Академический Документы
Профессиональный Документы
Культура Документы
Syndrome (ARDS)
1
Acute Respiratory Distress Syndrome
(ARDS)
• ARDS continues to contribute significantly to the disease burden in
today’s arena of pediatric critical care medicine.
• ARDS is a very heterogeneous disease which makes it difucult to
study
• Many studies have been performed (mainly in adult) but only lung
protective ventilation have been accepted as standard therapy
and had mortality benefit
• ARDS : acute, diffuse, inflammatory lung injury caused by diverse
pulmonary and non-pulmonary etiologies.
• ARDS in infant = Hyalin membran disease
• ARDS in adult does not same with ARDS in pediatric.
• Pediatric is not small adult
2
3
4
Pathophysiology
• ARDS follows cascade of events after direct
pulmonary or systemic insult resulting into the
disruption of alveolar-capillary unit.
• The pathophysiology of ARDS is complex and
multifaceted involving 3 distinct components:
1. nature of the stimulus
2. host response to the stimulus, and
3. the role of iatrogenic factors
5
6
7
ARDS - Pathogenesis
Instigation
• Endothelial injury: increased permeability of
alveolar - capillary barrier
• Epithelial injury : alveolar flood, loss of
surfactant, barrier vs. infection
• Proinflammatory mechanisms
ARDS Pathogenesis
Resolution
• Equally important
• Alveolar edema - resolved by active sodium
transport
• Alveolar type II cells - re-epithelialize
• Neutrophil clearance needed
ARDS - Pathophysiology
• Decreased compliance
• Alveolar edema
• Heterogenous
• “Baby Lungs”
11
12
13
14
15
Clinical Disorders Associated with ARDS
Noninfectious Pneumonia
14%
Cardiac Arrest 12%
Trauma 5%
• intrapulmonary shunt
• FiO2
• WOB
• inflammatory response
33
34
35
36
37
Lung Injury Zones
Overdistention
Lung Volume (ml/kg)
20 “Sweet Spot”
10
Atelectasis
0
13 33 38
Airway Pressure (cmH20)
ARDS: George Bush Therapy
“Kinder, gentler” forms of
ventilation:
•Low tidal volumes (6-8 vs.10-15
cc/kg)
•“Open lung”: Higher PEEP, lower
PIP
•Permissive hypercapnia: tolerate
higher pCO2
Lower Tidal Volumes for ARDS
40 Traditional
35 * Lower
30
25
Percent 20
15 *
10
5
0
ARDS Network,
Death
Vent free
days
NEJM, 342: 2000
* p < .001
Is turning the ARDS
patient “prone” to be
helpful?
Prone Positioning in ARDS
• Theory: let gravity improve matching
perfusion to better ventilated areas
• Improvement immediate
• Uncertain effect on outcome
43
Prone Positioning in Pediatric ARDS:
Longer May Be Better
• Compared 6-10 hrs PP vs. 18-24 hrs PP
• Overall ARDS survival 79% in 40 pts.
• Relvas et al., Chest 2003
46
47
Brief vs. Prolonged Prone Positioning in
Children
25
20
*
Oxygenation Index
15
**
*
(OI)
10
0
Pre-PP Brief PP Prolonged PP
• Rapid rate
• Low tidal volume
• Maintain open lung
• Minimal volume swings
High Frequency Oscillatory Ventilation
HFOV is the easiest way to
find the ventilation
“sweet spot”
HFOV: Benefits Vs. Conventional
Ventilation
HFOV vs. CMV in Pediatric Respiratory
Failure
40
Survival with CLD%
20
0
HFOV CV CV to HFOV to
HFOV CV
- Arnold et al, CCM, 1994
Surfactant in ARDS
• ARDS:
– surfactant deficiency
– surfactant present is dysfunctional
• Surfactant replacement improves physiologic
function
Surfactant in Pediatric ARDS
• Current randomized multi-center trial
• Placebo vs calf lung surfactant (Infasurf)
• Children’s at Egleston is a participating
center-study closed, await results
Steroids in Unresolving ARDS
• Randomized, double-blind, placebo-controlled trial
• Adult ARDS ventilated for > 7 days without
improvement
• Randomized:
– Placebo
– Methylprednisolone 2 mg/kg/day x 4 days,
tapered over 1 month
* p<.01
- Meduri et al., JAMA, 1998
Steroids in Unresolving ARDS
• Randomized, double-blind, placebo-controlled trial
• ARDSNetwork-180 adults
• Randomized:
– Placebo
– Methylprednisolone
– No mortality difference
– Decreased ventilator-free days but only if started
7-14 days
80
70
*
Survival %
60 71
50 58 58
40
53
30
20
10
0 NO
V
Dobyns et al.,
V
NO
O
CM
HF
+
+
J Peds, 2000
V
V
O
CM
HF
Partial Liquid Ventilation
Partial Liquid Ventilation
Mechanisms of action
oxygen reservoir
recruitment of lung volume
alveolar lavage
redistribution of blood flow
anti-inflammatory
Liquid Ventilation