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ART of ARDS

Critical Case Conference Click to edit Master subtitle style

Presented by: Reinalyn S. Cartago MD Fellow – in – Training 4/23/12 Gelza Mae Zabat and Joanna Marie Balbuena Resident Rotators

OUTLINE
 Objectives Clinical Scenario ARDS Definition and Background Criteria for the Diagnosis of ARDS Causes and Risk Factors Associated with

ARDS

Mechanism of Injury
 Stages of ARDS

MANAGEMENT

4/23/12

OBJECTIVES
 To be able to discuss a case of Acute

Respiratory Distress Syndrome

To review and discuss the definition, criteria

for diagnosis, and pathophysiology of ARDS

To enumerate risk factors and causes of ARDS

To discuss the management and critique

current literature on ARDS

4/23/12

The Case MC 23/M Call Center Agent 4/23/12 .

Filipino Call Center Agent January 2011  On and off undocumented fever malaise  Generalized body  Anorexia. single.The Case M. weight loss Chief Complaint:  Dyspnea of about 10 – 15 % February 2011  Consulted at our PROFILE:  Previously well. C. 23/M. with good functional capacity  institution due to persistence of above 4/23/12 symptoms .

The Case February 2011  Abdominal CT scan 1 week PTA  Cough productive of done whitish sputum  Retroperitoneal lymph nodes revealed: Tuberculosis  Pleuritic chest pain. easy fatigability  Worsening dyspnea  Generalized body Biopsy done  Quadruple anti- malaise  Fever with T max: 38  No additional koch’s therapy was started and was noted to be (+) for ELISA and Western blot  ICC screen was done medications taken 4/23/12 .

 HRZE. 1 tab BID PO prebreakfast T: 36. (-) CLAD/ NVE/ TPC  ECE. ambulatory. regular rhythm. clear breath sounds.The Case Diagnosed to have  PGH (04/12/11) TB pneumonia allegedly was positive Sputum AFB  Initial PE:  Conscious. no murmurs . (-) crackles/rales 4/23/12  AP. PPC. tachycardic. oriented.9 RR: 40  AS. 4 tabs OD  Paracetamol. speaks in sentences 6lpm  On O2 via Nasal Cannula at  BP: 120/70 CR: 130’s 500mg/tab. MEDS:  Ceftriaxone 1 g IV q8  Clarithromycin conversant.

The Case CXR 4/23/12 .

(+) CLAD. 2 Mask at 10tabs BID LPM • HRZE 3 tabs OD pre breakfast •AS. right/ Fluconazole 100mg OD NVE/ TPC • ECE. speaks words BUR 18 • supraclavicular retractions noted • Meropenem g IV q8h BP: 140/70 CR:1150’s RR: Combivent q6h 40 T: 37. follows PEEP 15 commands IFR 60 in .ADULT PULMONARY SVC AC MODE (04/16/11) 300 VT FiO2 100 • Conscious.4 Azithromycin 500mg/tab OD •O2 sats 80’s despite Face Co-trimoxazole 800/160/tab. (+) rhonchi bilateral 4/23/12 . PPC.

The Case ETA CS  No growth after 2 days Blood CS  No growth after 5 days Ortho-Toluidine Blue stain  Positive for Pneumocystis 4/23/12 .

Acute Respiratory Distress Definition Background 4/23/12 Syndrome (ARDS) .

5th Edition Acute onset of severe respiratory distress and cyanosis that was refractory to oxygen therapy and associated with diffuse CXR abnormality and decreased lung compliance 4/23/12  Ashbaugh. pathological and radiographic stages Characterized by non-cardiogenic pulmonary edema.. Bigelow.DEFINITION A syndrome often progressive and characterized by distinct clinical. Petty Lancet 1967 . and decreased lung compliance  Murray et al. lung inflammation. hypoxemia.

DEFINITION 4/23/12 .

First described in 1967 •Annual incidence 75/100.40%-60% • Decreased mortality in the late 1990’s: 30 – 40% • 4/23/12 .000 in the US • High mortality.

Diagnosing ARDS Criteria Differential Diagnosis 4/23/12 .

Acute and persistent Radiographic criteria: Bilateral pulmonary infiltrates consistent with the presence of edema Oxygenation criteria: Impaired oxygenation regardless of the PEEP concentration 4/23/12 .CRITERIA The 1994 North American-European Consensus Conference (NAECC) criteria: Onset .

4/23/12 .

4/23/12 .Limitations of the Current Descriptive definition Criteria Does not address the cause of lung injury Does not provide guidelines on how to define acute Radiological criteria are not sufficiently specific Does not account for the level of PEEP used.

