Presentation by Dr Papadakos Scribe Knowledge Resources www.scribeofegypt.com

1. Ventilator-InducedSurfactant Dysfunction
PJ Papadakos MD FCCM FCCP FAARC
Director Critical Care Medicine
Professor Anesthesiology, Surgery and Neurosurgery
University of Rochester
Professor Respiratory Care
Genesee Community College

2. Conflict of Interest DisclosurePeter Papadakos MD FCCM
Has no real or apparent
conflicts of interest to report.

3. 20 year collaboration Rotterdam and now Berlin

5. Basic PhysiologyThe Base of Good Care In all trauma patients

8. Pulmonary Surfactant

10. Pulmonary Surfactant was initially identified as a lipoprotein complex that reduces surface tension at the air- liquid interface of the lung

13. Lipids
Levels of total phospholipids decrease over time with cyclic opening and closing especially phosphatidylcholine and phosphatidylglycerol, which are essential for lowering surface tension at the alveolar capillary membrane.
Tsangaris l. et al Eur Respir J 2003, 21:495-501

14. Lung Mechanics change with Lung Collapse

15. Shear Forces

17. Eskaros and Papadakos Respiratory Monitoring in Millers Anesthesia 7thEdition

18. The cycle opening and closing of Alveolar Units
Deplete Surfactant and lead to further collapse through clumping.

23. Key to ImmunologyAnd host defence

24. Lung host defence mechanisms the lung is constantly challenged by inhaled pathogens
Pollutants an particles

25. of a family of proteins known as collectins.

28. Surfactant Proteins A and SP-D potentially bind several receptors, including Toll receptors

29. INCREASED SUCTION FORCES ACROSS ALVEOLAR WALLSURFACTANT INACTIVATION HIGH PERMEABILITY EDEMADECREASEDSURFACTANTACTIVITYINCREASED SURFACE TENSION AT ALVEOLAR WALL

32. NosocomialPneumonia

33. Medicare and Insurance Guidelines

34. Nosocomial Pneumonia
Head of Bed Up
Suctioning Mouth and Subglotic
Mouth Care
Oral intubation and Special ET tubes
Hand washing and gowns
Low gastric volumes
Humidification

35. Presence of atelectasis Leads to impairment of host defense  promotes nosocomial pneumonia

36. Nosocomial Pneumonia True Protection

38. Curr Opin Crit Care 10, 2004: 18-22

39. Surfactant Rplacement
1988

40. Therapy in Children

41. Early surfactant with brief ventilation Vs selective surfactant and MV for preterm with or at risk for RDS
Is associated with
-less need MV
-lower incidence of BPD
-fewer air leak syndromes

42. Which is better ? Natural or synthetic surfactant
Both surfactants are effective in the treatment & prevention of RDS
Early improvement with natural surfactant –
i) Requirement for ventilator support
ii) Fewer pneumothoraces
iii) Fewer deaths
Natural surfactants a desirable choice

43. Beractant
Survanta
Poractant a
Curosurf
Colfosceril
palimitate
Exosurf
Neosurf
Source
Bovine
lung
Porcine
lung
Synth
Bovine
liquid
Prophylaxis
Yes
Yes
Yes
Yes
Treatment
Yes
Yes
Yes
Yes
Initial dose
4 cc/kg
2.5 cc/kg
5cc/kg
5 cc/kg
Vial size
4 / 8 ml
1.5 ml
5 ml
3 / 5 ml
Storage
2-8 C
2-8 C
2-8 C
-10C
Max. doses
4
3
2
3
Getting
ready
Warm at
room temp
for 10 min
Wait for
30 min
Slowly warm
to room temp

44. Implementation of surfactant treatment during CPAP (INSURE)
Reduces the need for MV
Decreased need for surfactant
Relative risk for BPD of 0.51*
(95% CI 0.26 to 0.99)
An option to more effectively treat RDS, particularly in a care setting where transfer is necessary to provide MV

45. Adult Replacement

46. Permissive Atelectasis

47. Many Thanks