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Pediatric ARDS: Understanding It and Managing It James D. Fortenberry, MD Medical Director, Pediatric and Adult ECMO Medical Director, Critical Care Medicine Children’s Healthcare of Atlanta at Egleston
New and Improved Adult  Respiratory Distress Syndrome Acute  Respiratory Distress Syndrome
ARDS:  New Definition ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],-   1994  American - European Consensus  Conference
Clinical Disorders Associated with ARDS
The Problem: Lung Injury Other 4% Hemorrhage 5% Trauma 5% Noninfectious Pneumonia 14% Cardiac Arrest 12% Septic Syndrome 32% Infectious Pneumonia 28% Davis et al., J Peds 1993;123:35
ARDS - Pathogenesis ,[object Object],[object Object],[object Object],[object Object]
ARDS Pathogenesis ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
ARDS - Pathophysiology ,[object Object],[object Object],[object Object],[object Object]
ARDS:CT Scan View
Phases of ARDS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
ARDS - Outcomes ,[object Object],[object Object],[object Object],[object Object]
ARDS - Principles of Therapy ,[object Object],[object Object]
Therapies for ARDS Innovations: NO PLV Proning Surfactant Anti-Inflammatory Mechanical Ventilation Gentle ventilation: Permissive hypercapnia Low tidal volume Open-lung HFOV ECMO IVOX IV gas exchange AVCO 2 R Total Implantable Artificial Lung ARDS Extrapulmonary Gas Exchange
The Dangers of Overdistention ,[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],The Dangers of Atelectasis
Lung Injury Zones Atelectasis “ Sweet Spot” Overdistention
ARDS: George Bush Therapy ,[object Object],[object Object],[object Object],[object Object]
Lower Tidal Volumes for ARDS * * * p < .001 ARDS Network, NEJM, 342: 2000 22% decrease
Is turning the ARDS patient “prone” to be helpful?
Prone Positioning in ARDS ,[object Object],[object Object],[object Object]
 
Prone Positioning in Pediatric ARDS: Longer May Be Better ,[object Object],[object Object],[object Object]
Brief vs. Prolonged Prone Positioning in Children Oxygenation Index (OI) - Relvas et al., Chest 2003 * * **
High Frequency Oscillation: A Whole Lotta Shakin’ Goin’ On
It’s not absolute pressure, but  volume  or  pressure  swings that promote lung injury or atelectasis. - Reese Clark
[object Object],[object Object],[object Object],[object Object],High Frequency Ventilation
High Frequency Oscillatory Ventilation
 
HFOV is the easiest way to find the ventilation “ sweet spot”
HFOV: Benefits Vs. Conventional Ventilation
HFOV vs. CMV in Pediatric Respiratory Failure -  Arnold et al,  CCM , 1994 *
Surfactant in ARDS ,[object Object],[object Object],[object Object],[object Object]
Surfactant in Pediatric ARDS ,[object Object],[object Object],[object Object]
Steroids in Unresolving ARDS ,[object Object],[object Object],[object Object],[object Object],[object Object],Meduri et al, JAMA 280:159, 1998
Steroids in Unresolving ARDS * * p<.01 * - Meduri et al., JAMA, 1998
Steroids in Unresolving ARDS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Steinberg, NEJM, 354:1671,2006
Inhaled Nitric Oxide in Respiratory Failure ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Inhaled NO and HFOV In Pediatric ARDS Dobyns et al.,  J Peds , 2000 *
Partial Liquid Ventilation
Partial Liquid Ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Liquid Ventilation ,[object Object],[object Object],[object Object],[object Object]
ARDS- “Mechanical” Therapies Prone positioning - Unproven outcome      benefit Low tidal volumes - Outcome benefit in      large study Open-lung strategy - Outcome benefit in      small study HFOV -Outcome benefit in      small study ECMO - Proven in neonates      unproven in children
Pharmacologic Approaches to ARDS: Randomized Trials Glucocorticoids Fibrosing alveolitis - lowered mortality,    small study Surfactant - possible benefit in    children Inhaled NO - no benefit Partial liquid ventilation - no benefit
“…We must discard the old approach and continue to search for ways to improve mechanical ventilation.  In the meantime, there is no substitute for the clinician standing by the ventilator…” - Martin J. Tobin, MD
 

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Pediatric ards fortenberry

  • 1. Pediatric ARDS: Understanding It and Managing It James D. Fortenberry, MD Medical Director, Pediatric and Adult ECMO Medical Director, Critical Care Medicine Children’s Healthcare of Atlanta at Egleston
  • 2. New and Improved Adult Respiratory Distress Syndrome Acute Respiratory Distress Syndrome
  • 3.
  • 5. The Problem: Lung Injury Other 4% Hemorrhage 5% Trauma 5% Noninfectious Pneumonia 14% Cardiac Arrest 12% Septic Syndrome 32% Infectious Pneumonia 28% Davis et al., J Peds 1993;123:35
  • 6.
  • 7.
  • 8.  
  • 9.
  • 11.
  • 12.  
  • 13.
  • 14.
  • 15. Therapies for ARDS Innovations: NO PLV Proning Surfactant Anti-Inflammatory Mechanical Ventilation Gentle ventilation: Permissive hypercapnia Low tidal volume Open-lung HFOV ECMO IVOX IV gas exchange AVCO 2 R Total Implantable Artificial Lung ARDS Extrapulmonary Gas Exchange
  • 16.
  • 17.
  • 18. Lung Injury Zones Atelectasis “ Sweet Spot” Overdistention
  • 19.
  • 20. Lower Tidal Volumes for ARDS * * * p < .001 ARDS Network, NEJM, 342: 2000 22% decrease
  • 21. Is turning the ARDS patient “prone” to be helpful?
  • 22.
  • 23.  
  • 24.
  • 25. Brief vs. Prolonged Prone Positioning in Children Oxygenation Index (OI) - Relvas et al., Chest 2003 * * **
  • 26. High Frequency Oscillation: A Whole Lotta Shakin’ Goin’ On
  • 27. It’s not absolute pressure, but volume or pressure swings that promote lung injury or atelectasis. - Reese Clark
  • 28.
  • 30.  
  • 31. HFOV is the easiest way to find the ventilation “ sweet spot”
  • 32. HFOV: Benefits Vs. Conventional Ventilation
  • 33. HFOV vs. CMV in Pediatric Respiratory Failure - Arnold et al, CCM , 1994 *
  • 34.
  • 35.
  • 36.
  • 37. Steroids in Unresolving ARDS * * p<.01 * - Meduri et al., JAMA, 1998
  • 38.
  • 39.
  • 40.  
  • 41. Inhaled NO and HFOV In Pediatric ARDS Dobyns et al., J Peds , 2000 *
  • 43.
  • 44.
  • 45. ARDS- “Mechanical” Therapies Prone positioning - Unproven outcome benefit Low tidal volumes - Outcome benefit in large study Open-lung strategy - Outcome benefit in small study HFOV -Outcome benefit in small study ECMO - Proven in neonates unproven in children
  • 46. Pharmacologic Approaches to ARDS: Randomized Trials Glucocorticoids Fibrosing alveolitis - lowered mortality, small study Surfactant - possible benefit in children Inhaled NO - no benefit Partial liquid ventilation - no benefit
  • 47. “…We must discard the old approach and continue to search for ways to improve mechanical ventilation. In the meantime, there is no substitute for the clinician standing by the ventilator…” - Martin J. Tobin, MD
  • 48.