SlideShare a Scribd company logo
Ventilatory Management  of ARDS: What Have We Learned and What Questions are  Unanswered!  By Bob Kacmarek Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
Mechanical Ventilation ,[object Object],[object Object],[object Object],[object Object]
Hickling ICM 1990; 16:216 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Randomizied Controlled Trials LPVS Mortality Amato*  Steward  Brochard  Brower  NIH* (C) 71% 48.3% 37.9% 46%   40% (T) 38% 46.3% 46.6% 50%   31% *P < 0.002, P = 0.0054
 
Amato et al (To Be Submitted) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
DAYS  AFTER  ENTRY BROCHARD  &  BROWER  &  STEWART &  AMATO P < 0.0001 n =  341 CUMMULATIVE  SURVIVAL  P PLAT  > 33 P PLAT  < 23 23     27 27     33 ( Adjusted  for  APACHE  &  pH  &  PEEP ) 60 50 40 30 20 10 0 1.1 1.0 .9 .8 .7 .6 .5 .4 .3 .2 .1 0.0
PLATEAU  PRESSURES  (cmH 2 O) RELATIVE  RISK  OF  DEATH BROCHARD  &  BROWER  &  STEWART &  AMATO
Mortality vs Day 1 Plateau Pressure NIH Trial of 6 vs 12 ml/kg Tidal Volume
 
ARDSnet ,[object Object],[object Object],[object Object],[object Object]
Optimal Ventilatory Strategy in ARDS: What is Still Unclear ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Grasso Anes 2002; 96:795 ,[object Object],[object Object],[object Object],[object Object],[object Object]
Grasso Anes 2002; 96:795 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Lapinsky ICM 1999;25:1297
Lung Recruitment ,[object Object],[object Object],[object Object],[object Object],[object Object]
0 1 2 10 RELATIVE  RISK   PEEP = 10 UNIVARIATE
0 1 2 10 RELATIVE  RISK   PEEP = 10 APACHE
0 1 2 10 RELATIVE  RISK   PEEP = 10 APACHE pH
0 1 2 10 RELATIVE  RISK   PEEP = 10 APACHE pH FIO 2
0 1 2 10 RELATIVE  RISK   PEEP = 10 APACHE pH FIO 2   & P PLAT
RELATIVE  RISK  PEEP  ( cmH 2 O ) MORTALITY  ACROSS  PEEP  LEVELS  ( 6  TILES  ) (  Amato  &  Stewart  & Brochard  &  Brower  ) P = 0.001 n = 331
Setting PEEP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Takeuchi Anes 2002;97:682 • 3 approaches to setting PEEP in ARDS • N=7 sheep lavage injury in each group • Injury,  RMs   to restore P/F • Group 1 PEEP P CL + 2 • Group 2 PEEP   PMC EX • Group 3 PEEP based on PaO 2 at F I O 2 0.5 • Target PaO 2 60-100  mmHg
Takeuchi Anes 2002;97:682
Takeuchi Anes 2002;97:682
Khalad Sedeek (preliminary data)
Khalad Sedeek (preliminary data)
Karim Kamal (Preliminary Data) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
FIO2   0.54  1.00   1.00  0.375* 0.375*  0.375* PEEP   11.9  11.9   20   9.1   9.1   9.1    Karim Kamal (Preliminary Data)
Karim Kamal (Preliminary Data)
Karim Kamal (Preliminary Data) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],ARDS Network - ALVEOLI Trial
ALVEOLI:   PaO 2  =  55-80  mmHg  or  SpO 2  =  88-95% ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ARDSnet Alveoli At Entry ,[object Object],[object Object],[object Object]
ALVEOLI - Mortality Before Hospital Discharge Low PEEP  High PEEP Adjusted  p= 0.44 27.6 24.9 Low PEEP  High PEEP 25.1 27.2 Unadjusted p=0.56
French High PEEP Trial Canadian LOVS Trial ,[object Object],[object Object],[object Object],[object Object],[object Object]
HFO MOAT2 ,[object Object],[object Object],[object Object],[object Object],[object Object]
Conclusion ,[object Object],[object Object],[object Object]
HFO vs CMV ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Gattinoni NEJM 2001; 345:568
Prone Positioning ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
 
