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ARDS
Dr. Tura Lencho Anesthesiology and Critical Care Medicine 4/25/2020
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Objectives 1. ARDS brief review 2. Overview of mechanical ventilators3. Management of ARDS on MV
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Diagnosis
● ARDS can be diagnosed once cardiogenic pulmonary edema and alternative causes of acute hypoxemic respiratory failure and bilateral infiltrates have been excluded.○ Mild: PaO2/FiO2 < 300○ Moderate: P/F < 200○ Severe: P/F < 100
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Management Strategies for ARDS
● Noninvasive ventilation
● Invasive ventilation
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Management of acute respiratory failureIntubated patients
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Airway management ● Intubation
○ Indication:- Respiratory failure, airway protection, surgery○ Airway assessment:-
○ Induction: ensure (SOAP ME; Suction, Oxygen, Airway, Personnel, Meds, Equipments)
■ Regular - oxygen sedation oxygen intubate ■ RSI - oxygen - sedation intubate
○ Position:
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Basic Terminologies
1. Tidal Volume (TV) - lung volume with normal inhalation and exhalation when extra effort is not applied
2. Respiratory rate (RR) - breath per minute
3. minute ventilation = TV x RR 4. PEEP- positive end expiratory pressure
5. FiO2 - fraction of inspired oxygen
6. inspiratory pressure - pressure applied to the lungs during inhalation7. Peak inspiratory pressure - the maximum pressure applied to the lungs during inhalation8. Plateau pressure (Pplat 0.5 second inspiratory pause)- pressure that is applied to the small airways and alveoli.
9. inspiratory to expiratory (I:E) ratio - usually 1:3
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Mechanical ventilation modes
● Volume-modes 1. Assist-control ventilation (ACV) - set TV for spontaneous breath 2. Synchronized intermittent mandatory ventilation (SIMV) - variable TV
for spontaneous breath ● Pressure- modes :
1. Pressure control ventilation (PCV)2. Pressure support ventilation (PSV) - patient spontaneous3. Airway pressure release ventilation (APRV): Ph, PL, Th & TL
● Dual-modes: a. Pressure regulated volume control (PRVC)
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Set by operator directly FiO2 PEEP RR TV Ipressure I:E
ACV yes yes yes yes no yes Additional spont. breath is a set TV
SIMV yes yes Yes minimum
yes no/ (yes
spontaneous part) NO Additional spont breath, TV
varies
PSV yes yes No No yes NO Patient controls RR & TV
PCV yes yes yes no yes yes TV depends on pressure
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Volume modes Volume control SIMV
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Pressure modesPressure control Pressure support
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ARDS vent setting Lung protective vent setting
1. Low tidal volumes 6-8 ml/kg, based on predicted body weight (PBW) 2. PEEP > 5 cm HO23. Plateau pressure < 30 cm HO2
Goals:
1. Limit the risk of volutrauma 2. Limit the risk of atelectrauma3. Limit the risk of barotrauma
PBW M= 50 + 0.91 (height in cm-152.4) F= 45.5 + 0.91 (height in cm-152.4)
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Troubleshootings 1. Hypoxia - Gaol - PaO2 55-80 or SpO2 88-95 %
a. Ensure appropriate ETT placement - auscultate b/l chest b. Suction ETT, check Peak & plateau pressuresc. Adjust vent setting: FiO2, PEEP, and I:E d. Avoid patient dyssynchrony with ventilatore. Prone position f. Paralyzing g. Extracorporeal membrane oxygenation (ECMO)
2.3. Hypercarbia
a. Adjust vent setting: TV, RR, and other checks as for hypoxia b. Consider permissive hypercarbia if hypoxia is also an issue
4. High pressure: a. High peak airway pressure = airway issue. Check ETT for kinking, mucous plug,
bronchospasmb. High plateau pressure = alveolar issue. No complaint lung
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Galatooma !
Fayya Ta’a !
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Reference
1. http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf
2.