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Ventilator Induced Lung Injury

Ventilator Induced Lung Injury. Ventilator Induced Lung Injury. Barotrauma Volutrauma Stretch Injury Biochemical Injury. Ventilator Induced Lung Injury. Barotrauma Air leaking into pleural space Air leaking into interstitial space (PIE)

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Ventilator Induced Lung Injury

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  1. Ventilator Induced Lung Injury

  2. Ventilator Induced Lung Injury • Barotrauma • Volutrauma • Stretch Injury • Biochemical Injury

  3. Ventilator Induced Lung Injury • Barotrauma • Air leaking into pleural space • Air leaking into interstitial space (PIE) • Tearing at Bronchio-Alveolar Junction as lung is recruited and allowed to collapse • Most occurs in dependent lung zones (transition zone)

  4. Effect of 45 cmH2O PIP Control 5 min 20 min

  5. Ventilator Induced Lung Injury • Stretch Injury • Alters capillary transmural pressures • Changes in transmural pressure causes breaks in capillary endo and epithelium • Increases leak of proteinacious material • Promotes Atelectasis

  6. Ventilator Induced Lung InjuryStretch Injury AlveolarSpace A-CMembrane

  7. Ventilator Induced Lung Injury • Rodents ventilated with three modes: • High Pressure • (45 cmH2O), High Volume • Low Pressure (negative pressure ventilator), High Volume • High Pressure • (45 cmH2O), Low Volume (strapped chest and abdomen) • Dreyfuss,D ARRD 1988;137:1159

  8. Ventilator Induced Lung Injury • Volutrauma • Caused by cycling of the lung (change in surface area), independent of pressure required • Alters Surfactant function • Promotes Atelectasis • Increases capillary leak of proteinacious material • Promotes Atelectasis • Dreyfuss,D ARRD 1988;137:1159

  9. Ventilator Induced Lung Injury • Hyaline Membrane Disease is not really a disease, it’s the result of volume cycling the lungs • CMV produces consolidation, over inflation and hyaline membrane formation • HFOV uniformly inflates the lung without hyaline membrane formation • Meredith K, JAP 1989; 66:2150

  10. Ventilator Induced Lung Injury Premature baboon model Coalson J. Univ Texas San Antonio

  11. Ventilator Induced Lung Injury Premature baboon model Coalson J. Univ Texas San Antonio

  12. Alveolar Edema and Hyaline Membrane

  13. Hemorrhage and Edema

  14. Adult ARDS • HFOV - Caring for the Baby in Adults • Baby Lung Sitting on Top of a Consolidated Lung • Tidal Volumes of 6-10 ml/kg based on weight • Tidal Volumes of 20-50 ml/kg based on open lung units • Histology is similar to infant lung injury

  15. Ventilator Induced Lung Injury • Adult Acute Respiratory Failure • Atelectasis • Overdistended airways and alveoli • Cellular accumulation • Hyaline Membranes Lamy ARRD 1976; 114:267

  16. Ventilator Induced Lung Injury • Adult ARDS late stage lung structural changes • Enlarged air space • Septal destruction • Fibrotic lesions

  17. ARDS Pulmonary Injury Sequence • Phase 1 Early Exudative Treatment • Endo/Epithelial Damage • Type 1 Alveolar Cell Injury and/or Loss • Capillary Congestion • Interstitial/Alveolar Edema, Hemorrhage • Protein Accumulation • Surfactant Deactivation • Atelectasis • Hyaline Membrane Formation • Inflammatory Cell Migration • Volutrauma - Increased Protein Leak, Atelectasis, etc.

  18. ARDS Pulmonary Injury Sequence • Phase 2 Proliferative (Day 5-10) • Proliferation of Type 2 Cells • Fibroblast Migration • Interstitial Collagen Formation • Increased Dead Space • Decreased Compliance • Increased Pulmonary Vascular Resistance

  19. ARDS Pulmonary Injury Sequence • Phase 3 Fibrotic (Day 10-14) • Lung Destruction • Emphysematous Changes • Fibrosis • Pulmonary Vascular Obliteration • Chronic Lung Disease

  20. Ventilator Induced Lung Injury • Biochemical Injury • Biochemical agents (mediators) attack the lung • Recruit fibrotic proliferation cells to the lung • Atelectasis promotes release of chemical mediators • Mediators released in the lung can attack other organ systems • Cells • Macrophages • Endothelial and Epithelial Cells • Platelets • Neutrophils • Mediators • Cytokines • Leukotrienes • PAF (Platelet Activating Factor) • Thromboxane • TNF (Tumor Necrotizing Factor) • Complement Proteins • Interleukin-1,8