Mortality Low PLV 6-month 30.3% CMV 21.5% High PLV 24.8% 28-day 26.3%  15.0% 19.1% Overall 25.4% 19.9% n=99 n=107 n=105 n=311 (26) (20) (16) (62) (30) (26) (23) (79)
Mortality Comparison ,[object Object],Ventilation Strategy 28-Day Mortality 15.0% 19.7% ARDSnet  &quot;low stretch&quot; arm age < 65 yrs (n=350) PLV-007 CMV arm age < 65 yrs (n=107) TV    6ml/kg/IBW PEEP    9 cmH 2 0 EIP    28 cmH 2 0 TV    9 ml/kg/IBW PEEP    14 cmH 2 0 EIP    28 cmH 2 0
Management of ARDS Summary ,[object Object],[object Object],[object Object],[object Object]
Management of ARDS Summary ,[object Object],[object Object],[object Object],[object Object],[object Object]
Management of ARDS Summary ,[object Object],[object Object],[object Object],[object Object],[object Object]
Thank You
 
 
 

More Related Content

What's hot

Ventilatory strategies in ARDS
Ventilatory strategies in ARDSVentilatory strategies in ARDS
Ventilatory strategies in ARDSisakakinada
 
ARDS - Diagnosis and Management
ARDS - Diagnosis and ManagementARDS - Diagnosis and Management
ARDS - Diagnosis and Management
Vitrag Shah
 
Ards and ventilator management
Ards and ventilator managementArds and ventilator management
Ards and ventilator management
Amr Elsharkawy
 
Lung protective strategies in anaesthesia
Lung protective strategies in anaesthesiaLung protective strategies in anaesthesia
Lung protective strategies in anaesthesiadrsoliman
 
Mechanical Ventilation in ARDS vs COPD
Mechanical Ventilation in ARDS vs COPDMechanical Ventilation in ARDS vs COPD
Mechanical Ventilation in ARDS vs COPDcairo1957
 
Ventilation strategies in ards rachmale
Ventilation strategies in ards   rachmaleVentilation strategies in ards   rachmale
Ventilation strategies in ards rachmaleDang Thanh Tuan
 
Ards
ArdsArds
Lung protective strategies grooms
Lung protective strategies   groomsLung protective strategies   grooms
Lung protective strategies groomsDang Thanh Tuan
 
Ventilator Induced Lung Injury
Ventilator Induced Lung InjuryVentilator Induced Lung Injury
Ventilator Induced Lung Injury
Dr.Mahmoud Abbas
 
Ventilation in ards by tarun
Ventilation in  ards by tarunVentilation in  ards by tarun
Ventilation in ards by tarun
Tarun Prudvi Betha
 
Acute respiratory distress syndrome(ARDS)
Acute respiratory distress syndrome(ARDS)Acute respiratory distress syndrome(ARDS)
Acute respiratory distress syndrome(ARDS)
Melaku Yetbarek,MD
 
The best definition of ARDS
The best definition of ARDSThe best definition of ARDS
The best definition of ARDS
Dr.Mahmoud Abbas
 
ARDS: An Evidence-based Update. By Mac Sweeney.
ARDS: An Evidence-based Update. By Mac Sweeney.ARDS: An Evidence-based Update. By Mac Sweeney.
ARDS: An Evidence-based Update. By Mac Sweeney.
SMACC Conference
 
Acute Respiratory Distress Syndrome
Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome
Acute Respiratory Distress SyndromeDang Thanh Tuan
 
ARDS and conventional ventilator therapy
ARDS and conventional ventilator therapyARDS and conventional ventilator therapy
ARDS and conventional ventilator therapy
scanFOAM
 
Ards m ibrahim
Ards m ibrahimArds m ibrahim
Ards m ibrahim
Mohamed ELSAYED
 
Acute Respirtaory Distress Syndrome
Acute Respirtaory Distress SyndromeAcute Respirtaory Distress Syndrome
Acute Respirtaory Distress Syndrome
David Hersey
 

What's hot (20)

Ventilatory strategies in ARDS
Ventilatory strategies in ARDSVentilatory strategies in ARDS
Ventilatory strategies in ARDS
 
ARDS - Diagnosis and Management
ARDS - Diagnosis and ManagementARDS - Diagnosis and Management
ARDS - Diagnosis and Management
 
