4. N-Acetylcysteine 5. Mucolytics 6. Albumin Next Wave 1. Statins 2. Aspirin 3. ACEI / ARB 4. Macrolides 5. Insulin 6. Vitamin D 7. Antibodies • Complement • Interleukins 8. Stem cells 9. Growth factors 10. Gene therapy
  76. 76. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X Clinically Untested 1. Prostacyclin 2. Almitrine 3. Ibuprofen 4. N-Acetylcysteine 5. Mucolytics 6. Albumin Next Wave 1. Statins 2. Aspirin 3. ACEI / ARB 4. Macrolides 5. Insulin 6. Vitamin D 7. Antibodies • Complement • Interleukins 8. Stem cells 9. Growth factors 10. Gene therapy
  77. 77. ALTA Study • 282 patients with ALI • Aerosolized albuterol vs saline Ventilator-free days • albuterol 14.4 vs control 16.6 d • 95% CI difference –4.7 to 0.3 d; P = 0.087 Hospital death • albuterol 23.0% vs control 17.7% • 95% CI difference –4.0 to 14.7%, P=0.30
  78. 78. BALTI 2 Study • 326 ARDS patients • PaO2/FiO2 < 200 mmHg • IV salbutamol vs placebo 28 day mortality • salbutamol: 34% vs Control 23% • RR 1∙47, 95% CI 1∙03 to 2∙08
  79. 79. Nitric Oxide Severe ARDS • n = 329, six trials • RR 1.01; 95% CI 0.78 to 1.32; p = 0.93 Mild to Moderate ARDS • n = 740, seven trials • RR1.12, 95% CI 0.89 to 1.42; p = 0.33
  80. 80. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  81. 81. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  82. 82. ECMO CESAR STUDY • 170 patients with severe respiratory failure 6 month mortality outcome • ECMO centre 63% vs referral 47% • RR 0·69; 95% CI 0·05 to 0·97, p=0·03
  83. 83. ECMO ANZICS H1N1 ECMO Case Series • 2009 influenza A(H1N1) - associated ARDS • 68 patients • Median PaO2/FiO2 56 (48-63) mmHg • 71% survival
  84. 84. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  85. 85. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  86. 86. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  87. 87. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  88. 88. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  89. 89. Ventilatory Adjuncts Fluids Drugs ECMO Ventilation
  90. 90. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies are probably negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
  91. 91. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies may be negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
  92. 92. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies may be negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
  93. 93. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies may be negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
  94. 94. ARDS – A Condition That…. 1. can’t diagnose 2. of limited use 3. no specific treatment for 4. people don’t die from …….doesn’t actually exist
  95. 95. Final Thoughts 1. ARDS studies need to be able to identify alveolar injury 2. Did the AECCC prevent us from adequately investigating some therapies? 3. Are critical care syndromes really of any use?
  96. 96. http://www.flickr.com/photos/furlined/6744550629
  97. 97. References at: www.criticalcarereviews.com/SMACC
  98. 98. Autopsy Case Series • 712 Autopsies • 356 ARDS patients • 159 had DAD (45%) • 75% of severe ARDS had DAD
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