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Ards goals


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Ards goals

  1. 1. Therapeutic strategies for acute lung injury CME review article in Critical care medicine 2010 Vol.38,No.8 Dr Wahid Altaf
  2. 2. Study <ul><li>Goal : Provide practical evidence-based review to assist care for patients with severe acute lung injury and acute respiratory distress syndrome. </li></ul><ul><li>Data resource: Pubmed. </li></ul><ul><li>Study selection: ALI/ARDS. </li></ul><ul><li>Data synthesis :Author review. </li></ul><ul><li>Conclusion: Definition, therapies and guidelines for ARDS. </li></ul>
  3. 3. Severe ARDS definition <ul><li>Canada and Australia :One of the following criteria while receiving lung-protective ventilation strategy </li></ul><ul><li>Refractory hypoxemia </li></ul><ul><li>Refractory acidosis </li></ul><ul><li>Refractory barotraumas </li></ul><ul><li>United Kingdom and Ireland: One of the following </li></ul><ul><li>Lung injury score > 3 </li></ul><ul><li>Uncompensated hypercapnia. </li></ul>
  4. 5. Initial evaluation <ul><li>Evaluate underlying cause. </li></ul><ul><li>Treat underlying cause. </li></ul><ul><li>Alternate diagnosis if cause not found. </li></ul>
  5. 6. Therapeutic Strategies <ul><li>Initial Interventions </li></ul><ul><li>Low Tidal volume </li></ul><ul><li>Low inspiratory pressures </li></ul><ul><li>Moderate PEEP </li></ul><ul><li>Fluid conservative hemodynamic </li></ul><ul><li>management if possible. </li></ul>
  6. 7. Strategies for improving life- threatening hypoxemia. <ul><li>Recruitment Manoeuvres and High PEEP. </li></ul><ul><li>Rationale: Aerate collapsed and flooded </li></ul><ul><li>alveoli to improve oxygenation, reduce </li></ul><ul><li>VILI and improve compliance. </li></ul><ul><li>Risks: Over inflation of non collapsed </li></ul><ul><li>alveoli, decreased alveolar fluid </li></ul><ul><li>clearance, additional VALI, </li></ul><ul><li>hemodynamic compromise( decreased Blood </li></ul><ul><li>pressure and arrhythmias). </li></ul>
  7. 8. Evidence for Recruitment Manoeuvres and High PEEP <ul><li>Three large multicentre trials found no significant difference in mortality rates. </li></ul><ul><li>Recent trials reveal significant benefits in multiple secondary outcomes </li></ul><ul><li>Canada and Australia study. Fewer </li></ul><ul><li>episodes of refractory hypoxemia and </li></ul><ul><li>deaths related to it. </li></ul><ul><li>France Study( EXPRESS). More ventilator free days, more organ failure free days and reduced use of rescue therapies for severe hypoxemia. </li></ul>
  8. 9. Recommendations <ul><li>Consider earlier application for refractory hypoxemia when PP< 30 cm of water and after achieving patient ventilator synchrony. </li></ul><ul><li>Avoid RM in patients with Shock, pneumothorax or with focal disease. </li></ul><ul><li>Assess improvement in oxygenation and compliance at regular intervals. </li></ul><ul><li>Avoid/Abort if no improvement, worsened hypotension or hypoxemia. </li></ul>
  9. 10. Prone positioning <ul><li>Rationale: Recruitment of dependent atelectatic lung to improve V/Q mismatching. </li></ul><ul><li>Risks: Local complications and those due to turning patients. </li></ul><ul><li>Evidence: No survival benefits in Four RCT’s but two trials noted improvement in survival, oxygenation and plateau pressures after keeping patients prone for 20 hrs daily. </li></ul>
  10. 11. Recommendations <ul><li>Consider for patients with severe ARDS and life threatening hypoxemia and/or elevated plateau pressures. </li></ul><ul><li>Guidelines to prevent complications. </li></ul><ul><li>Target prone positioning for at least 20 hrs daily. </li></ul><ul><li>If no improvement in oxygenation by end of day don’t continue and consider another therapy. </li></ul>
