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Pediatric
Acute Respiratory Distress Syndrome
Dr. Mohammad Avais
UPRIMS&R Saifai
Bismillahirehmaniraheem
ARDS: Old Definition
Criteria:
1. Acute onset (<7 days)
2. Bilateral CXR infiltrates
3. Absence of left atrial hypertensio...
Berlin Definition of ARDS 2012
The significant changes in New Berlin definitions:
Improvement:
a)The ALI category was eliminated and replaced with a grad...
Pediatric Critical Care Medicine 2015
Pediatr Crit Care Med 2015; XX:00–00
• Oxygenation Index = (FIO2 × mean airway pressure ×
100)/PaO2.
• Oxygenation Saturation Index = (FIO2 × mean airway press...
When To Suspect ARDS
Causing Direct Injury
• Pneumonia
• Gastric aspiration
• Less Common
• Pulmonary contusion
• Fat embo...
ARDS - Pathogenesis
Intensive Care Medicine, 2005
Pulmonary Edema
Breakdown of
barriers
Lymphatic
movement
ALVEOLAR EDEMA
Alveolar
lumen
FULL of
fluid
Interstitial
fluid
Pu...
Phases of ARDS
• Acute - exudative, inflammatory
(0 - 3 days)
• Subacute - proliferative
(4 - 10 days)
• Chronic - fibrosi...
Diagnosis
• Pulse oximetry
• Arterial Blood Gas.
• Capnography (end-tidal CO2 measurement)
• A-aO2 gradient: Calculated by...
MANAGEMENT
• Control of causative factor
• Infection- early antibiotic therapy.
• Shock- intravascular volume expansion wi...
Oxygen Administration
• Nasal cannula
• Flow rate <5 L/min.
• FIO2 = 21%+ (nasal cannula flow (L min) × 3)
• Simple mask
•...
• Airway Adjuncts.
• Oropharyngeal Airway.
• Nasopharyngeal airway, or Nasal trumpet.
• Positive Pressure Respiratory Supp...
• Non-conventional ventilation
• High frequency ventilation
• Liquid ventilation
• Drug-based therapies
• Nitric oxide
• S...
Ventilation strategies
• Controlled Oxygen Exposure (FiO2)
• PaO2 target is 55 to 80 mm Hg (SpO2 target 88%-95%).
• Decrea...
Ventilator Goals
• Predicted body weight should be used, based on calculation
from gender and from height or length or fro...
• Tidal Volume (VT)
• Patient-specific tidal volumes according to disease severity.
• VT 3–6 mL/Kg of predicted body weigh...
• Inspiratory Time
• The I:E ratio may be increased to 1:1 or 2:1 (inverse ratio ventilation) to
improve oxygenation.
• Th...
• Weaning
• In volume-controlled ventilation, the VTis usually reduced to
about 4–6 ml/kg.
• In pressure-controlled ventil...
Lung Injury Zones
0
10
20
13 33 38
Airway Pressure (cmH20)
LungVolume(ml/kg)
Atelectasis
“Sweet Spot”
Overdistention
Dangers
The Dangers of Over distention
• Repetitive shear stress
a) Inflammatory Response
b) Air Trapping
• Phasic volume ...
Indications for HFOV
• High-frequency oscillatory ventilation uses high-frequency very-low tidal
volumes and laminar air f...
Differences Between CMV and HFOV
CMV HFV
Rate (BPM)
Tidal volume (cc/kg)
Alveolar pressure
swings (cmH20)
End exp. lung vo...
HFOV is the easiest way to find the ventilation
“sweet spot”
Is turning the patient “prone” helpful?
no significant benefit of prone positioning (20 hrs./day for 7 days)
Permissive Hypercapnia
• Presence of hypercapnia in the setting of a mechanically ventilated
patient receiving limited ins...
Pediatric ECMO
• Potential candidates
• Neonate - 18 years
• Reversible disease process
• Severe respiratory/cardiac failu...
ECM
O
Pneumonia, sepsis, drowning, trauma,
blood transfusion, pancreatitis, drug
overdose, DIC, burns
1. Acute onset
2. Severe h...
Non-respiratory management Respiratory management
Management
1. Intravascular volume resuscitation &
inotropes
2. Blood tr...
Respiratory Management in Pediatric
ARDS
Non-conventional ventilation
stable monitorEvaluation for Respiratory failure
Res...
