Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.
-
Upload
aleesha-armstrong -
Category
Documents
-
view
219 -
download
2
Transcript of Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.
![Page 1: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/1.jpg)
Acute Lung Injuryand
ARDS
Andreas CredeEmergency Medicine Registrar
![Page 2: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/2.jpg)
Overview
• Introduction
• Definition
• Pathophysiology
• Treatment
• New Stuff
• References
![Page 3: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/3.jpg)
Introduction
• 1st described 1967 (Ashbaugh et al)
• Incidence 1.5 -7.5/ 100000 population
• 28 day mortality 25 – 30%1
• Diagnosis clinical
![Page 4: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/4.jpg)
Definition
• Acute onset (<7days) respiratory failure/distress• Diffuse, bilateral infiltrates on CXR• Absent left atrial hypertension (PAOP
≤18mmHg)• Or absent clinical evidence of left atrial
hypertension
• PaO2/ FiO2 <300mmHg (ALI)
• PaO2/ FiO2 <200mmHg (ARDS)2
![Page 5: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/5.jpg)
![Page 6: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/6.jpg)
Risk Factors
• Alcoholism
• Genetic predisposition
![Page 7: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/7.jpg)
Causes
• Direct Injury1
• Pneumonia• Aspiration• Drowning• Amniotic fluid and fat embolism• Alveolar haemorrhage• Smoke, toxic gas inhalation• Reperfusion (incl rapid drainage pleural effusion)• Unilateral lung re-implantation
![Page 8: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/8.jpg)
Causes
• Indirect Injury1
• Severe Sepsis• Massive transfusion• Shock• Pancreatitis• Salicylate/ narcotic overdose• Anaphylaxis• Cardiopulmonary bypass
![Page 9: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/9.jpg)
Differential
• LVF
• Fluid overload
• Mitral stenosis
• Lymphangitis carcinomatosis
• Interstitial lung disease1
![Page 10: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/10.jpg)
Physical/ chemical injuryActivation Innate
Inflammatory Cascade
Leakage Protein Rich Oedema FluidInflammatory Cellular
Infiltrates
Diffusion AbnormalitiesV/Q Mismatch
Hypoxia
Respiratory Failure
![Page 11: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/11.jpg)
Physical/ chemical injuryActivation Innate
Inflammatory Cascade
Cellular InfiltrateAtelectasis
Oedema Fluid
Reduced Thoracic Compliance + Vasoconstriction
Hypoxia
Respiratory Failure
![Page 12: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/12.jpg)
Physical/ chemical injuryActivation Innate
Inflammatory Cascade
Small Vessel Thrombosis
Increased Dead Space
Hypoxia
Respiratory Failure
![Page 13: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/13.jpg)
Alveolar Damage
Capillary Damage
Leakage Oedema
Fluid
InflammatoryCellular Infiltrates
V/Q Mismatch
Atelectasis
↓ThoracicCompliance
↑Dead Space
Hypoxic Vasoconstriction
Hypoxia
![Page 14: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/14.jpg)
Respiratory Failure
Atelectasis/ Reduced Lung Compliance
Hypoxaemia↑ Dead Space
![Page 15: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/15.jpg)
![Page 16: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/16.jpg)
Histologically
• Exudative Phase3 • Neutrophilic Infiltrate• Alveolar Haemorrhage• Proteinaceous Pulmonary Oedema• Cytokines (TNF, IL1,8)
» ↑ Inflammation» ↑ Oxidative Stress and Protease Activity» ↓ Surfactant Activity» Atelectasis
![Page 17: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/17.jpg)
Histologically
• Elastase- induced capillary and alveolar damage3
• ↑ Alveolar flooding
• ↓ Fluid clearance
• Capillary thrombosis• ↓ Anticoagulant proteins• ↑ Procoagulant proteins (Tissue Factor)• ↑ Anti- fibrinolytic Protein (Plasminogen Activator
Inhibitor)
![Page 18: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/18.jpg)
Post Acute Phase
• Fibroproliferative Phase3
– Variable time period– Fibrosis– Chronic Inflammation– Neovascularisation
