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DISTRESS SYNDROME
Michael L. Fiore, MD – Fellow in Critical Care
Medicine
Mary W. Lieh-Lai, MD, Director, ICU and
Fellowship Program Division of Critical Care
Medicine
Children’s Hospital of Michigan/Wayne State
University
Children’s Hospital of Michigan
A.K.A.
Adult
Respiratory
Distress
Syndrome
Da Nang Lung
Transfusion
Lung
Post Perfusion
disease in neonates
ARDS is also observed in children
New criteria and definition
Difficulties:
lacks specific criteria
trigger
diffuse alveolar damage with
capillary injury
development of hypercarbia
fibrosing alveolitis
compliance
pulmonary hypertension
Recovery phase
gradual resolution of hypoxemia
resolution of radiographic
abnormalities
sepsis
Inciting event
Inflammatory mediators
Damage to microvascular endothelium
Type I cell
Alveolar
macrophage
Endothelial
Cell
RBC’s Type II
cell
Capillary
Type I cell
Alveolar
macrophage
Endothelial
Cell
RBC’s Type II
cell
Capillary
Neutrophils
Surfactant damage
Decreased FRC
Cell
O2
Arterial O2 O2
Venous
O2
Inflow Outflow
O2 O2 O2 O2
(Q) capillary (Q)
DO2 = Q X CaO2
DO2 = Q X (1.34 X Hb X SaO2) X 10
Q = cardiac output
CaO2 = arterial oxygen content
Normal DO2: 520-570 ml/min/m2
Max O2 Max O2
extraction extraction
VO2 VO2
Critical DO2 Critical DO2
DO2 DO2
dependency
Oxygen utilization by non-ATP
ECMO
Innovative strategies
Nitric oxide
Liquid ventilation
Exogenous surfactant
Children’s Hospital of Michigan
MANAGEMENT
Monitoring:
Respiratory
Hemodynamic
Metabolic
Infections
Fluids/electroly
tes
mechanical ventilation
oxygen/PEEP
VO2
preload
afterload
contractility
Children’s Hospital of Michigan
CONVENTIONAL
VENTILATION
Oxygen
PEEP
Inverse I:E ratio
Lower tidal volume
Ventilation in prone
position
change in pressure
in ARDS
When possible, plateau pressures <
35 cm H2O
Tidal volume should be decreased if
necessary to achieve this, permitting
increased pCO2
Children’s Hospital of Michigan
PEEP - Benefits
Increases transpulmonary
distending pressure
Displaces edema fluid into
interstitium
Decreases atelectasis
Improved compliance
Improved oxygenation
for 72 hours
No differences in development of
Carl Sagan
patients
Multicenter trial
– Conventional mechanical
ventilation vs. mechanical
ventilation supplemented with
partial venoarterial bypass
Children’s Hospital of Michigan
– No benefit
Partial Liquid
Ventilation (PLV)
Ventilating the lung with conventional
ventilation after filling with
perfluorocarbon
Perflubron
20 times O and 3 times the CO
2 2
solubility
Heavier than water
pulmonary compliance
8 of 10 survivors
few complications
No randomized or case controlled
ventilation
No difference in survival, ICU stay, or
complications
Children’s Hospital of Michigan
High Frequency
Oscillating Ventilator
(HFOV)
Raise MAP
Recruit lung volume
Small changes in tidal volume
Impedes venous return necessitating
intravascular volume expansion
and/or pressors
disease
Children’s Hospital of Michigan
New England Journal of
Medicine 2000;342:1301-8
No improvement in survival
4) vs. placebo
No differences in oxygenation, chest
rate
PROGNOSIS
Severity of illness