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![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](https://image.slidesharecdn.com/ardsmanagement-150326094018-conversion-gate01/85/Ards-management-23-320.jpg)
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Ards management
- 1. ARDS MANAGEMENT SAMIR EL ANSARY ICUPROFESSOR AIN SHAMS CAIRO
- 2. Global Critical Care https://www.facebook.com/groups/1451610115129555/#!/groups/145 1610115129555/ Wellcomein our new group ..... Dr.SAMIR EL ANSARY
- 3. 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
- 4. Early pathologic featuresof ARDS • Diffuse alveolar damage (DAD) • There is minimal alveolar septal thickening, hyperplasia of pneumocytes • Eosinophilic hyaline membranes present
- 8. Links Between VILIand MSOF Biotrauma and Mediator Injuries
- 9. What does surfactantdo? Alveoli without surfactant Alveoli with surfactant
- 10. Cyanosis Pao2 / Fio2< 200 REFRACTORY HYPOXEMIA
- 11.
- 12. 1 A Portalfor Gas & Bacteria? Microvascular Fracture in ARDS
- 13. Excessive PEEP, particularlyin combination with hypovolemia, can decrease cardiac output and oxygen delivery, and increase the risk of barotrauma
- 14.
- 16. CT scan showedSevere surgical emphysema and pneumomediasteum
- 20. Diseased Lungs Do NotFully Collapse, Despite Tension Pneumothorax …and They cannot always be fully “opened” Dimensions of a fully Collapsed Normal Lung
- 21.
- 22. Spectrum of RegionalOpening 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
- 23. How Much CollapseDepends 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
- 24.
- 25.
- 26. Recruitment Maneuvers (RMs) Proposedfor improving Arterial oxygenation Enhancing alveolar recruitment All consisting of short-lasting increases in intrathoracic pressures
- 27. Recruitment Maneuvers (RMs) –Vitalcapacity maneuver (inflation of the lungs up to 40 cm H2O, maintained for 15 - 26 seconds) –Intermittent sighs –Extended sighs
- 28. Recruitment Maneuvers (RMs) –Intermittentincrease of PEEP –Continuous positive airway pressure (CPAP) –Increasing the ventilatory pressures to a plateau pressure of 50 cm H2O for 1-2 minutes
- 29. Other manoeuvres • Pronepositioning ventilation • Prolonged inspiration • Inverse ratio ventilation
- 30. Limit of openlung strategy • To minimise VILI to the less damaged alveoli Max insp pressure (plateau pressure 30-32cm H20)
- 31. Limit of openlung strategy Max pressure remains unchanged TV will decrease Alveolar ventilation will decrease Alv V: dead space vent ratio will decrease
- 32. Increasing PaCO2 • Managementoptions 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
- 33. Increasing PaCO2 • Permissivehypercapnia • Tracheal gas insuflation •Reduce •dead space
- 34. Increasing PaCO2 As alveolarventilation decreases will require increasing FIO2 Otherwise will result in alveloar hypoxia and arterial hypoxaemia
- 35. Liquid Ventilation More clinical trialsare req. to demonst. efficacy.
- 36. • Inert • Noodor • No color • Low surface tension • Carry large amount of O2 & CO2 Perfluorocarbon (PFC)
- 37. Medication: Morphine sulfate (0.1mg/kg/dose), pavulon (0.1mg/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
- 39. ON START OFGAS 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
- 40. High-frequency Oscillatory Ventilation •Active expiration Pressurised circuit
- 41.
- 42.
- 43. 43 Pressure transmission HFOV P T proximal trachea alveoli Dueto the attenuation of the pressure wave by the time it reaches the alveolar region it is reduced down to .1 - 5 cmH2O
- 44. BRONCHOTRON VENTILATOR CONVENTIONAL ( = LOWFREQUENCY ) VENTILATION UNIT PULSATION ( = HIGH FREQUENCY ) VENTILATION UNIT
- 45. However … Risks ofbarotrauma and hemodynamic compromise with high frequency ventilation can approximate those of conventional ventilation
- 46. KINETIC THERAPY MEDISCUS AIRCUSHION BED PULMONAIR MEDISCUS TRAUMA BED ROTOREST
- 48. APPLICATION OF SURFACTANT CUROSURF- SURVANTA ALVEOLFACT 50 – 200 mg/kgBW BY ENDOTRACHEAL OR ENDOBRONCHIAL ROUTE
- 49. APPLICATION OF SURFACTANT •PREVENT END-EXPIRATORY COLLAPSE OF ALVEOLI • RECRUITMENT OF ATELECTATIC LUNG AREAS • IMPROVED COMPLIANCE • IMPROVED OXYGENATION • IMPROVED VENTILATION /PERFUSION RATIO
- 50. SECRETION ELEMINATION VIA IPPB •BETTER DISTRIBUTION OF MEDICATED AEROSOLS • BRONCHOSPASMOLYTIC • IMPROVED OXYGENATION • SECRETOLYSIS
- 51. JET THERAPY • SECRETOLYSIS( SECRETION MOBILISATION ) • DISSOLUTION OF RESORPTIVE ATELECTASES • IMPROVED OXYGENATION • INTRACRANIAL PRESSURE REDUCTION
- 52. CLINI – JET HIGHFREQUENCY JET VENTILATION HFJV HANDY INSTRUMENT PRODUCES SHORT GAS PULSES FOR SECRETOLYSIS DISSOLVE SECRETIONS ( KETCHUP EFFECT )
- 53. INCENTIVE SPIROMETRY SUSTAINED MAXIMALINSPIRATION • ALVEOLAR RECRUITMENT • PREVENTION OF ATELECTASES • MUSCLE TRAINING • COUGH PROVOCATION • IMPROVED OXYGENATION AND VENTILATION
- 54. Dilates pulmonary blood vesselsand helps reduce shunting REDUCTION IN INTRAPULMONARY R-L SHUNT Nitric Oxide
- 55. GOOD LUCK SAMIR ELANSARY ICU PROFESSOR AIN SHAMS CAIRO elansarysamir@yahoo.com Global Critical Care https://www.facebook.com/groups/1451610115129555/#!/groups/145 1610115129555/ Wellcome in our new group ..... Dr.SAMIR EL ANSARY