• Resolution3
– Improvement of hypoxaemia– Improved dead space and lung compliance– Resolution radiographic abnormalities– Can take up to 1 year– Residual restrictive or obstructive picture
![Page 19: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/19.jpg)
Long Term
• Chronic Respiratory Disease
• Muscle Fatigue
• Muscle Wasting
• Weakness
![Page 20: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/20.jpg)
Treatment
• Ventilation
• Fluid Management
• Steroids
• Other Stuff
![Page 21: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/21.jpg)
Ventilation
• Tidal Volumes
• PEEP
• Positioning
• Weaning Protocols
![Page 22: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/22.jpg)
Tidal Volume
• Recommended 4-6ml/kg4
• High tidal volumes4
• Overdistention of alveoli• Local inflammatory response resulting in systemic
inflammation• TNF, IL6, IL10,
![Page 23: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/23.jpg)
Tidal Volume4
• Low tidal volume ventilation• Weight
• Predicted not actual
• Plateau Pressure • ≤30cm H2O
• Resp Rate • Titrated to pH 7.3-7.45
• PEEP and FiO2 • Adjusted to maintain saturation
• Low tidal volume may result in hypercarbia• ARMA (Respiratory Management in ALI/ARDS Trial)
• NaHCO3 infusions/ hyperventilation to maintain pH
![Page 24: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/24.jpg)
Tidal Volumes
• Same sedation strategies• No ↑ duration of ventilation• High frequency oscillatory ventilation
shown no benefit over low tidal volume ventilation
• 30 day mortality not statistically significant (37% vs 52%, p=0.10)
• Earlier recovery from hypoxia
• Only ventilation strategy shown to reduce mortality (40% - 31%)4
![Page 25: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/25.jpg)
PEEP
• Recommendation: lowest PEEP/ FiO2 to maintain saturation
• Recruits collapsed alveoli• In dependant regions• Over-distends in non-dependant regions
• ↓ Repetitive opening/ closing of alveoli: ↓ airway damage
• Endothelial/ epithelial stretch injury with subsequent capillary injury
• Similar cytokine response as ↑tidal volume
![Page 26: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/26.jpg)
PEEP
![Page 27: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/27.jpg)
PEEP
• ALVEOLI Trial4• Higher PEEP = improved oxygenation• In hospital mortality equal btw high and low PEEP• Time on ventilator similar• Duration non- pulmonary organ failure equal
![Page 28: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/28.jpg)
PEEP
Adverse effects of PEEP Cardiac output• Volutrauma Lung water High VA/Q Dead space Endothelial permeability Epithelial permeability Bronchial blood flow
![Page 29: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/29.jpg)
Fessler, ARRD 1993
![Page 30: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/30.jpg)
PEEP + Lung Perfusion
Permutt, JAP 1961
![Page 31: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/31.jpg)
PEEP
• Some Endpoints• Best PaO2
• Lowest Shunt
• Best O2 delivery
• Best lung perfusion
• Plateau Pressure ≤30cm H2O
• Optimise aeration on CT• Pressure/ volume curve becomes concave
![Page 32: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/32.jpg)
Positioning
• Prone positioning1,4
• Redistribution of blood & ventilation to least affected areas of lung
• Secretion clearance• Shifts mediastinum anteriorly – assists recruitment
of atelectatic areas• ? reduce lung injury• Reduced lung compression by abdominal contents
![Page 33: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/33.jpg)
Supine Ventilation
• ± 40% lung volume under lung, especially patients with large hearts
![Page 34: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/34.jpg)
Prone Ventilation
![Page 35: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/35.jpg)
Effect of Blood Flow in Prone Positioning7
Perc
en
t Flo
w
25
50
0
Supine
MidD ND
Dorsal VentralProne
Ventral Dorsal
D Mid
ND
![Page 36: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/36.jpg)