Ards and ventilator management
Ards and ventilator managementArds and ventilator management
Ards and ventilator management
 
Lung protective strategies in anaesthesia
Lung protective strategies in anaesthesiaLung protective strategies in anaesthesia
Lung protective strategies in anaesthesia
 
Mechanical Ventilation in ARDS vs COPD
Mechanical Ventilation in ARDS vs COPDMechanical Ventilation in ARDS vs COPD
Mechanical Ventilation in ARDS vs COPD
 
Ards gray
Ards   grayArds   gray
Ards gray
 
Ventilation strategies in ards rachmale
Ventilation strategies in ards   rachmaleVentilation strategies in ards   rachmale
Ventilation strategies in ards rachmale
 
Ards
ArdsArds
Ards
 
Lung protective strategies grooms
Lung protective strategies   groomsLung protective strategies   grooms
Lung protective strategies grooms
 
Ventilator Induced Lung Injury
Ventilator Induced Lung InjuryVentilator Induced Lung Injury
Ventilator Induced Lung Injury
 
Ventilation in ards by tarun
Ventilation in  ards by tarunVentilation in  ards by tarun
Ventilation in ards by tarun
 
Acute respiratory distress syndrome(ARDS)
Acute respiratory distress syndrome(ARDS)Acute respiratory distress syndrome(ARDS)
Acute respiratory distress syndrome(ARDS)
 
Ards azocar
Ards   azocarArds   azocar
Ards azocar
 
The best definition of ARDS
The best definition of ARDSThe best definition of ARDS
The best definition of ARDS
 
ARDS: An Evidence-based Update. By Mac Sweeney.
ARDS: An Evidence-based Update. By Mac Sweeney.ARDS: An Evidence-based Update. By Mac Sweeney.
ARDS: An Evidence-based Update. By Mac Sweeney.
 
Acute Respiratory Distress Syndrome
Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome
Acute Respiratory Distress Syndrome
 
ARDS and conventional ventilator therapy
ARDS and conventional ventilator therapyARDS and conventional ventilator therapy
ARDS and conventional ventilator therapy
 
Ards guidelines john
Ards guidelines   johnArds guidelines   john
Ards guidelines john
 
Ards m ibrahim
Ards m ibrahimArds m ibrahim
Ards m ibrahim
 
Acute Respirtaory Distress Syndrome
Acute Respirtaory Distress SyndromeAcute Respirtaory Distress Syndrome
Acute Respirtaory Distress Syndrome
 

Similar to Ventilatory management of ards kacmarek

Ventilator Management In Different Disease Entities
Ventilator Management In Different Disease EntitiesVentilator Management In Different Disease Entities
Ventilator Management In Different Disease EntitiesDang Thanh Tuan
 
Acute respiratory distress syndrome carre
Acute respiratory distress syndrome   carreAcute respiratory distress syndrome   carre
Acute respiratory distress syndrome carreDang Thanh Tuan
 
Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)
Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)
Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)
omarhassaballa
 
PEEP:Bring the Evidence to the Bedside
PEEP:Bring the Evidence to the BedsidePEEP:Bring the Evidence to the Bedside
PEEP:Bring the Evidence to the BedsideDr.Mahmoud Abbas
 
ARDS & COPD Ventilation along with the trials conducted and what to be follow...
ARDS & COPD Ventilation along with the trials conducted and what to be follow...ARDS & COPD Ventilation along with the trials conducted and what to be follow...
ARDS & COPD Ventilation along with the trials conducted and what to be follow...
MayuriGupta65
 
5 High Frequency Oscillatory Ventilation
5 High Frequency Oscillatory Ventilation5 High Frequency Oscillatory Ventilation
5 High Frequency Oscillatory VentilationDang Thanh Tuan
 
Mechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrcMechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrcchandra talur
 
APRV
APRVAPRV
APRV
ceswyn
 
Management of persistent hypoxemic respiratory failure in the icu garpestad
Management of persistent hypoxemic respiratory failure in the icu   garpestadManagement of persistent hypoxemic respiratory failure in the icu   garpestad
Management of persistent hypoxemic respiratory failure in the icu garpestadDang Thanh Tuan
 
