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Ards management

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Ards management

  1. 1. ARDS MANAGEMENT SAMIR EL ANSARY ICU PROFESSOR AIN SHAMS CAIRO
  2. 2. Pulmonary capillary leak Inactivation of surfactant Interstitial & alveolar edema Severe & refractory hypoxemia SHUNTING - Stiff lungs Alveolar atalectasis Damage to alveolar capillary membrane DIFFUSE lung injury CAUSES
  3. 3. Early pathologic features of ARDS • Diffuse alveolar damage (DAD) • There is minimal alveolar septal thickening, hyperplasia of pneumocytes • Eosinophilic hyaline membranes present
  4. 4. Links Between VILI and MSOF Biotrauma and Mediator Injuries
  5. 5. What does surfactant do? Alveoli without surfactant Alveoli with surfactant
  6. 6. Cyanosis Pao2 / Fio2 < 200 REFRACTORY HYPOXEMIA
  7. 7. Gas Extravasation Barotrauma
  8. 8. 1  A Portal for Gas & Bacteria? Microvascular Fracture in ARDS
  9. 9. Excessive PEEP, particularly in combination with hypovolemia, can decrease cardiac output and oxygen delivery, and increase the risk of barotrauma
  10. 10. Subcutaneous emphysema
  11. 11. CT scan showed Severe surgical emphysema and pneumomediasteum
  12. 12. Diseased Lungs Do Not Fully Collapse, Despite Tension Pneumothorax …and They cannot always be fully “opened” Dimensions of a fully Collapsed Normal Lung
  13. 13. Tension Cysts
  14. 14. Spectrum of Regional Opening Pressures (Supine Position) Superimposed Pressure Inflated 0 Alveolar Collapse (Reabsorption) 20-60 cmH2O Small Airway Collapse 10-20 cmH2O Consolidation  Lung Units at Risk for Tidal Opening & Closure = Opening Pressure
  15. 15. How Much Collapse Depends on the Plateau R = 100% 20 60 100 Pressure [cmH2O] 20 40 60 TotalLungCapacity[%] R = 22% R = 81% R = 93% 0 0 R = 0% R = 59% Some potentially recruitable units open only at high pressure More Extensive Collapse But Lower PPLAT Less Extensive Collapse But Greater PPLAT
  16. 16. Mechanical Ventilator
  17. 17. PRESSURE VOLUME CURVE
  18. 18. Recruitment Maneuvers (RMs) Proposed for improving Arterial oxygenation Enhancing alveolar recruitment All consisting of short-lasting increases in intrathoracic pressures
  19. 19. Recruitment Maneuvers (RMs) –Vital capacity maneuver (inflation of the lungs up to 40 cm H2O, maintained for 15 - 26 seconds) –Intermittent sighs –Extended sighs
  20. 20. Recruitment Maneuvers (RMs) –Intermittent increase of PEEP –Continuous positive airway pressure (CPAP) –Increasing the ventilatory pressures to a plateau pressure of 50 cm H2O for 1-2 minutes
  21. 21. Other manoeuvres • Prone positioning ventilation • Prolonged inspiration • Inverse ratio ventilation
  22. 22. Limit of open lung strategy • To minimise VILI to the less damaged alveoli Max insp pressure (plateau pressure 30-32cm H20)
  23. 23. Limit of open lung strategy Max pressure remains unchanged TV will decrease Alveolar ventilation will decrease Alv V: dead space vent ratio will decrease