Positioning
• Prone position4
• Transient improvement PaO2/FiO2
• No improvement: survival/ time on ventilator/ time in ICU
• Role:» High FiO2
» High plateau pressures
![Page 37: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/37.jpg)
Weaning Protocols
• Reduce duration of mechanical ventilation vs patients managed by IMV protocol4
• Daily spontaneous breathing trial4• 30-120 mins unassisted ventilation• 4 Criteria before commencement
– Some reversal of underlying cause
– PEEP ≤8cm H2O/ FiO2 ≤50%
– Haemodynamic stability– Ability to initiate inspiratory effort
![Page 38: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/38.jpg)
Fluid Management
![Page 39: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/39.jpg)
Fluid Management
• Fluid movement regulated by:• Starling equation• Vessel wall
– Ability to filter fluid– Selective permeability to proteins
![Page 40: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/40.jpg)
Fluid Management
![Page 41: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/41.jpg)
Fluid Management
• Study of conservative vs liberal fluid management5
• 60 day mortality: 25.5 vs 28.4% p=0.30• 1st 28 days ventilator free: 14.6 vs 12.1 p<0.001• 1st 28 days ICU free: 13.4 vs 11.2 p<0.001• Difference in organ failure and need for dialysis not
statistically significant• No specific mention of CVP/ PAOP levels which to
aim for• Conservative = 4mmHg Liberal = 10-14mmHg CVP
![Page 42: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/42.jpg)
Steroids
• Theoretical use to ↓inflammatory response associated with ARDS6
• 2006 study6
• No ↓60 day mortality (28.6% vs 29.2% p= 0.10)• Use of steroids 14+ days post onset: ↑ mortality• ↓ need for vasopressors• ↑ ventilator and shock free days• ↑ neuromuscular weakness• Short term improvement in oxygenation
![Page 43: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/43.jpg)
Other stuff
• Extracorporeal membrane oxygenation• Improvement in oygenation• No ↑ long term survival
• Vasodilators• Improved oygenation• No ↑ long term survival
• Ketoconazole• Pentoxyfilline• Nutritional modification• Antioxidants• Surfactant• B2 stimulants1
![Page 44: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/44.jpg)
Emergency Department Summary
• PREVENT!
• Low tidal volume ventilation
• Restrict PEEP
• Restrict Fluids (if possible)
• Initiate Weaning Protocol
• Supine Ventilation
![Page 45: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/45.jpg)
Conclusion
• Many theoretical therapies
• Only proven strategy to improve survival is low tidal volume ventilation
• Therapies to reduce number of days needing scarce resources valuable in our setting
![Page 46: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/46.jpg)
Thank You
![Page 47: Acute Lung Injury and ARDS Andreas Crede Emergency Medicine Registrar.](https://reader036.fdocuments.us/reader036/viewer/2022062421/56649cec5503460f949b823d/html5/thumbnails/47.jpg)
References• 1. Wheeler, A.P. and Bernard, G.R. 2007,Acute Lung Injury and the Acute
Respiratory Distress Syndrome: A Clinical Review. Lancet; 369: 1553–65• 2. The Acute Respiratory Distress Syndrome Network. 2000, Ventilation
With Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. N Engl J Med; 342:1301-08
• 3 Plantadosi, C.A and Schwartz, D.A. 2004, The Acute Respiratory Distress Syndrome. Ann Intern Med; 141:460-470.
• 4. Girard, T>D> and Bernard,G.R. 2007, Mechanical Ventilation in ARDS: A State-of-the-Art Review. Chest; 131;921-929
• 5. The National Heart, Lung and Blood Institue Acute Respiratory Distress Syndrome Clinical Trials Network. 2006, Comparison of Two Fluid-Management Strategies in Acute Lung Injury. N Engl J Med; 354:2564-75
• 6. The National Heart, Lung and Blood Institue Acute Respiratory Distress Syndrome Clinical Trials Network. 2006, Efficacy and Safety of Corticosteroids for Persistent Acute Respiratory Distress Syndrome. N Engl J Med; 354:1671-84
• 7. www.slideshare.net