NIV updated
NIV updatedNIV updated
NIV updated
EM OMSB
 
Final case pediatric mechanical ventilation
Final case pediatric mechanical ventilationFinal case pediatric mechanical ventilation
Final case pediatric mechanical ventilation
Ahmed AlGahtani, RRT
 
Pa O2 How Low Can You Go
Pa O2  How Low Can You GoPa O2  How Low Can You Go
Pa O2 How Low Can You Goazrifki
 
Post Operative Management
Post Operative ManagementPost Operative Management
Post Operative Management
CTEPH
 
Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...
Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...
Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...
scanFOAM
 
Mechanical Ventilation of Patients with COPD and Asthma
Mechanical Ventilation of Patients with COPD and AsthmaMechanical Ventilation of Patients with COPD and Asthma
Mechanical Ventilation of Patients with COPD and Asthma
Dr.Mahmoud Abbas
 
Controversial Issues in NIV
Controversial Issues in NIVControversial Issues in NIV
Controversial Issues in NIVGamal Agmy
 
High Frequency Ventillation
High Frequency VentillationHigh Frequency Ventillation
High Frequency VentillationDr.Mahmoud Abbas
 
Patient prosthesis mismatch
Patient prosthesis mismatchPatient prosthesis mismatch
Patient prosthesis mismatch
Jyotindra Singh
 

Similar to Ventilatory management of ards kacmarek (20)

Ventilator Management In Different Disease Entities
Ventilator Management In Different Disease EntitiesVentilator Management In Different Disease Entities
Ventilator Management In Different Disease Entities
 
Acute respiratory distress syndrome carre
Acute respiratory distress syndrome   carreAcute respiratory distress syndrome   carre
Acute respiratory distress syndrome carre
 
Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)
Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)
Ventilatormanagementindifferentdiseaseentities 100330220411-phpapp01(1)
 
PEEP:Bring the Evidence to the Bedside
PEEP:Bring the Evidence to the BedsidePEEP:Bring the Evidence to the Bedside
PEEP:Bring the Evidence to the Bedside
 
ARDS & COPD Ventilation along with the trials conducted and what to be follow...
ARDS & COPD Ventilation along with the trials conducted and what to be follow...ARDS & COPD Ventilation along with the trials conducted and what to be follow...
ARDS & COPD Ventilation along with the trials conducted and what to be follow...
 
5 High Frequency Oscillatory Ventilation
5 High Frequency Oscillatory Ventilation5 High Frequency Oscillatory Ventilation
5 High Frequency Oscillatory Ventilation
 
Mechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrcMechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrc
 
Ards
ArdsArds
Ards
 
APRV
APRVAPRV
APRV
 
Management of persistent hypoxemic respiratory failure in the icu garpestad
Management of persistent hypoxemic respiratory failure in the icu   garpestadManagement of persistent hypoxemic respiratory failure in the icu   garpestad
Management of persistent hypoxemic respiratory failure in the icu garpestad
 
NIV updated
NIV updatedNIV updated
NIV updated
 
Final case pediatric mechanical ventilation
Final case pediatric mechanical ventilationFinal case pediatric mechanical ventilation
Final case pediatric mechanical ventilation
 
Pa O2 How Low Can You Go
Pa O2  How Low Can You GoPa O2  How Low Can You Go
Pa O2 How Low Can You Go
 
Post Operative Management
Post Operative ManagementPost Operative Management
Post Operative Management
 
Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...
Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...
Mechanical ventilation in PARDS - same as adults? - Demirakca - TBS24tion_in_...
 
Care For Vent Pt
Care For Vent PtCare For Vent Pt
Care For Vent Pt
 
Mechanical Ventilation of Patients with COPD and Asthma
Mechanical Ventilation of Patients with COPD and AsthmaMechanical Ventilation of Patients with COPD and Asthma
Mechanical Ventilation of Patients with COPD and Asthma
 
Controversial Issues in NIV
Controversial Issues in NIVControversial Issues in NIV
Controversial Issues in NIV
 
High Frequency Ventillation
High Frequency VentillationHigh Frequency Ventillation
High Frequency Ventillation
 
Patient prosthesis mismatch
Patient prosthesis mismatchPatient prosthesis mismatch
Patient prosthesis mismatch
 

