MANAGEMENT OF ARDS

1. MANAGEMENT OFARDS Carl W. Peters, MD Clinical Associate Professor Division of Critical Care Medicine Department of Anesthesiology University of Florida College of Medicine Gainesville, Florida, USA

11. ARDS--OUTLINE • HISTORY • FEATURES OF THE SYNDROME • PATHOPHYSIOLOGY • MANAGEMENT • VENTILATORY • NON-VENTILATORY

12. ARDS MANAGEMENT • 85 YEAR FEMALE • 10% BURN TO LOWER BACK • ONE OPERATION FOR SKIN GRAFTING • RECEIVING WOUND CARE

13. ARDS MANAGEMENT • TWO WEEKS IN BURN ICU • SUDDENLY HAS A SEIZURE • UNRESPONSIVE • INTUBATED • ASPIRATING • Gastric Contents at Time of Intubation

14. ARDS MANAGEMENT • FIVE DAYS--MUCH WORSE • HYPOXEMIC • PaO2 = 65, FiO2 = .95 • Pa02/Fi02 = 68 • HYPOTENSIVE • SBP = 75 • VASOPRESSIN, PHENYLEPHRINE, MILRINONE • NO URINE OUTPUT

16. ARDS--HISTORY • 12 PATIENTS: • ACUTE RESPIRATORY DISTRESS • CYANOSIS DESPITE OXYGEN SUPPLEMENT • DECREASED LUNG COMPLIANCE • DIFFUSE PULMONARY INFILTRATES Ashbaugh, Petty et al, Lancet 1967; 12:319-323

17. ARDS--HISTORY • 4-POINT LUNG-INJURY SCORE • LEVEL OF PEEP • PaO2 / FiO2 RATIO • STATIC LUNG COMPLIANCE • DEGREE OF INFILTRATION ON CHEST XRAY • NATURE OF INCITING DISORDER • INCLUDES POSSIBILITY OF NON-PULMONARY ORGAN DYSFUNCTION MURRAY, MATTHAY, LUCE AM REV RESPIR DIS 1988:138:720

18. ARDS--DEFINITION • BERNARD, ARTIGAS, BRIGHAM, 1994: • ACUTE ONSET • BILATERAL PULMONARY INFILTRATES • PCWP < 18, NO L.A. HTN • PaO2 / FiO2 RATIO < 200 = ARDS • PaO2 / FiO2 RATIO < 300 = A.L.I., “LESS SEVERE” FORM OF LUNG INJURY AM J RESPIR CRIT CARE MED 1994 149:818-24

19. WARE L, MATTHEY M; NEJM 2000 342(18);1334-1349

20. ARDS—1994 DEFINITION • ADVANTAGES • REGOGNIZES VARIABILITY OF CLINICAL LUNG INJURY • SIMPLE TO APPLY • DISADVANTAGES • TOO SIMPLE ? • UNDERLYING CAUSE & INVOLVEMENT OF OTHER ORGAN SYSTEMS NOT ASSESSED • RADIOLOGIC CRITERION FOR PRESENCE OF BILATERAL PULMONARY INFILTRATES • INCONSISTENTLY APPLIED

21. ARDS-THE PROCESS • MEMBRANE INJURY • ENDOTHELIAL OR EPITHELIAL • EITHER MEMBRANE INJURED • MANY CAUSES, SAME RESULT • MEMBRANE LEAKAGE • NON-HYDROSTATIC • PROTEIN-RICH FLUID LEAKAGE • ALVEOLI FLOODED

22. ARDS-THE PROCESS • MEMBRANE DAMAGE • CONTINUING • INFLAMATION • “RIDE-ALONG” NEUTROPHILS • CYTOKINES • V.I.L.I. • OLD IDEA: LARGE TIDAL VOLUME • OVERDISTEND/INJURY/DEADSPACE • COLLAPSED ALVEOLI

23. ARDS-THE PROCESS • ALVEOLAR DAMAGE • PERMEABILITY • SURFACTANT • HYPOXEMIA • SEVERE V-Q MISMATCH • FIBROBLASTS • RESOLUTION????