Berlin ARDS Taskforce 2012
ARDS- “Mechanical” Therapies
no benefit
Low tidal volumes Outcome benefit in large study
Prone positioning Unproven outcom...
Outcome
• Average mortality in children with an oxygenation index ≥13 at study
entry was 36% vs. 20% in those with an oxyg...
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Pediatric Acute Respiratory Distress Syndrome

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Pediatric Acute Respiratory Distress Syndrome

  1. 1. Pediatric Acute Respiratory Distress Syndrome Dr. Mohammad Avais UPRIMS&R Saifai Bismillahirehmaniraheem
  2. 2. ARDS: Old Definition Criteria: 1. Acute onset (<7 days) 2. Bilateral CXR infiltrates 3. Absence of left atrial hypertension • PAWP pressure < 18 mm Hg. 1. Severe hypoxemia a) Acute lung injury - PaO2 : F1O2 < 300 b) Acute respiratory distress syndrome - PaO2: F1O2 < 200 1994 American – European Consensus Conference Adult Respiratory Distress Syndrome Acute Respiratory Distress Syndrome
  3. 3. Berlin Definition of ARDS 2012
  4. 4. The significant changes in New Berlin definitions: Improvement: a)The ALI category was eliminated and replaced with a gradation of ARDS severity (mild, moderate, and severe) based on the degree of oxygenation disturbance. b)A minimum of 5 cm of water positive end-expiratory pressure (PEEP) was required. c)The determination of cardiac failure was rendered more subjective in view of the decreased utilization of pulmonary artery catheters. Limitations: a)Necessity of invasive measurement of arterial oxygen. b)The PaO2/FIO2 (P/F) ratio is influenced by ventilator pressures (4–7). c)The differences in risk factors, aetiology, pathophysiology, and outcomes between adults and children were not considered Pediatr Crit Care Med 2015; XX:00–00
  5. 5. Pediatric Critical Care Medicine 2015 Pediatr Crit Care Med 2015; XX:00–00
  6. 6. • Oxygenation Index = (FIO2 × mean airway pressure × 100)/PaO2. • Oxygenation Saturation Index = (FIO2 × mean airway pressure × 100)/SpO2.
  7. 7. When To Suspect ARDS Causing Direct Injury • Pneumonia • Gastric aspiration • Less Common • Pulmonary contusion • Fat emboli • Near drowning • Inhalational injury Causing Indirect Injury • Sepsis • Shock after severe trauma • Less Common • Cardiopulmonary bypass • Drug overdose • Acute pancreatitis • Massive blood transfusions Indian J Pediatr (2010) 77:1296–1302 + persistent hypoxemia refractory to oxygen
  8. 8. ARDS - Pathogenesis Intensive Care Medicine, 2005
  9. 9. Pulmonary Edema Breakdown of barriers Lymphatic movement ALVEOLAR EDEMA Alveolar lumen FULL of fluid Interstitial fluid Pulmonary capillary NORMAL ALVEOLI Alveolar lumen EMPTY of fluid Pulmonary capillary Protein
  10. 10. Phases of ARDS • Acute - exudative, inflammatory (0 - 3 days) • Subacute - proliferative (4 - 10 days) • Chronic - fibrosing alveolitis ( > 10 days)
  11. 11. Diagnosis • Pulse oximetry • Arterial Blood Gas. • Capnography (end-tidal CO2 measurement) • A-aO2 gradient: Calculated by subtracting arterial Po2 from alveolar. For the comparison to be valid, it must be at the same Fio2. NELSON 19TH EDITION
  12. 12. MANAGEMENT • Control of causative factor • Infection- early antibiotic therapy. • Shock- intravascular volume expansion with crystalloids and vasopressors. • Careful fluid administration • Goal-directed fluid management. • Analgesia and sedation. • Nutrition. • Blood Transfusion. • Psychosocial support. Indian J Pediatr (2010) 77:1296–1302
  13. 13. Oxygen Administration • Nasal cannula • Flow rate <5 L/min. • FIO2 = 21%+ (nasal cannula flow (L min) × 3) • Simple mask • Flow rate 5 to 10 L/min. • Venturi mask • Adapter can be chosen to provide between 30 and 50% oxygen. • Flow rates of 5-10 L/min
