The document discusses two types of acute respiratory distress syndrome (ARDS) - pulmonary (direct) ARDS and extrapulmonary (indirect) ARDS. It notes key differences in characteristics and responses to mechanical ventilation strategies between the two types. Specifically, extrapulmonary ARDS patients tend to have better responses to higher levels of positive end-expiratory pressure (PEEP) compared to pulmonary ARDS patients. The document also reviews various mechanical ventilation strategies and studies regarding lung-protective ventilation in ARDS.

1. Lung Protective Strategies: The Effects of Vt, PEEP & Alveolar Recruitment David Grooms BS, RRT Sentara Norfolk General, Leigh & Bayside Hospitals

4. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158

5. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Response to PEEP Recruitment Potential Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

6. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158

7. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Response to PEEP Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

8. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158

9. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20 cm) Response to PEEP High Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

10. Characteristics of Extrapulmonary ARDS (In-direct) Viera et al. Am J Respir Crit Care Med 1998:158

11. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP High Recruitment Potential Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

12. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158

13. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

14. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158

15. ARDS CT and PV Curve (slow inflation) # 6 -10 0 10

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70. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Excellent (10-20cm) Response to PEEP Low High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

71. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158

72. Contrasts between 2 types of ARDS Kallet, R & Branson, R. Resp. Care Journal, Apr 2007, Vol 52 No 4 <10 cm often absent >10 usually present Lower inflec. Pt Severely Reduced Reduced Lung Compl. Good (8-12cm) Excellent (10-20cm) Response to PEEP Low High Recruitment Potential High Low Risk of overdistention Normal Reduced Chest Wall Compliance Pulmonary ARDS Extrapulmonary ARDS Mechanics

73. Characteristics of Pulmonary ARDS (Direct) Viera et al. Am J Respir Crit Care Med 1998:158

75. Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000

76. Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 Both static and single deformations were significantly less injurious than cyclic deformations at each deformation level

77. Tschumperlin, D et al. Am J Respir Crit Care Med, Vol 162. pp 357-362, 2000 Reducing the amplitude reduced cell death Cell Death dependent on frequency

78. ARDS Network

83. Lower PEEP/Higher FiO 2 FiO 2 .3 .4 .4 .5 .5 .6 .7 .7 .7 .8 .9 .9 .9 1.0 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-24 Higher PEEP/Lower FiO 2 FiO 2 .3 .3 .4 .4 .5 .5 .5-.8 .8 .9 1.0 PEEP 12 14 14 16 16 18 20 22 22 22-24 Target enrollment- 750 ALI, ARDS pts.

89. Oxygen Dissociation Curve ARDSnet Study 88-94% PaO2 55-80

93. Overdistention/Increased Transalveolar Pressure of Good alveoli Nieman, G

95. Crit Care Med 2004 Vol. 32, No. 9

97. Pt. Switched To AVTS Mode. Maintained @ 8-9cc’s/Kg Pt. Placed on 6cc/Kg Vt Pt. Placed on 8-9cc/Kg Vt Pt. Placed on 6cc/Kg Vt SNGH Burn/Trauma Unit

101. Rimensberger P et al. CCM 1999;27:1940-1945

102. Crit Care Med 2006 Vol. 34, No. 5

103. Villar, et al. Crit Care Med 2006 Vol. 34, No. 5 Amato, M. et al. 1998. NEJM

104. Minimizing Atelectatictrauma (repeated opening and closing) Nieman, G.

106. The Effects of Recruitment on End-expiratory Lung Volume Barbas CSV Am J Respir Crit Care Med 2002;165:A218 APRV/HFOV puts pt. at this point

108. Rimensberger P et al. CCM 1999;27:1940-1945

109. +350 cc’s

112. I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP MAP Vt Vt

113. I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP Vt Vt

114. I-times in Pressure Modes for Full Flow deceleration improve gas distribution and minimize PC level F T P T MAP Vt Min.Insp. Pressure Adjustments Needed Vt Vt

116. Normal Ventilation with Normal MAP P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15

117. Increase in Insp. Pressure What will happen to MAP? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 25

118. Increase in Insp. Pressure What will happen to Plat ? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 25

119. Increase in PEEP, What will happen to MAP & Plat? P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 10

120. APRV (Basically inverse Ratio with Spont. Breathing during insp. Phase.) Can Increase MAP and keep safe Plat. & spont. Breath. P Time PEEP PEEP Plat Peak Insp Mean Insp Pressure Mean Exp Pressure + = MAP 5 20 15 = If Flow is Fully dec. Spontaneous Breaths

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