Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome Clay Wu, DO Brett Lindgren,...
Transcript of Acute Respiratory Distress SyndromeAcute Respiratory Distress Syndrome Clay Wu, DO Brett Lindgren,...
Acute Respiratory Distress Syndrome
Clay Wu, DO
Brett Lindgren, DO
Last updated: August 19, 2019
Content
• Definition
• Epidemiology
• Pathophysiology
• Etiologies
• Treatment
Content
• Definition
• Epidemiology
• Pathophysiology
• Etiologies
• Treatment
Mortality rates
27 %
32 %
45 %
All meet chest imaging criteria for ARDS
Content
• Definition
• Epidemiology
• Pathophysiology
• Etiologies
• Treatment
Statistics
• 10% of all patients admitted to the ICU had ARDS
• 23% of mechanically ventilated patients had ARDS
• Increasing mortality with increased severity of ARDS (up to 46%)
Bellani G, Laffey JG, Pham T, et al. JAMA 2016
Content
• Definition
• Epidemiology
• Pathophysiology
• Etiologies
• Treatment
Phases of ARDS
Exudative Proliferative
Fibrotic
Recovery
Hallmark feature is diffuse alveolar damage
Phases of ARDS
• Exudative Phase (First 7 to 10 days)• Pro-inflammatory phase mediated
by alveolar macrophages.
• Leads to damage of the alveolar endothelial and epithelial barriers with accumulation of protein-rich edema fluid within the interstitium and alveolus
Early diffuse alveolar damage
Phases of ARDS
• Proliferative Phase (10-21 days)• Proliferation of Type II
pneumocytes and fibroblasts which aims to restore barrier functions of epithelium, endothelium, and interstitium. Can lead to recovery or fibrotic phase.
Late diffuse alveolar damage
Phases of ARDS
• Fibrotic Phase (> 21 days); Not present in all• Inadequate or delayed re-epithelialization leading to development of
interstitial and intra-alveolar fibrosis.
• Leads to prolonged mechanical ventilation and increased mortality.
Content
• Definition
• Epidemiology
• Pathophysiology
• Etiologies
• Treatment
Etiologies
Direct Lung Injury Indirect Lung Injury
Pneumonia (bacterial, viral, fungal, etc) Sepsis (non-pulmonary source)
Aspiration Transfusion of blood products
Pulmonary contusion Pancreatitis
Inhalational injury Major burn injury
Near drowning Drug overdose
Cardiopulmonary bypass
Content
• Definition
• Epidemiology
• Pathophysiology
• Etiologies
• Treatment
Proven Therapies
Ventilator Basic Principles
• Reduce volutrauma (i.e. low tidal volume, low driving pressure)• Prevent overdistention which may further injure alveolar epithelium
• Permissive hypercapnia
• Goal plateau pressure < 30
• Reduce atelectrauma (i.e. PEEP)• Reduce repetitive opening and closing of alveoli
Lung Protective Strategy (ARDSNet)
• In patients with ARDS, low tidal volume ventilation (initial TV 6ml/kg PBW) had lower mortality and more ventilator-free days.
Brower RG, et al. NEJM. 2000
Prone Positioning (PROSEVA)
• Among patients with moderate-severe ARDS (P:F ratio < 120 mmHg), prone positioning reduces 28-day mortality.
Guerin, Claude, et al. NEJM. 2013
Benefit likely 2/2 more uniform distribution of ventilation and less compression of left lower lobe.
Conservative Fluid Therapy (FACCT)
• A conservative fluid management strategy targeting a CVP <4 mmHg• improves lung function
• decreases ventilator days
• reduces ICU days
• DOES NOT reduce mortality
Wiedemann HP, et al. NEJM. 2006
Debatable Therapies
Debatable therapies
• Neuromuscular blockade
• Steroids (early, never in late (>13 days)
• Pulmonary vasodilators• Inhaled nitric oxide
• Inhaled prostacyclin• Improves oxygenation, but failed to improve mortality
• Veno-venous Extracorporeal membrane oxygenation (VV ECMO)
Neuromuscular Blockade (ACURASYS v. ROSE)
National Heart, Lung, and Blood Institute PETAL Clinical Trials Network. NEJM. 2019
Paralysis with cisatracurium for 48 hours in early severe ARDS improves 90 day survival and increases ventilator-free days.
Papazian L, et al. NEJM. 2010
Paralysis with cisatracurium for 48 hours did not result in a significant difference in 90 day survival compared to lighter sedation targets.
Ineffective therapies
• High-frequency oscillation
• Surfactant replacement
• Neutrophil elastase inhibition
Summary of TreatmentsIn
cre
asin
g in
ten
sity
of
inte
rve
nti
on
300 250 200 150 100 50PaO2/FiO2
Low Tidal Volume Ventilation
Low-Moderate PEEP
Higher PEEP
Mild ARDS Moderate ARDS Severe ARDS
Proven Mortality Benefit
Prone Position
Neuromuscular Blockade
Glucocorticoids (within 14 days of onset)
Inhaled NO
Inhaled prostacyclin
VV ECMO
Rescue Therapies