More from Dang Thanh Tuan

Sutherland chi dinh thuc hien crrt-vn
Sutherland   chi dinh thuc hien crrt-vnSutherland   chi dinh thuc hien crrt-vn
Sutherland chi dinh thuc hien crrt-vnDang Thanh Tuan
 
Smoyer dialysis va dich thay the crrt-vn
Smoyer   dialysis va dich thay the crrt-vnSmoyer   dialysis va dich thay the crrt-vn
Smoyer dialysis va dich thay the crrt-vnDang Thanh Tuan
 
Skippen chong dong crrt-vn
Skippen   chong dong crrt-vnSkippen   chong dong crrt-vn
Skippen chong dong crrt-vnDang Thanh Tuan
 
Internet tiep can mach mau crrt-vn
Internet   tiep can mach mau crrt-vnInternet   tiep can mach mau crrt-vn
Internet tiep can mach mau crrt-vnDang Thanh Tuan
 
Internet mang loc va dich loc crrt-vn
Internet   mang loc va dich loc crrt-vnInternet   mang loc va dich loc crrt-vn
Internet mang loc va dich loc crrt-vnDang Thanh Tuan
 
Internet dieu tri thay the than crrt-vn
Internet   dieu tri thay the than crrt-vnInternet   dieu tri thay the than crrt-vn
Internet dieu tri thay the than crrt-vnDang Thanh Tuan
 
Internet cac phuong thuc dieu tri thay the than crrt-vn
Internet   cac phuong thuc dieu tri thay the than crrt-vnInternet   cac phuong thuc dieu tri thay the than crrt-vn
Internet cac phuong thuc dieu tri thay the than crrt-vnDang Thanh Tuan
 
Goldstein crrt tre em - chi dinh - crrt-vn
Goldstein   crrt tre em - chi dinh - crrt-vnGoldstein   crrt tre em - chi dinh - crrt-vn
Goldstein crrt tre em - chi dinh - crrt-vnDang Thanh Tuan
 
Gambro dieu tri thay the than lien tuc crrt-vn
Gambro   dieu tri thay the than lien tuc crrt-vnGambro   dieu tri thay the than lien tuc crrt-vn
Gambro dieu tri thay the than lien tuc crrt-vnDang Thanh Tuan
 
07 capnography trends in procedural sedation
07 capnography trends in procedural sedation07 capnography trends in procedural sedation
07 capnography trends in procedural sedationDang Thanh Tuan
 
The evolution of pediatric mechanical ventilators
The evolution of pediatric mechanical ventilatorsThe evolution of pediatric mechanical ventilators
The evolution of pediatric mechanical ventilatorsDang Thanh Tuan
 
19 introduction of volumetric capnography
19 introduction of volumetric capnography19 introduction of volumetric capnography
19 introduction of volumetric capnographyDang Thanh Tuan
 
18 basics of pediatric airway anatomy, physiology and management
18 basics of pediatric airway anatomy, physiology and management18 basics of pediatric airway anatomy, physiology and management
18 basics of pediatric airway anatomy, physiology and managementDang Thanh Tuan
 
17 capnography part4 non-intubated
17 capnography part4 non-intubated17 capnography part4 non-intubated
17 capnography part4 non-intubatedDang Thanh Tuan
 
16 capnography part3 intubated
16 capnography part3 intubated16 capnography part3 intubated
16 capnography part3 intubatedDang Thanh Tuan
 
15 capnography part2 introduction
15 capnography part2 introduction15 capnography part2 introduction
15 capnography part2 introductionDang Thanh Tuan
 
14 capnography part1 overview
14 capnography part1 overview14 capnography part1 overview
14 capnography part1 overviewDang Thanh Tuan
 
13 icu monitoring standards and capnography
13 icu monitoring standards and capnography13 icu monitoring standards and capnography
13 icu monitoring standards and capnographyDang Thanh Tuan
 
12 mainstream sidestream capnpgraphy
12 mainstream   sidestream capnpgraphy12 mainstream   sidestream capnpgraphy
12 mainstream sidestream capnpgraphyDang Thanh Tuan
 

More from Dang Thanh Tuan (20)

Sutherland chi dinh thuc hien crrt-vn
Sutherland   chi dinh thuc hien crrt-vnSutherland   chi dinh thuc hien crrt-vn
Sutherland chi dinh thuc hien crrt-vn
 