  14. 14. • Airway Adjuncts. • Oropharyngeal Airway. • Nasopharyngeal airway, or Nasal trumpet. • Positive Pressure Respiratory Support. • High-flow nasal cannula delivers gas flow at 4-16 L/min. • Bi-level positive airway pressure (BiPAP) • Mechanical ventilation • Controlled oxygen exposure (FiO2) • Avoidance of volutrauma (low VT) and atelectrauma (appropriate PEEP) Indian J Pediatr (2010) 77:1296–1302
  15. 15. • Non-conventional ventilation • High frequency ventilation • Liquid ventilation • Drug-based therapies • Nitric oxide • Surfactant • Corticosteroids and other anti-inflammatory agents • Positioning (Prone ventilation) Indian J Pediatr (2010) 77:1296–1302
  16. 16. Ventilation strategies • Controlled Oxygen Exposure (FiO2) • PaO2 target is 55 to 80 mm Hg (SpO2 target 88%-95%). • Decrease FiO2 below 0.6 as soon as possible. • Permissive Hypercapnia • Target arterial pH levels - 7.30 to 7.45. • Mode of Ventilation • Time-cycled, pressure regulated, volume controlled mode. Indian J Pediatr (2010) 77:1296–1302 Kinder, gentler” forms of ventilation “Open lung” Higher PEEP, lower PIP
  17. 17. Ventilator Goals • Predicted body weight should be used, based on calculation from gender and from height or length or from ulna length. • Set the PEEP slightly higher than the lower inflection point • Lower tidal volume (generally < 6 mL/kg) • Static peak pressure <40 cm H20 • Wean oxygen to <60% Pediatr Crit Care Med 2015; XX:00–00
  18. 18. • Tidal Volume (VT) • Patient-specific tidal volumes according to disease severity. • VT 3–6 mL/Kg of predicted body weight and plateau pressure 28 cmH2O. • In pressure controlled mode, VT should be accurately monitored. • Positive End-Respiratory Pressure (PEEP) • Moderately elevated levels of PEEP (10–15 cm H2O) titrated to the observed oxygenation and hemodynamic response in patients with severe ARDS. • In absence of routine static PV curve measurement PEEP is increased by 2–3 cm H2O increments to maintain saturation between 90-95% with FiO2<0.6. • If PV loops monitoring are available, then it is desirable to keep the PEEP above the lower inflection point. • markers of oxygen delivery, respiratory system compliance, and hemodynamics should be closely monitored as PEEP is increased. Pediatr Crit Care Med 2015; XX:00–00
  19. 19. • Inspiratory Time • The I:E ratio may be increased to 1:1 or 2:1 (inverse ratio ventilation) to improve oxygenation. • The exhaled tidal volume should be continuously monitored to prevent injurious ventilation and monitoring of ventilatory inspiratory pressure is important to prevent ventilator-induced lung injury. • At least daily assessment of predefined clinical and physiologic criteria of extubation readiness in order to avoid unnecessary prolonged ventilation. Pediatr Crit Care Med 2015; XX:00–00
  20. 20. • Weaning • In volume-controlled ventilation, the VTis usually reduced to about 4–6 ml/kg. • In pressure-controlled ventilation, the PIP is gradually reduced in steps of 1–2 cm H2O. • PEEP and FiO2 are reduced while monitoring the PaO2. • Extubation • FiO2 of less than 40%, PEEP of 4–5 cm H2O, rate of 15/min or less, PIP of less than 15 cm H2O; the child is hemodynamically stable and sensorium is normal/near normal with presence of protective reflexes. • Expert clinical judgment is best for extubation. Indian J Pediatr (2010) 77:1296–1302
  21. 21. Lung Injury Zones 0 10 20 13 33 38 Airway Pressure (cmH20) LungVolume(ml/kg) Atelectasis “Sweet Spot” Overdistention
  22. 22. Dangers The Dangers of Over distention • Repetitive shear stress a) Inflammatory Response b) Air Trapping • Phasic volume swings: volutrauma • Injury to normal alveoli The Dangers of Atelectasis Compliance Intrapulmonary shunt FiO2 WOB Inflammatory response