24. ARDS CAUSES WARE L, MATTHEY M. NEJM 2000 342(18) 1334-1349

25. WARE L, MATTHEY M; NEJM 2000; 342(18) 1334-1349

26. WARE L, MATTHEY M. NEJM 2000 352(18), 1334-1349

27. ARDS MANAGEMENT • GENERAL ISSUES: • SEARCH FOR CAUSE • TREAT INFECTIONS • PROVIDE ADEQUATE NUTRITION • ENTERALLY WHENEVER POSSIBLE • PREVENT GI BLEEDING AND DVTs • REMEMBER • ARDS IS PART OF A SEVERE SYSTEMIC CONDITION • TREAT THE WHOLE ILLNESS

28. ARDS MANAGEMENT • GOALS: • BEST OXYGENATION • LOWEST FiO2 • LIMIT SIDE EFFECTS OF TREATMENT • SUPPORT THE PATIENT • WHILE THE LUNGS & OTHER SYSTEMS HEAL

29. ARDS MANAGEMENT MODALITIES • VENTILATORY TECHNIQUES • LUNG PROTECTIVE VENTILATION STRATEGIES • OTHER TECHNIQUES / MODALITIES • NITRIC OXIDE • PRONE POSITIONING • SURFACTANT REPLACEMENT • PARTIAL LIQUID VENTILATION • HIGH-FREQUENCY OSCILLATORY VENTILATION • PHARMACOLGIC THERAPY • FLUID MANAGEMENT • NUTRITION

30. WARE L, MATTHEY M; NEJM 2000 342(18) 1334-1349

31. ARDS MANAGEMENTVENTILATORY ISSUES • TWO GOALS: • OPTIMAL • OXYGENATION & VENTILATION • AVOID • INJURIOUS EFFECTS OF MV ON LUNGS • “VENTILATOR-INDUCED LUNG INJURY”

32. ARDS MANAGEMENTVENTILATORY ISSUES • LUNG PROTECTIVE VENTILATION: • PEEP / CPAP • RECRUIT COLLAPSED ALVEOLI • MINIMIZE SHUNT • LOWER SUPPLEMENTAL OXYGEN • USE LOW TIDAL VOLUMES • MINIMIZE • ALVEOLAR OVERDISTENTION • CYCLIC AIRWAY OPENING / CLOSING • Alveolar “Shear Forces”

33. PIANTADOSI C, SCHWARTZ D; ANN INTERN MED 2004:141;460-470

34. BARBAS C, deMATOS G, PINCELLI M, ET AL CUR OPIN CRIT CARE 2005; 11:18-28

35. ARDS MANAGEMENTVENTILATORY ISSUES • HOW MUCH PEEP IS ENOUGH • 5 to 20 CM H20 • HOW MUCH VOLUME IS ENOUGH • UNKNOWN • PROBABLY 6 to 8 ML / KG • MUCH LESS THAN “TRADITIONAL” VOLUMES • 10 to 12 ML / KG • HOW MUCH PEAK PRESSURE IS TOO MUCH • APPROX 35 CM H2O PLATEAU PRESSURE LIMIT

36. MOLONEY E, GRIFFITHS M. BR J ANAESTH 2004:92:261-270

37. ARDS MANAGEMENTVENTILATORY ISSUES • PRESSURE-VOLUME CURVES • USEFUL ? • AT OR SLIGHTLY ABOVE LIP: • RECRUIT COLLAPSED ALVEOLI • DECREASE SHUNT • ABOVE UIP • ALVEOLI OVER-DISTEND • WORSEN V.I.L.I

38. BARBAS C, deMATOS G, PINCELLI M, ET AL CUR OPIN CRIT CARE 2005;11:18-28

41. TOBIN M. NEJM 2001;344(26) 1986-1996

42. ARDS MANAGEMENTVENTILATORY ISSUES • “PROTECTIVE” (LOW VOLUME) VENTILATION • 5 STUDIES • LARGEST SHOWED BENEFIT; 3--NONE • ARDS NET STUDY, 861 PTS, • 6 ML/KG, PLAT<30CM H20 vs 12 ML/KG & PLAT<50CM H2O • START WITH HIGHER PEEP • 25% FEWER DEATHS LOW VOLUME 1. MALONEY E, GRIFFITHS M. BR J ANAESTH 2004:92: 261-270 2. ARDSNET. NEJM 2000:342:1301-1308

43. ARDS MANAGEMENT • OTHER TECHNIQUES / MODALITIES • NITRIC OXIDE • PRONE POSITIONING • SURFACTANT REPLACEMENT • PARTIAL LIQUID VENTILATION • HIGH-FREQUENCY OSCILLATORY VENTILATION • PHARMACOLGIC THERAPY • FLUID MANAGEMENT • NUTRITION

44. LOS ANGELES

45. CALIFORNIA SURFERS

46. HOLLYWOOD BIG SHOTS

47. LOS ANGELES TRAFFIC

48. LOS ANGELES TRAFFIC

49. LOS ANGELES TRAFFIC