Smoyer dialysis va dich thay the crrt-vn
Smoyer   dialysis va dich thay the crrt-vnSmoyer   dialysis va dich thay the crrt-vn
Smoyer dialysis va dich thay the crrt-vn
 
Skippen chong dong crrt-vn
Skippen   chong dong crrt-vnSkippen   chong dong crrt-vn
Skippen chong dong crrt-vn
 
Internet tiep can mach mau crrt-vn
Internet   tiep can mach mau crrt-vnInternet   tiep can mach mau crrt-vn
Internet tiep can mach mau crrt-vn
 
Internet mang loc va dich loc crrt-vn
Internet   mang loc va dich loc crrt-vnInternet   mang loc va dich loc crrt-vn
Internet mang loc va dich loc crrt-vn
 
Internet dieu tri thay the than crrt-vn
Internet   dieu tri thay the than crrt-vnInternet   dieu tri thay the than crrt-vn
Internet dieu tri thay the than crrt-vn
 
Internet cac phuong thuc dieu tri thay the than crrt-vn
Internet   cac phuong thuc dieu tri thay the than crrt-vnInternet   cac phuong thuc dieu tri thay the than crrt-vn
Internet cac phuong thuc dieu tri thay the than crrt-vn
 
Goldstein crrt tre em - chi dinh - crrt-vn
Goldstein   crrt tre em - chi dinh - crrt-vnGoldstein   crrt tre em - chi dinh - crrt-vn
Goldstein crrt tre em - chi dinh - crrt-vn
 
Gambro dieu tri thay the than lien tuc crrt-vn
Gambro   dieu tri thay the than lien tuc crrt-vnGambro   dieu tri thay the than lien tuc crrt-vn
Gambro dieu tri thay the than lien tuc crrt-vn
 
07 capnography trends in procedural sedation
07 capnography trends in procedural sedation07 capnography trends in procedural sedation
07 capnography trends in procedural sedation
 
The evolution of pediatric mechanical ventilators
The evolution of pediatric mechanical ventilatorsThe evolution of pediatric mechanical ventilators
The evolution of pediatric mechanical ventilators
 
20 patient monitoring
20 patient monitoring20 patient monitoring
20 patient monitoring
 
19 introduction of volumetric capnography
19 introduction of volumetric capnography19 introduction of volumetric capnography
19 introduction of volumetric capnography
 
18 basics of pediatric airway anatomy, physiology and management
18 basics of pediatric airway anatomy, physiology and management18 basics of pediatric airway anatomy, physiology and management
18 basics of pediatric airway anatomy, physiology and management
 
17 capnography part4 non-intubated
17 capnography part4 non-intubated17 capnography part4 non-intubated
17 capnography part4 non-intubated
 
16 capnography part3 intubated
16 capnography part3 intubated16 capnography part3 intubated
16 capnography part3 intubated
 
15 capnography part2 introduction
15 capnography part2 introduction15 capnography part2 introduction
15 capnography part2 introduction
 
14 capnography part1 overview
14 capnography part1 overview14 capnography part1 overview
14 capnography part1 overview
 
13 icu monitoring standards and capnography
13 icu monitoring standards and capnography13 icu monitoring standards and capnography
13 icu monitoring standards and capnography
 
12 mainstream sidestream capnpgraphy
12 mainstream   sidestream capnpgraphy12 mainstream   sidestream capnpgraphy
12 mainstream sidestream capnpgraphy
 

Recently uploaded

Sex determination from mandible pelvis and skull
Sex determination from mandible pelvis and skullSex determination from mandible pelvis and skull
Sex determination from mandible pelvis and skull
ShashankRoodkee
 
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptxSURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
Bright Chipili
 
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness JourneyTom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
greendigital
 
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in DehradunDehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
chandankumarsmartiso
 
Journal Article Review on Rasamanikya
Journal Article Review on RasamanikyaJournal Article Review on Rasamanikya
Journal Article Review on Rasamanikya
Dr. Jyothirmai Paindla
 
basicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdfbasicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdf
aljamhori teaching hospital
 
Identification and nursing management of congenital malformations .pptx
Identification and nursing management of congenital malformations .pptxIdentification and nursing management of congenital malformations .pptx
Identification and nursing management of congenital malformations .pptx
MGM SCHOOL/COLLEGE OF NURSING
 