3. The most important of these are incorporated into the GOCA stratification system 4/23/12 . 2. The factors that affect prognosis should be taken into account. The collection of epidemiologic data should be based on the 1994 NAECC definitions. The severity of ALI/ARDS should be assessed by the Lung Injury Score (LIS) or by the APACHE III or SAPS II scoring systems.The 1998 NAECC Updated Recommendations 1.

The 1998 NAECC Updated Recommendations 4. It will be also useful to record: • Information relating to etiology (at a minimum. and whether death was associated with withdrawal of care • Presence of failure of other organs and other time dependent covariates 4/23/12 . direct or indirect cause) • Mortality. including cause of death.

Lung Injury Score 4/23/12 .

GOCA 4/23/12 .

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DIFFERENTIALS Similar CXR findings:  Acute Lung Injury  Diffuse Pneumonia  Cardiogenic Pulmonary Edema  Diffuse Alveolar Hemorrhage  Acute Interstitial Pneumonia  Acute Eosinophilic Pneumonia 4/23/12 .

Causes of ARDS Pulmonary (direct) Non-Pulmonary (indirect) 4/23/12 .

CAUSES PULMONARY NON-PULMONARY 4/23/12 .

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Risk Factors for ARDS Risk Factors Predictive of Poor Outcome 4/23/12 .

RISK FACTORS 4/23/12 .

Mechanism of Injury Pathophysiology Stages of ARDS 4/23/12 .

4/23/12 .

consolidation • • Cellular necrosis.Severe injury to the alveolocapillary unit: alveolocapillary leak Permeability pulmonary edema (protein rich edema fluid) Surfactant disruption • Hyaline membrane formation • Alveolar collapse. epithelial hyperplasia. inflammation Fibrosis 4/23/12 .

4/23/12 .

Matthay.DIFFERENCE IN PATHOLOGIES THRU TIME EXUDATIVE PHASE (day0. NEJM 2000.7) 5 days post-injury PROLIFERATIVE PHASE (day 7-21) 12 days post-injury 17 days post-injury Ware. AJRCCM 4/23/12 . Gattinoni et al.

DE.Stressing ARDistressS  Principles of Mechanical Ventilation Medical/ Non-Ventilatory Management Other Treatment Modalities 4/23/12 .

Characteristics of ARDS / ALI Exudative stage: heterogeneous lung injury normally aerated poorly Aerated (“recruitable”) non aerated V/Q < 1 4/23/12 .

VENTILATORY STRATEGIES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROME 4/23/12 .

Previous Ventilator Settings in ARDS high Vt (10-14 ml/kg). high Pplat Hyperaerated part Recruited Non-aerated segments Lung segments “core disease” Alveolar overdistention Alveolar overdistention Selective barotrauma = Volutrauma 4/23/12 .

6  Use sufficient PEEP to prevent cyclic atelectasis  Consider that the mode of ventilation is less  May tolerate hypercapnia. if necessary 4/23/12 important than attending to the above goals .Ventilatory Strategies in ARDS: Standard of Care  Principle: Lung Protection  Avoid alveolar overdistention: Vt < 6 ml/PBW  Ensure Pplat < 30 cm H20  Maintain FiO2 < 0.

4/23/12 .

plat Press = 30 cm H2O)  22% reduction in mortality in patients receiving smaller tidal volume  Number-needed to treat: 12 patients 4/23/12 .patients with ALI/ARDS at 10 centers. 861 ARDS network study patients Patients randomized to tidal volumes of 12 mL /kg or 6 ml/kg(volume control. assist control.

• Consequence of low VT’s but current lung protective strategies do not cause clinically significant hypercapnia Safety of a very high PaCo2 is not proven Still unclear how low a value of arterial pH can be considered safe PHC usually well-tolerated.3 aside from increasing respiratory rate 4/23/12 PERMISSIVE HYPERCAPNIA • • • . the ARDSNet used NaHCO3 when pH < 7.

PEEP PEEP “Pneumatic splint” or prevents derecruitment. prevents 4/23/12 re-collapse (PEEP does NOT recruit but maintains recruitment) .Effect of PEEP in ARDS On end of expiration. Keeps the opened or recruited alveoli open.

ARMA 4/23/12 .

NEJM 2004. 351:327-34. High PEEP Trial (ALVEOLI trial) ARDSNet. 4/23/12 .Lower vs.