  11. 12. High-frequency oscillatory ventilation <ul><li>Rationale: Uses low tidal volumes and high mean airway pressure to achieve lung recruitment and improve oxygenation. </li></ul><ul><li>Risks: Hemodynamic deterioration, barotraumas ,Ventilator asynchrony. </li></ul><ul><li>Evidence: Several studies reveal improved oxygenation after early administration. </li></ul>
  12. 13. Recommendation <ul><li>Institute HFOV earlier in severe ARDS patients. </li></ul><ul><li>Not to be used in patients with shock, Severe airway obstruction, Intracranial haemorrhage or refractory barotraumas and use cautiously in severely acidotic patients. </li></ul>
  13. 14. Inhaled Nitric Oxide. <ul><li>Rationale: Redistributes blood flow towards well ventilated lungs improving oxygenation, attenuates inflammatory response. May be cytotoxic to epithelial cells as well. </li></ul><ul><li>Evidence and Risks: No survival benefits in fact trend towards increased mortality rates and renal dysfunction. </li></ul>
  14. 15. Recommendation <ul><li>Consider in life threatening hypoxemia if previous interventions fail. </li></ul><ul><li>Initiate at 1 ppm and increase every 30 mins until improved oxygenation is achieved but don’t exceed 10 ppm, if no improvement gradually discontinue, if improvement decrease dose daily to minimum required to achieve oxygenation but don’t use for more than 4 days. </li></ul>
  15. 16. Glucocorticoids <ul><li>Rationale and risks: Helps by inhibiting neutrophil activation, fibroblast proliferation, and collagen deposition. May increase incidence of severe neuromyopathic events. Subjects started on steroids 14 days after diagnosis had increased mortality rates. </li></ul><ul><li>Evidence: Clinical trials show no survival benefits, two small RCT’s show improvement in oxygenation and lung injury scores for up to 1 week. </li></ul>
  16. 17. Recommendation <ul><li>Consider steroids when previous therapies have failed. </li></ul><ul><li>Not to initiate after 14 days of diagnosis and in patients on neuromuscular blockers. </li></ul><ul><li>Use methyl prednisolone at dose of </li></ul><ul><li>1 mg/kg/day assess in 3 days if no improvement discontinue, if improvement continue (optimal duration unknown, may be 7 days), physician to weigh risks and benefits and underlying infection to be treated appropriately. </li></ul>
  17. 18. Strategies for improving life threatening respiratory acidosis <ul><li>Buffer therapy </li></ul><ul><li>Rationale: Severe respiratory acidosis may deter some physicians from employing lung protective strategies. </li></ul><ul><li>Evidence and risks: Sodium bicarbonate (increases partial pressure of co2) or tris-hydroxymethyl aminomethane infusion (s/e volume overload, hyperkalemia and hypoglycaemia). </li></ul>
  18. 19. Recommendations <ul><li>For life threatening respiratory acidosis consider tris-hydroxy methyl aminomethane (THMA) provided there is no renal dysfunction. Glucose and potassium levels to be monitored. If THMA contraindicated then use bicarbonate infusion cautiously. </li></ul><ul><li>Consider renal replacement therapy. </li></ul>
  19. 20. Strategy for refractory cases <ul><li>ECLS </li></ul><ul><li>Rationale: performs gas exchange artificially and gives rest to lungs. ECMO or EC CO2 removal circuits. </li></ul><ul><li>Risks: Associated with anticoagulation and large vascular access. </li></ul><ul><li>Evidence: Earlier studies dismal outcomes, recent trial about transferring patients to tertiary centre for management for severe ARDS showed improved outcome. </li></ul>
  20. 21. Recommendations <ul><li>Consider when previous therapies fail. </li></ul><ul><li>ECMO or EC Co2 removal should be used as part of protocol at experienced medical centres. </li></ul>
  21. 25. <ul><li>Thanks. </li></ul>