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptxTriangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Dr. Rabia Inam Gandapore
 
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptxThyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Dr. Rabia Inam Gandapore
 
A Classical Text Review on Basavarajeeyam
A Classical Text Review on BasavarajeeyamA Classical Text Review on Basavarajeeyam
A Classical Text Review on Basavarajeeyam
Dr. Jyothirmai Paindla
 
Colonic and anorectal physiology with surgical implications
Colonic and anorectal physiology with surgical implicationsColonic and anorectal physiology with surgical implications
Colonic and anorectal physiology with surgical implications
Dr Maria Tamanna
 
Cervical & Brachial Plexus By Dr. RIG.pptx
Cervical & Brachial Plexus By Dr. RIG.pptxCervical & Brachial Plexus By Dr. RIG.pptx
Cervical & Brachial Plexus By Dr. RIG.pptx
Dr. Rabia Inam Gandapore
 
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptxHow STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
FFragrant
 
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAdv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS
AkankshaAshtankar
 
263778731218 Abortion Clinic /Pills In Harare ,
263778731218 Abortion Clinic /Pills In Harare ,263778731218 Abortion Clinic /Pills In Harare ,
263778731218 Abortion Clinic /Pills In Harare ,
sisternakatoto
 
Aortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 BernAortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 Bern
suvadeepdas911
 
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachIntegrating Ayurveda into Parkinson’s Management: A Holistic Approach
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
Ayurveda ForAll
 
Non-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdfNon-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdf
MedicoseAcademics
 
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptxANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
Swetaba Besh
 
Ophthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE examOphthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE exam
KafrELShiekh University
 

Recently uploaded (20)

Sex determination from mandible pelvis and skull
Sex determination from mandible pelvis and skullSex determination from mandible pelvis and skull
Sex determination from mandible pelvis and skull
 
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptxSURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
SURGICAL ANATOMY OF THE RETROPERITONEUM, ADRENALS, KIDNEYS AND URETERS.pptx
 
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness JourneyTom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journey
 
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in DehradunDehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
Dehradun #ℂall #gIRLS Oyo Hotel 8107221448 #ℂall #gIRL in Dehradun
 
Journal Article Review on Rasamanikya
Journal Article Review on RasamanikyaJournal Article Review on Rasamanikya
Journal Article Review on Rasamanikya
 
basicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdfbasicmodesofventilation2022-220313203758.pdf
basicmodesofventilation2022-220313203758.pdf
 
Identification and nursing management of congenital malformations .pptx
Identification and nursing management of congenital malformations .pptxIdentification and nursing management of congenital malformations .pptx
Identification and nursing management of congenital malformations .pptx
 
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptxTriangles of Neck and Clinical Correlation by Dr. RIG.pptx
Triangles of Neck and Clinical Correlation by Dr. RIG.pptx
 
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptxThyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
Thyroid Gland- Gross Anatomy by Dr. Rabia Inam Gandapore.pptx
 
A Classical Text Review on Basavarajeeyam
A Classical Text Review on BasavarajeeyamA Classical Text Review on Basavarajeeyam
A Classical Text Review on Basavarajeeyam
 
Colonic and anorectal physiology with surgical implications
Colonic and anorectal physiology with surgical implicationsColonic and anorectal physiology with surgical implications
Colonic and anorectal physiology with surgical implications
 
Cervical & Brachial Plexus By Dr. RIG.pptx
Cervical & Brachial Plexus By Dr. RIG.pptxCervical & Brachial Plexus By Dr. RIG.pptx
Cervical & Brachial Plexus By Dr. RIG.pptx
 
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptxHow STIs Influence the Development of Pelvic Inflammatory Disease.pptx
How STIs Influence the Development of Pelvic Inflammatory Disease.pptx
 
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMSAdv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS
Adv. biopharm. APPLICATION OF PHARMACOKINETICS : TARGETED DRUG DELIVERY SYSTEMS
 
263778731218 Abortion Clinic /Pills In Harare ,
263778731218 Abortion Clinic /Pills In Harare ,263778731218 Abortion Clinic /Pills In Harare ,
263778731218 Abortion Clinic /Pills In Harare ,
 
Aortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 BernAortic Association CBL Pilot April 19 – 20 Bern
Aortic Association CBL Pilot April 19 – 20 Bern
 
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
Integrating Ayurveda into Parkinson’s Management: A Holistic ApproachIntegrating Ayurveda into Parkinson’s Management: A Holistic Approach
Integrating Ayurveda into Parkinson’s Management: A Holistic Approach
 
Non-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdfNon-respiratory Functions of the Lungs.pdf
Non-respiratory Functions of the Lungs.pdf
 
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptxANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
ANATOMY AND PHYSIOLOGY OF URINARY SYSTEM.pptx
 
Ophthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE examOphthalmology Clinical Tests for OSCE exam
Ophthalmology Clinical Tests for OSCE exam
 

Ventilatory management of ards kacmarek

  • 1. Ventilatory Management of ARDS: What Have We Learned and What Questions are Unanswered! By Bob Kacmarek Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
  • 2.
  • 3.
  • 4. Randomizied Controlled Trials LPVS Mortality Amato* Steward Brochard Brower NIH* (C) 71% 48.3% 37.9% 46% 40% (T) 38% 46.3% 46.6% 50% 31% *P < 0.002, P = 0.0054
  • 5.  
  • 6.
  • 7. DAYS AFTER ENTRY BROCHARD & BROWER & STEWART & AMATO P < 0.0001 n = 341 CUMMULATIVE SURVIVAL P PLAT > 33 P PLAT < 23 23  27 27  33 ( Adjusted for APACHE & pH & PEEP ) 60 50 40 30 20 10 0 1.1 1.0 .9 .8 .7 .6 .5 .4 .3 .2 .1 0.0
  • 8. PLATEAU PRESSURES (cmH 2 O) RELATIVE RISK OF DEATH BROCHARD & BROWER & STEWART & AMATO
  • 9. Mortality vs Day 1 Plateau Pressure NIH Trial of 6 vs 12 ml/kg Tidal Volume
  • 10.  
  • 11.
  • 12.
  • 13.  
  • 14.  
  • 15.
  • 16.
  • 18.
  • 19. 0 1 2 10 RELATIVE RISK  PEEP = 10 UNIVARIATE
  • 20. 0 1 2 10 RELATIVE RISK  PEEP = 10 APACHE
  • 21. 0 1 2 10 RELATIVE RISK  PEEP = 10 APACHE pH
  • 22. 0 1 2 10 RELATIVE RISK  PEEP = 10 APACHE pH FIO 2
  • 23. 0 1 2 10 RELATIVE RISK  PEEP = 10 APACHE pH FIO 2 & P PLAT
  • 24. RELATIVE RISK PEEP ( cmH 2 O ) MORTALITY ACROSS PEEP LEVELS ( 6 TILES ) ( Amato & Stewart & Brochard & Brower ) P = 0.001 n = 331
  • 25.
  • 26. Takeuchi Anes 2002;97:682 • 3 approaches to setting PEEP in ARDS • N=7 sheep lavage injury in each group • Injury, RMs to restore P/F • Group 1 PEEP P CL + 2 • Group 2 PEEP PMC EX • Group 3 PEEP based on PaO 2 at F I O 2 0.5 • Target PaO 2 60-100 mmHg
  • 31.
  • 32. FIO2 0.54 1.00 1.00 0.375* 0.375* 0.375* PEEP 11.9 11.9 20 9.1 9.1 9.1  Karim Kamal (Preliminary Data)
  • 34.
  • 35.
  • 36.
  • 37.
  • 38. ALVEOLI - Mortality Before Hospital Discharge Low PEEP High PEEP Adjusted p= 0.44 27.6 24.9 Low PEEP High PEEP 25.1 27.2 Unadjusted p=0.56
  • 39.
  • 40.
  • 41.
  • 42.
  • 44.
  • 45.  
  • 46. Mortality Low PLV 6-month 30.3% CMV 21.5% High PLV 24.8% 28-day 26.3% 15.0% 19.1% Overall 25.4% 19.9% n=99 n=107 n=105 n=311 (26) (20) (16) (62) (30) (26) (23) (79)
  • 47.
  • 48.
  • 49.
  • 50.
  • 52.  
  • 53.  
  • 54.