  24. 24. Increasing PaCO2 • Management options Increase resp rate Minute volume Delivered TV TV ml/kg Resp rate 6.4 L 640 ml 8 10 6.4 L 480 ml 6 14 6.4 L 320 ml 4 20 6.4 L 160 ml 2 40 Anatomical dead space 150ml
  25. 25. Increasing PaCO2 • Permissive hypercapnia • Tracheal gas insuflation •Reduce •dead space
  26. 26. Increasing PaCO2 As alveolar ventilation decreases will require increasing FIO2 Otherwise will result in alveloar hypoxia and arterial hypoxaemia
  27. 27. Liquid Ventilation More clinical trials are req. to demonst. efficacy.
  28. 28. • Inert • No odor • No color • Low surface tension • Carry large amount of O2 & CO2 Perfluorocarbon (PFC)
  29. 29. Medication: Morphine sulfate (0.1mg/kg/dose), pavulon (0.1 mg/kg/dose) Rimar (30 ml/kg) Ventilation settings: Ti 5 sec, hold 10 sec, Te 5 sec (3-6 cycles/min) CO2 eleminated by increase tidal volume O2 managed by change O2 content and FRC
  30. 30. ON START OF GAS VENTILATION ONE HOUR AFTER PLV 48 HOUR AFTER PLV 3 WEEKS AFTER PLV Partial liquid ventilation with perflubron in premature infants with severe respiratory distress syndrome
  31. 31. High-frequency Oscillatory Ventilation • Active expiration Pressurised circuit
  32. 32. High-frequency Ventilation
  33. 33. 35cm H20 90 cm 3-9 hz 0.1-3ml/kg
  34. 34. 42 Pressure transmission HFOV P T proximal trachea alveoli Due to the attenuation of the pressure wave by the time it reaches the alveolar region it is reduced down to .1 - 5 cmH2O
  35. 35. BRONCHOTRON VENTILATOR CONVENTIONAL ( = LOW FREQUENCY ) VENTILATION UNIT PULSATION ( = HIGH FREQUENCY ) VENTILATION UNIT
  36. 36. However … Risks of barotrauma and hemodynamic compromise with high frequency ventilation can approximate those of conventional ventilation
  37. 37. KINETIC THERAPY MEDISCUS AIR CUSHION BED PULMONAIR MEDISCUS TRAUMA BED ROTOREST
  38. 38. APPLICATION OF SURFACTANT CUROSURF - SURVANTA ALVEOLFACT 50 – 200 mg/kgBW BY ENDOTRACHEAL OR ENDOBRONCHIAL ROUTE
  39. 39. APPLICATION OF SURFACTANT • PREVENT END-EXPIRATORY COLLAPSE OF ALVEOLI • RECRUITMENT OF ATELECTATIC LUNG AREAS • IMPROVED COMPLIANCE • IMPROVED OXYGENATION • IMPROVED VENTILATION /PERFUSION RATIO
  40. 40. SECRETION ELEMINATION VIA IPPB • BETTER DISTRIBUTION OF MEDICATED AEROSOLS • BRONCHOSPASMOLYTIC • IMPROVED OXYGENATION • SECRETOLYSIS
  41. 41. JET THERAPY • SECRETOLYSIS ( SECRETION MOBILISATION ) • DISSOLUTION OF RESORPTIVE ATELECTASES • IMPROVED OXYGENATION • INTRACRANIAL PRESSURE REDUCTION
  42. 42. CLINI – JET HIGH FREQUENCY JET VENTILATION HFJV  HANDY INSTRUMENT  PRODUCES SHORT GAS PULSES  FOR SECRETOLYSIS  DISSOLVE SECRETIONS ( KETCHUP EFFECT )
  43. 43. INCENTIVE SPIROMETRY SUSTAINED MAXIMAL INSPIRATION • ALVEOLAR RECRUITMENT • PREVENTION OF ATELECTASES • MUSCLE TRAINING • COUGH PROVOCATION • IMPROVED OXYGENATION AND VENTILATION
  44. 44. Dilates pulmonary blood vessels and helps reduce shunting REDUCTION IN INTRAPULMONARY R-L SHUNT Nitric Oxide
  45. 45. GOOD LUCK SAMIR EL ANSARY ICU PROFESSOR AIN SHAMS CAIRO elansarysamir@yahoo.com

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