  21. Ware and Matthay NEJM 342 (18): 1334

  22. Pulmonary Injury Sequence • There are two injury zones during mechanical ventilation • Low Lung Volume Ventilation tears adhesive surfaces • High Lung Volume Ventilation over-distends, resulting in “Volutrauma” • The difficulty is finding the “Sweet Spot” Froese AB, Crit Care Med 1997; 25:906

  23. Ventilator Induced Lung Injury Twenty Years of One Year Follow Up of Lung Function (DLCO) in ARDS Survivors Suchyta MR, ERS 1997

  24. Ventilator Induced Lung Injury • HFOV with Surfactant as Compared to CMV with Surfactant in the Premature Primate • HFOV resulted in • Less Radiographic Injury • Less Oxygenation Injury • Less Alveolar Proteinaceous Debris • Jackson C AJRCCM 1994; 150:534

  25. Ventilator Induced Lung Injury • High Lung Volume Strategies with HFOV • Extended Surfactant Activity • Normalized Lamellar Body Phospholipid levels • Improved lung mechanics • All Conventional Ventilator Strategies • Resulted in Death or Decreased Surfactant Performance • Froese A, ARRD 1993; 148:569

  26. Ventilator Induced Lung Injury

  27. Ventilator Induced Lung Injury Control animal histology Sugiura M, JAP 1994; 77:1355

  28. Ventilator Induced Lung Injury HFOV animal histology Sugiura M, JAP 1994; 77:1355

  29. Ventilator Induced Lung Injury CMV animal histology Sugiura M, JAP 1994; 77:1355

  30. Ventilator Induced Lung Injury • HFOV Stimulates Significantly Less Neutrophil Activity Than CMV • Neutrophil Activity Has a Role in the Genisis of ARDS, Releasing Active Oxygen Species, Proteinases and Arachidonic Acid Metabolites. • Sugiura M, JAP 1994; 77:1355

  31. Ventilator Induced Lung Injury • HFOV produces less inflammatory markers than CMV • Imai Y, AJRCCM 1994; 150:1550

  32. Ventilator Induced Lung Injury • Activation of alveolar macrophages and pro-inflammatory cytokines play a pivotal role in Ventilator Induced Lung Injury Takata M, AJRCCM 1997; 156:272

  33. Risk Factors for ARDS • Trauma • Shock Syndromes - Sepsis, Cardiogenic • Gastric Aspiration • Burns • Diffuse Pneumonias • Near Drowning • Drug Overdose • Metabolic Events - Pancreatitis, Uremia • Systemic Mediator Release Associated Diseases • Disseminated Intravascular Coagulopathy • Cardiopulmonary Bypass -- Anaphylaxis • Extrapulmonary Infection -- Transfusion Reaction

  34. Lung Inflation PatternsMulti-Scan CT (10 scans/sec) 30 kg Pig Pre Lavage Pressure Control Ventilation Paw 13 cmH2O PEEP 5 cmH2O Weiler N. et al, 1999, personal communication

  35. Lung Inflation PatternsMulti-Scan CT (10 scans/sec) 30 kg Pig Pre Lavage Pressure Control Ventilation Paw 23 cmH2OPEEP 15 cmH2O Weiler N et al, 1999, personal communication

  36. Lung Inflation PatternsMulti-Scan CT (10 scans/sec) 30 kg Pig Post Lavage Pressure Control Ventilation Paw 13 cmH2O PEEP 5 cmH2O Weiler N et al, 1999, personal communication

  37. Lung Inflation PatternsMulti-Scan CT (10 scans/sec) 30 kg Pig Post Lavage Pressure Control Ventilation Paw 23 cmH2OPEEP 15 cmH2O Weiler N et al, 1999, personal communication

  38. Lung Inflation PatternsMulti-Scan CT (10 scans/sec) 30 kg Pig Post Lavage Pressure Control Ventilation Paw 33 cmH2OPEEP 25 cmH2O Weiler N et al, 1999, personal communication

  39. Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Post Lavage HFOV Paw 23 cmH2O Weiler N. Heinrichs W, et al 1999

  40. “Open up the lung up and keep it open!” Burkhard Lachmann, 1992

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