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Update in ARDS
This document discusses updates in the treatment of acute respiratory distress syndrome (ARDS). It begins by outlining the speaker's conflicts of interest and objectives to understand the definition, physiology, and treatment options for ARDS. It then reviews the limitations of the original ARDS definition from 1994 and improvements made in the 2012 Berlin definition. Various treatment trials are summarized, including low tidal volume ventilation, use of neuromuscular blocking agents, higher vs. lower positive end-expiratory pressure, prone positioning, and early rescue therapy with extracorporeal membrane oxygenation. The speaker's contact information is provided at the end.
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Update in ARDS
- 2. 2 Update in ARDS MaximilianoTamae Kakazu, MD FCCP Director, Pulmonary and Critical Care Medicine Fellowship Division of Pulmonary, Critical Care and Sleep Medicine Spectrum Health Medical Group
- 3. Conflicts of interest Receivedfees as consultant from Getinge Group in 2016 unrelated to this presentation. 3
- 4. Objectives Recognize the impactof the definition of ARDS Understand the physiology of ARDS Understand the treatment options for ARDS
- 5. Objectives Recognize the impactof the definition of ARDS Understand the physiology of ARDS Understand the treatment options for ARDS
- 6. Objectives Recognize the impactof the definition of ARDS Understand the physiology of ARDS Understand the treatment options for ARDS
- 7. Pressure and Volumeare related * Volume * Dreyfuss. AJRCCM 1998; 157:294-323 Normal rabbits Rabbits after surfactant depletionPressure High Elastance Low Elastance
- 8. Tidal Volume Reductionin Patients with Acute Lung Injury When Plateau Pressures Are Not High Secondary analysis of ARDS network trial. Each study group was stratified by quartile of Day 1 Pplat. Beneficial effect of Vt reduction from 12 to 6 ml/kg predicted body weight, regardless of the Pplat before Vt reduction.Hager. AJRCCM 2005;
- 9.
- 10. Chiumello. AJRCCM 2008;178:346-355 Supl Malhotra. N Engl J Med 2007;357:1113-20
- 11. Recommended criteria bythe American- European Consensus Conference on ARDS Bernard et al. AJRCCM1994; 149:818-24
- 12. • No definitionof acute onset. • No mention about PEEP or FIO2. • Required pulmonary artery wedge pressure <18 mmHg. • Patients with ARDS can have elevated PAWP Limitations of the the American-European Consensus Conference on ARDS definition
- 13. AECC 1994 Berlin2012 Onset Acute, not specified New or worsening within 1 week Oxygenation ALI PaO2/FIO2 <300 ARDS PaO2/FIO2 <200 Mild PaO2/FIO2 200-300 Moderate PaO2/FIO2 100- 199 Severe PaO2/FIO2 <100 PEEP Not specified Minimum PEEP of 5 cmH2O Infiltrates on chest radiograph Bilateral infiltrates on a frontal chest radiograph Bilateral infiltrates involving two or more quadrants on a frontal chest radiograph or CT Heart Failure Pulmonary artery wedge pressure ≤17 mm Hg Absence of left atrial hypertension Left ventricular failure insufficient to solely account for clinical state Severity Based on oxygenation criteria Based on oxygenation criteria
- 14. • Diagnosis • Prognosis. •Implement results of trials into clinical practice • Planning resource allocation.
- 15. Bellani, G. JAMA.2016;315
- 16. • Within 48h • PaO2/FiO2 <150 mmHg with PEEP >5 cmH2O and VT 6-8 ml/kg IBW Neuromuscular blocking agents in ARDS Papazian, L. NEJM 2010;3
- 17. Higher vs LowerPEEP in ALI/ARDS Briel. JAMA 2010; 303 (9) 865-873
- 18. Briel. JAMA 2010;303 (9) 865-873 Metanalysis of Higher vs Lower PEEP in Patients With ALI and ARDS
- 19.
- 20. • Within 48h • PaO2/FiO2 <150 mmHg with PEEP >5 cmH2O and VT 6-8 ml/kg IBW Neuromuscular blocking agents in ARDS Papazian, L. NEJM 2010;3
- 21. Bellani, G. JAMA.2016;315
- 22. • ARDS criteriaconfirmed 12-24 hr after starting mechanical ventilation • Patients enrolled within 36 h • PaO2/FiO2 < 150 mmHg with FiO2>60% and PEEP >5 cm H2O Guerin, C. NEJM 2013;368:2
- 23. Bellani, G. JAMA.2016;315
- 24. Ferguson, N. IntensiveCare Med (2012
- 25.