  23. 23. Indications for HFOV • High-frequency oscillatory ventilation uses high-frequency very-low tidal volumes and laminar air flow to protect the lung and maintain open lung at minimal volume swings • Severe persistent air leak- pneumothorax, bronchopleural fistulae • Neonatal: HMD (*) Pneumonia Meconium aspiration Lung hypoplasia • Secretion-induced lung collapse Indian J Pediatr (2010) 77:1296–1302 It’s not absolute pressure, but volume or pressure swings that promote lung injury or atelectasis. - Reese Clark
  24. 24. Differences Between CMV and HFOV CMV HFV Rate (BPM) Tidal volume (cc/kg) Alveolar pressure swings (cmH20) End exp. lung volume 0-120 4-20 5-50 low 120-1200 0.1-5 0.1-5 high
  25. 25. HFOV is the easiest way to find the ventilation “sweet spot”
  26. 26. Is turning the patient “prone” helpful? no significant benefit of prone positioning (20 hrs./day for 7 days)
  27. 27. Permissive Hypercapnia • Presence of hypercapnia in the setting of a mechanically ventilated patient receiving limited inspiratory pressures and reduced tidal volumes • Permissive hypercapnia should be considered for moderate-to-severe PARDS to minimize ventilator-induced lung injury and maintaining pH 7.15–7.30 within lung protective strategy • Exceptions to permissive hypercapnia should include intracranial hypertension, severe pulmonary hypertension, selected congenital heart disease lesions, hemodynamic instability and significant ventricular dysfunction. www.pccmjournal.org
  28. 28. Pediatric ECMO • Potential candidates • Neonate - 18 years • Reversible disease process • Severe respiratory/cardiac failure • < 10 days mechanical ventilation • Acute, life-threatening deterioration
  29. 29. ECM O
  30. 30. Pneumonia, sepsis, drowning, trauma, blood transfusion, pancreatitis, drug overdose, DIC, burns 1. Acute onset 2. Severe hypoxemia (PaO 2/FiO2 ratio 200 for ARDS and 300 for ALI) 3. Bilateral pulmonary infiltrate 4. No evidence of left atrial hypertension Child with respiratory distress Clinical assessment, pulse oximetry, CXR and ABG Confirm diagnosis of ALI/ARDS Identify underlying risk factors Management Indian J Pediatric (2010) 77:1296–1302
  31. 31. Non-respiratory management Respiratory management Management 1. Intravascular volume resuscitation & inotropes 2. Blood transfusion 3. Corticosteroids 4. Nutrition 5. Analgesia, sedation Control of underlying cause if possible e.g. antibiotics for sepsis and pneumonia Indian J Pediatr (2010) 77:1296–1302
  32. 32. Respiratory Management in Pediatric ARDS Non-conventional ventilation stable monitorEvaluation for Respiratory failure Respiratory failure Ventilatory support Conventional ventilation •PRVC mode •VT <6 ml/Kg •PEEP above the lower inflection point •Recruitment maneuvers •FiO2 below 0.6 •Peak inspiratory pressure < 30 cm H2O HFOV, CPAP Target •PaO2 of 60 to 80 mm Hg •pH of 7.30 to 7.45 a) Prone positioning b) High frequency ventilation c) Surfactant d) Inhaled NO, prostacyclin e) ECMO FAILUR E Stable MonitorWean and extubate Indian J Pediatr (2010) 77:1296–1302
  33. 33. Berlin ARDS Taskforce 2012
  34. 34. ARDS- “Mechanical” Therapies no benefit Low tidal volumes Outcome benefit in large study Prone positioning Unproven outcome benefit Open-lung strategy Outcome benefit in small study HFOV Outcome benefit in small study ECMO Proven in neonates Unproven in children Steroid Acute Fibrosing Alveolitis No benefit Lowered mortality, small study Surfactant possible benefit in children Inhaled NO PLV No benefit No benefit
  35. 35. Outcome • Average mortality in children with an oxygenation index ≥13 at study entry was 36% vs. 20% in those with an oxygenation index ≤12. Indian J Pediatr (2010) 77:1296–1302
  36. 36. Thank youThank you
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Pediatric Acute Respiratory Distress Syndrome

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