ARDS - trauma
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This document discusses a case of acute respiratory failure in a 300 kg patient who presented with sudden severe hypoxia and unconsciousness. It then provides an overview of acute respiratory failure, distinguishing between hypercapnic and hypoxemic respiratory failure. Various causes of each type are described in detail. The case is specifically focused on acute respiratory distress syndrome (ARDS), explaining its pathogenesis, risk factors, complications, and management including a landmark ARMA clinical trial showing benefit of lower tidal volumes.
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ARDS - trauma
- 1. Acute Respiratory Distress Syndrome. Case presentation Dr. Adel Hassan Sen. Consult. Anesthesiologist HOD Anesthesia & ICU. Kalba Hospital, MOH. 31st March 2014
- 3. F. 35ys , 300 Kgs, Lt. TIBIA/FIBULA Fx (Impacted In place). 8th D -in pat. w.- after admission, sudden severe hypoxia PH 7.22 PaCO2 =72 mmhg PaO2=43 mmhg HCO36 , Unconscious. Anesthesia on duty was called to IPW. Supported ventilation shifted pt. to ICU. Management started as will be discussed later.
- 4. Acute Respiratory Failure • Failure in one or both gas exchange functions: oxygenation and carbon dioxide elimination • In practice: PaO2<60mmHg or PaCO2>46mmHg • Derangements in ABGs and acid-base status
- 5. Acute Respiratory Failure • Hypercapnic v Hypoxemic respiratory failure • ARDS and ALI
- 6. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Problem VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 7. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Problem VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 8. Hypercapnic Respiratory Failure Alveolar Hypoventilation Brainstem respiratory depression Drugs (opiates) Obesity-hypoventilation syndrome PI max Central Hypoventilation Neuromuscular Disorder nlPI max Critical illness polyneuropathy Critical illness myopathy Hypophosphatemia Magnesium depletion Myasthenia gravis Guillain-Barre syndrome
- 9. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Disorder VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 10. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 11. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding • Increased dead space ventilation • advanced emphysema • PaCO2 when Vd/Vt >0.5 • Late feature of shunt-type • edema, infiltrates
- 12. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding • VCO2 only an issue in pts with ltd ability to eliminate CO2 • Overfeeding with carbohydrates generates more CO2
- 13. Hypoxemic Respiratory Failure Is PaCO2 increased? Hypoventilation (PAO2 - PaO2)? Hypoventilation alone Respiratory drive Neuromuscular dz Hypovent plus another mechanism Shunt Inspired PO2 High altitude FIO2 (PAO2 - PaO2) No NoYes Is low PO2 correctable with O2? V/Q mismatch No Yes Yes
- 14. The Case of Patient ES 77F s/p MVC. Injuries include multiple L rib fxs, L hemopneumothorax s/p chest tube placement, L iliac wing fx. PMH: atrial arrhythmia, on coumadin. INR>2 HD#1 RR 30s and shallow. Pain a/w breathing deeply. Placed on BiPAP overnight PID#1 BiPAP 80%: 7.45/48/66/32/+10
- 15. Hypoxemic Respiratory Failure Is PaCO2 increased? Hypoventilation (PAO2 - PaO2)? Hypoventilation alone Respiratory drive Neuromuscular dz Hypovent plus another mechanism Shunt Inspired PO2 High altitude FIO2 (PAO2 - PaO2) No NoYes Is low PO2 correctable with O2? V/Q mismatch No Yes Yes
- 16. Hypoxemic Respiratory Failure V/Q mismatch V/Q mismatch DO2/VO2 Imbalance PvO2>40mmHg PvO2<40mmHg DO2: anemia, low CO VO2: hypermetabolism
- 17. Hypoxemic Respiratory Failure V/Q mismatch SHUNT V/Q = 0 DEAD SPACE V/Q = ∞ Atelectasis Intraalveolar filling Pneumonia Pulmonary edema Pulmonary embolus Pulmonary vascular dz Airway dz (COPD, asthma) Intracardiac shunt Vascular shunt in lungs ARDS Interstitial lung dz Pulmonary contusion
- 18. Hypoxemic Respiratory Failure V/Q mismatch SHUNT V/Q = 0 DEAD SPACE V/Q = ∞ Atelectasis Intraalveolar filling Pneumonia Pulmonary edema Pulmonary embolus Pulmonary vascular dz Airway dz (COPD, asthma) Intracardiac shunt Vascular shunt in lungs ARDS Interstitial lung dz Pulmonary contusion
- 19. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • Severe ALI • B/L radiographic infiltrates • PaO2/FiO2 <200mmHg (ALI 201-300mmHg) • No e/o L Atrial P; PCWP<18
- 20. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • Develops ~4-48h • Persists days-wks • Diagnosis: – Distinguish from cardiogenic edema – History and risk factors
- 24. Inflammatory Alveolar Injury Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
- 25. Inflammatory Alveolar Injury Fluid in interstitium and alveoli Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
- 26. Inflammatory Alveolar Injury Fluid in interstitium and alveoli • Impaired gas exchange • Compliance • PAP Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
- 27. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Exudative phase Fibrotic phaseProliferative phase Diffuse alveolar damage
- 28. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Direct Lung Injury • Infectious pneumonia • Aspiration, chemical pneumonitis • Pulmonary contusion, penetrating lung injury • Fat emboli • Near-drowning • Inhalation injury • Reperfusion pulmonary edema s/p lung transplant
- 29. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Indirect Lung Injury • Sepsis • Severe trauma with shock / hypoperfusion • Burns • Massive blood transfusion • Drug overdose: ASA, cocaine, opioids, phenothiazines, TCAs. • Cardiopulmonary bypass • Acute pancreatitis
- 30. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Complications • Barotrauma • Nosocomial pneumonia • Sedation and paralysis persistent MS depression and neuromuscular weakness
- 31. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • 861 patients, 10 centers • Randomized • Tidal Vol 12mL/kg PDW, PlatP<50cmH2O • Tidal Vol 6mL/kg PDW, PlatP<30cmH2O • NNT 12 • 31% mortality v 39.8% • 65.7% breathing without assistance by day 28 v 55% • Significantly more ventilator-free days • Significantly more days without failure of nonpulmonary organs/systems