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

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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

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The Case
MC 23/M Call Center Agent
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The Case
M. C. 23/M, single, Filipino Call Center Agent January 2011
On and off

undocumented fever malaise

Generalized body Anorexia, weight loss

Chief Complaint:
Dyspnea

of about 10 15 %
February 2011
Consulted at our

PROFILE:
Previously well, 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

kochs therapy was started and was noted to be (+) for ELISA and Western blot

ICC screen was done

medications taken
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The Case
Diagnosed to have
PGH (04/12/11)

TB pneumonia allegedly was positive

Sputum AFB

Initial PE: Conscious, oriented,

MEDS:
Ceftriaxone 1 g IV q8 Clarithromycin

conversant, ambulatory, speaks in sentences 6lpm

On O2 via Nasal Cannula at

BP: 120/70 CR: 130s

500mg/tab, 1 tab BID PO prebreakfast

T: 36.9

RR: 40

AS, PPC, (-) CLAD/ NVE/ TPC ECE, clear breath sounds,

HRZE, 4 tabs OD Paracetamol,

(-) crackles/rales
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AP, tachycardic, regular

rhythm, no murmurs

The Case
CXR

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ADULT PULMONARY SVC AC MODE (04/16/11) 300 VT FiO2 100 Conscious, follows PEEP 15 commands IFR 60 in , speaks words BUR 18 supraclavicular retractions noted

Meropenem g IV q8h BP: 140/70 CR:1150s RR: Combivent q6h 40 T: 37.4 Azithromycin 500mg/tab OD O2 sats 80s despite Face Co-trimoxazole 800/160/tab, 2 Mask at 10tabs BID LPM

HRZE 3 tabs OD pre breakfast AS, PPC, (+) CLAD, right/ Fluconazole 100mg OD

NVE/ TPC

ECE, (+) rhonchi bilateral

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The Case
ETA CS
No growth after 2

days

Blood CS
No growth after 5

days

Ortho-Toluidine Blue

stain

Positive for

Pneumocystis

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Acute Respiratory Distress

Definition Background
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Syndrome (ARDS)

DEFINITION
A syndrome often progressive and

characterized by distinct clinical, pathological and radiographic stages

Characterized by non-cardiogenic pulmonary

edema, lung inflammation, hypoxemia, and decreased lung compliance

Murray et al., 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, Bigelow, Petty Lancet 1967

DEFINITION

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First described in 1967 Annual incidence 75/100,000 in the US High mortality- 40%-60% Decreased mortality in the late 1990s: 30 40%

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Diagnosing ARDS
Criteria Differential Diagnosis
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CRITERIA
The 1994 North American-European Consensus Conference (NAECC) criteria:
Onset - 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

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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,
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The 1998 NAECC Updated Recommendations

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

4. It will be also useful to record:
Information relating to etiology (at a

minimum,

direct or indirect cause)

Mortality, including cause of death, and

whether

death was associated with withdrawal of care

Presence of failure of other organs and other

time

dependent covariates

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Lung Injury Score

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GOCA

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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

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Causes of ARDS
Pulmonary (direct) Non-Pulmonary (indirect)
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CAUSES
PULMONARY NON-PULMONARY

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Risk Factors for ARDS

Risk Factors Predictive of Poor Outcome

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RISK FACTORS

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Mechanism of Injury
Pathophysiology Stages of ARDS
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Severe injury to the alveolocapillary unit: alveolocapillary leak Permeability pulmonary edema (protein rich edema fluid) Surfactant disruption Hyaline membrane formation Alveolar collapse, consolidation

Cellular necrosis, epithelial hyperplasia, inflammation Fibrosis

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DIFFERENCE IN PATHOLOGIES THRU TIME

EXUDATIVE PHASE (day0- 7) 5 days post-injury

PROLIFERATIVE PHASE (day 7-21)

12 days post-injury

17 days post-injury
Ware, Matthay. NEJM 2000. Gattinoni et al. AJRCCM

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DE- Stressing ARDistressS

Principles of Mechanical Ventilation Medical/ Non-Ventilatory Management Other Treatment Modalities
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Characteristics of ARDS / ALI

Exudative stage: heterogeneous lung injury
normally aerated poorly Aerated (recruitable) non aerated

V/Q < 1
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VENTILATORY STRATEGIES FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROME

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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

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Ventilatory Strategies in ARDS: Standard of Care

Principle: Lung Protection
Avoid alveolar overdistention: Vt < 6 ml/PBW Ensure Pplat < 30 cm H20 Maintain FiO2 < 0.6 Use sufficient PEEP to prevent cyclic

atelectasis

Consider that the mode of ventilation is less May tolerate hypercapnia, if necessary
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important than attending to the above goals

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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, plat Press = 30 cm H2O)

22% reduction in mortality in patients

receiving smaller tidal volume

Number-needed to treat: 12 patients
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Consequence of low VTs 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, the ARDSNet used NaHCO3 when pH < 7.3 aside from increasing respiratory rate
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PERMISSIVE HYPERCAPNIA

Effect of PEEP in ARDS

On end of expiration,

PEEP

PEEP

Pneumatic splint or prevents derecruitment; Keeps the opened or recruited alveoli open, prevents 4/23/12 re-collapse (PEEP does NOT recruit but maintains recruitment)

ARMA

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Lower vs. High PEEP Trial (ALVEOLI trial)

ARDSNet. NEJM 2004, 351:327-34.

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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. Amer J Girard & Bernard. Chest

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> 6 hrs x 10

PRONE POSITION VENTILATION on Mortality

decreased VAP increased Sud pressure ulcers et al. CMAJ April 22,4/23/12

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
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Percentage 13 13 2 1.9 1.6 0.6 0.4 0.2

NIV as first-line intervention in ARDS

54%

of patients

46%
Antonelli M. et al. Crit Care Med 2007;35:18-25

of patients 4/23/12

Other Modes of Ventilation

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 Airway Pressure Release

Ventilation

Inverse ratio ventilation High frequency ventilation Liquid Ventilation Extracorporeal Life Support 4/23/12

Airway Pressure Release Ventilation

pressure-targeted, 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. Chest 2010;137;12034/23/12 1216

Dernaika et al. Amer J

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

High Frequency Oscillatory Ventilation

HFOV allows small tidal volumes using high respiratory rates. 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 - Low end-expiratory pressures are avoided - High peak pressures are avoided
- Alveolar recruitment is maintained

Chan et al. CHEST 2007; 131:

Outcomes same

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Liquid Ventilation
Partial or total Perfluorocarbon - dissolves 17 x more O2

than saline & 4 x CO2. Non-toxic, not absorbed thru resp epith
Improved lung recruitment with lower

surface tension, dependent areas reached

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Diaz et al. Crit Care Med 2010; 38:1644

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; in experienced centers only High risk of bleeding; BT 1.7 li/day

Peek et al. Lancet 2009;

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Non Ventilatory Management

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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

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Complications

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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

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Long Term Outcomes

Mortality Outcomes
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MORTALITY

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ONE YEAR OUTCOMES IN SURVIVORS

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 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

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Looking Back
MGH

(Clinical Correlation and Summary)

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