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Ventilation Strategies For ARDS Patients by Prof DR Tarek Abd El Gawad Head of PICU Ain Shams University
Ventilation Strategies For ARDS Patients by Prof DR Tarek Abd El Gawad Head of PICU Ain Shams University
for
ARDS Patients
By
Mortality:
In Europe, the mortality rates ranged from
27-36.5%. In an Asian population it was
double that recorded in Europe (62%).In
Egypt it was 65-73%.
Clinical disorders
associated with
development of ARDS
Direct lung injury Indirect lung injury
– Pneumonia
– Sepsis
– Aspiration of gastric
contents – Severe trauma
– Pulmonary contusion – Cardiopulmonary
– Fat emboli bypass
– Near drowning – Drug overdose
– Reperfusion edema – Acute pancreatitis
(post transplant)
– Multiple blood
– Inhalational injury
product
transfusions
Pathogenesis of ARDS
(Ware &Matthay,2000)
Stages of ARDS
Acute, exudative phase
• Rapid onset of respiratory
failure after trigger
• Diffuse alveolar damage
with inflammatory cell
infiltration
• Hyaline membrane
formation
• Capillary injury
• Protein-rich edema fluid in
alveoli
• Disruption of alveolar
epithelium
Stages of ARDS
Subacute Proliferative
phase
• Persistent hypoxemia
• Development of
hypercarbia
• Fibrosing alveolitis
• Further decrease in
pulmonary compliance
• Pulmonary hypertension
Stages of ARDS
Chronic, Fibrotic
phase
• Obliteration of
alveolar and
bronchiolar spaces
and pulmonary
capillaries
• Deposition of excess
collagen and
extracellular
matrices and is
associated with
alveolar fibrosis
Laboratory Studies
To date no lab finding
pathognomonic of ARDS.
-ABG shows:
Early:
hypoxemia
respiratory alkalosis
Late:
respiratory acidosis
Laboratory Studies
• Leukocytosis,Leukopenia and anemia
are common.
• Inadequate Oxygenation(PaO2< 80
mmHg on FiO2 ≥ 0.6).
• High PEEP
• Adequate oxygenation
Precaution:
Most patients require heavy
sedation
Positive end-expiratory
pressure (PEEP)
• Increases trans-pulmonary
distending pressure
• Displaces edema fluid into
interstitium
• Decreases atelectasis
• Decrease right to left shunt
• Improves compliance
• Improves oxygenation
Positive end-expiratory
pressure (PEEP)
Hazards :
• Raise airway pressures
alveolar overinflation or
barotrauma
• Decrease venous return
depressing cardiac output (CO) and
oxygen delivery hypotension
• PEEP may cause intra-cardiac
shunting in patients with a
patent foramen ovale
Oxygenation:
∀ ↓ FiO2 < 50% if possible.
• O2 is a toxic medicine ( produce
oxygen radicals which is harmful
• It can be calculated according to
Fio2:PEEP ratio
F i O 20
20 .30
.3 0 .40
.4 0 .40
.4 0 .50
.5 0 .50
.5 0 .60
.6 0 .70
.7 0 .70
.7 0 .70
.7 0 .80
.8 0 .90
.9 0 .90
.9 0 .91
.9 1 .0
P E E P5 5 8 8 1 0 1 0 1 0 1 2 1 4 1 4 1 4 1 6 1 8 2 0-2
Inverse I:E ratio
I:E (2:1 to 3:1)
• Longer inspiratory time.
CMV (A/C), VCV, Vt 8 mL/kg, then 7 mL/kg after 1 hr, then 6 mL/kg
after next 1 hr, increase inspiratory rate to maintain minute ventilation,
I:E ratio 1:2, PEEP and FiO2 per FiO2/PEEP table
Pplat < no no
↑ VT by 1 mL/kg VT 5 mL/kg VT 4 mL/kg
30 cm H2O
yes
↑ VT to 7-8 mL/kg Severe dyspnea
no
yes
↑ rate yes <7.30 >7.45 FiO2 ≤ 0.4 no
Consider HCO3 pH < 7.15 pH ↓ rate
↑ VT PEEP= 8
no
7.30-7.45 yes
↑ rate
Evaluate for weaning
Positioning
Positioning
“PRONING”
1-Improved gas exchange
2-More uniform alveolar ventilation
3-Recruitment of atelectasis in dorsal
regions
4-Improved postural drainage.
5-Redistribution of perfusion away from
edematous, dependent regions.
Positioning
“PRONING”
HOW?
– Spine instability
– Hemo-dynamic instability
– Arrhythmias
– Thoracic and abdominal surgeries
– Increased intracranial pressure
Positioning
“PRONING”
Complications:
- Extubation
- ETT obstruction
- Dislodging CVCs
- Hemo-dynamic instability
- Facial edema
- Pressure sores
Alternative Therapies
for ARDS
Partial liquid ventilation PLV:
•PDE-I
•Inhibit neutrophil chemostaxis and
activation.
•Lisophylline inhibit release of FF
from cell memb. under oxidative
stress
•TNF : IL-1 ; IL-6
•No evidence suggestive of any
benefit.
Selective Pulmonary
Vasodilators
Nitric oxide:
1-Improves Oxygenation.