Amer J Girard & Bernard.PRONE POSITION VENTILATION • • • • Improves oxygenation but not survival MOA: • Limits expansion of cephalic & parasternal lung regions • Relieves cardiac & abdominal compression on dorsal lung • Makes uniform the regional V/Q ratios • Facilitates drainage of secretions Associated w/ adverse events NO sufficient evidence to support routine use of prone position in patients with ARDS Dernaika et al. Chest 4/23/12 > 6 hrs x 10 .

PRONE POSITION VENTILATION on Mortality decreased VAP • increased Sud pressure ulcers et al. CMAJ April 22.4/23/12 • .

9 1.4 0.6 0.6 0.2 .Prone Positioning: Maneuver-related Complications Complication Airway obstruction (secretion) Transient oxygen desaturation Arrhythmias Hypotension Vomiting Accidental loss of central venous catheter Accidental extubation Accidental loss of thoracic or abdominal drains Pelosi et al Eur Events 102 / 772 97 / 764 16 / 773 15 / 773 12 / 773 5 / 775 3 / 772 2 / 671 4/23/12 Percentage 13 13 2 1.

et al.NIV as first-line intervention in ARDS 54% of patients 46% Antonelli M. Crit Care Med 2007.35:18-25 of patients 4/23/12 .

Other Modes of Ventilation 4/23/12 .

 Airway Pressure Release Ventilation Inverse ratio ventilation High frequency ventilation Liquid Ventilation Extracorporeal Life Support 4/23/12 .

137. time-cycled mode similar to conventional pressure-controlled ventilation (PCV) allows spontaneous breathing during inflation by pressure release mechanism leading to more comfortable ventilation alveolar recruitment high airway pressure maintains adequate Outcome on survival not yet proven Esan et al.12034/23/12 1216 Dernaika et al. Amer J . Chest 2010.Airway Pressure Release Ventilation  pressure-targeted.

Inverse Ratio Ventilation • • • • • Prolong inspiratory time (I:E > 1) Exact MOA unclear but may be due to alveolar recruitment with inc in mean airway P lower peak inspiratory & end expiratory airway P and better distribution of ventilation Patient usually paralyzed auto-PEEP & hemodynamic compromise risk Dernaika et al. Am J Med 4/23/12 Sci .

Vt at 1-2 ml/kg with rates of up to 20 cycles/sec or 60300/min to allow pCO2 to hover to near-normal levels HFOV oscillates the lung around a constant mean airway pressure that is higher than usual conventional MV .High Frequency Oscillatory Ventilation • • HFOV allows small tidal volumes using high respiratory rates.High peak pressures are avoided . 131: Outcomes same 4/23/12 .Low end-expiratory pressures are avoided . CHEST 2007.Alveolar recruitment is maintained • • Chan et al.

dependent areas reached 4/23/12 Diaz et al.dissolves 17 x more O2 than saline & 4 x CO2. Non-toxic. 38:1644 – . Crit Care Med 2010.Liquid Ventilation  Partial or total  Perfluorocarbon . not absorbed thru resp epith  Improved lung recruitment with lower surface tension.

in experienced centers only  High risk of bleeding. BT 1. 4/23/12 .Extracorporeal Life Support  patient's blood is circulated to external machine (veno- venous circuit) that provides oxygenation or CO2 removal  used routinely in neonates with severe ARF  ? Survival benefit.7 li/day Peek et al. Lancet 2009.

Non Ventilatory Management

4/23/12

Pharmacologic Management
 Glucocorticoids  Methylprednisolone 1 mkd  Improved oxygenation & LIS in some studies;

ARDSnet inc mort if given > 14 d
Vasodilators (vasodilatation in aerated lung portions  V/Q improvement)
 Inhaled Nitric Oxide  Prostaglandin E1  Neb Prostacyclin (Prostaglandin I2)

Esan et al. Chest

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Fluid Management

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Fluid Management 4/23/12 .

Complications 4/23/12 .

Ventilator Induced Lung Injury Alveolar over distension with high tidal volumes SIRS/ sepsis  Increased levels of inflammatory mediators in BAL Multiple organ dysfunction Hypercapnia/Acidosis BAROTRAUMA. VOLUTRAUMA. BIOTRAUMA VAP 4/23/12 .

Long Term Outcomes Mortality Outcomes 4/23/12 .

MORTALITY 4/23/12 .

ONE YEAR OUTCOMES IN SURVIVORS 4/23/12 .

 120pts randomized to low Vt or high Vt  25%mortality w/ low tidal volume 45% mortality w/ high tidal volume  20% had restrictive defect and 20% had obstructive defect 1 yr after recovery About 80% had DLCO reduction 1 yr after recovery 4/23/12 .

Looking Back  MGH… (Clinical Correlation and Summary) 4/23/12 .

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