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The management of acute respiratory distress syndrome

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Dang Thanh Tuan
Dang Thanh Tuan
Salud y medicina
1 de 48
The Management of Acute Respiratory Distress Syndrome 署立桃園醫院 胸腔內科 林倬睿醫師
Outlines ,[object Object],[object Object],[object Object],[object Object]
定義 Definition ,[object Object],[object Object],[object Object],[object Object]
致病原因 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Differential Diagnosis ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lancet 2007; 369:1553-65
Prognosis & Outcome ,[object Object],[object Object],[object Object],[object Object],Lancet 2007; 369:1553-65
Pathophysiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lancet 2007; 369:1553-65
NEJM 2000;342:1334-1349
NEJM 2000;342:1334-1349
NEJM 2000;342:1334-1349
Treatment ,[object Object],[object Object],[object Object],[object Object],[object Object]
Supportive Care ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ventilator Strategy
Ventilator-induced Lung Injury (VILI) ,[object Object],[object Object],[object Object],[object Object],Over Distension Collapse
Volutrauma ,[object Object],[object Object],[object Object],[object Object],AJRCCM 1998; 157: 294-323
Atelectrauma ,[object Object],[object Object],[object Object],PEEP PEEP PEEP Lung edema
The PEEP Effect NEJM 2006;354:1839-1841
Ventilator-induced Lung Injury (VILI) Upper Deflection point Lower Inflection point
[object Object],Lung-Protective Ventilation NEJM 2000; 342: 1301-1308 39.8% 31.0% Result (p<0.001) 9.1 8.1 Actual PEEP Protocol Protocol PEEP <50 <30 P plateau 12 6 Tidal Volume (ml/kg) Conventional ventilation Lung-protective ventilation 18-24 14-18 14 10-14 10 8-10 5-8 5 PEEP 1.0 0.9 0.8 0.7 0.6 0.5 0.4 0.3 FiO2 Principle for FiO2 and PEEP Adjustment
[object Object],[object Object],[object Object],Lung-Protective Ventilation NEJM 2000; 342: 1301-1308
Concerns when using lung-protective strategy… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Other Ventilator Strategies ,[object Object],[object Object],[object Object]
Lung Recruitment ,[object Object],[object Object],[object Object],NEJM 2007; 354: 1775-1786
Lung Recruitment NEJM 2007; 354: 1775-1786
Lung Recruitment NEJM 2007; 354: 1775-1786
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lung Recruitment Sensitivity : 71% Specificity : 59% NEJM 2007; 354: 1775-1786
[object Object],[object Object],[object Object],[object Object],Lung Recruitment
Prone Position
Prone Position ,[object Object],[object Object],[object Object],[object Object]
Prone Position NEJM 2001;345:568-573
Prone Position NEJM 2001;345:568-573
[object Object],[object Object],[object Object],[object Object],[object Object],Prone Position
High-Frequency Oscillatory Ventilation (HFOV)
HFOV Frequency: 180-600 breaths/min (3-10Hz)
Effect of HFOV on gas exchange in ARDS patients AJRCCM 2002; 166:801-8
Survival difference of ARDS patients treated with HFOV or CMV 30-day: P=0.057 90-day: P=0.078 AJRCCM 2002; 166:801-8
HFOV ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Chest 2007; 131:1907-1916
Adjunctive Therapy ,[object Object],[object Object],[object Object],[object Object],[object Object]
Steroid therapy NEJM 2006;354:1671-1684
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Steroid therapy NEJM 2006;354:1671-1684
Fluid Management NEJM 2006;354:2564-2575
Fluid Management NEJM 2006;354:2564-2575
Fluid Management NEJM 2006;354:2213-24
[object Object],[object Object],[object Object],Fluid Management
Extracorporeal Membrane Oxygenation (ECMO) ,[object Object],[object Object],[object Object]
Nitric Oxide ,[object Object],[object Object],[object Object],[object Object]
Unproven Treatments ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Lancet 2007; 369:1553-65
Conclusions ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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The management of acute respiratory distress syndrome

Notas del editor

  1. Limitations: 生理定義不需要標準呼吸器治療 , 醫師判讀有差異
  2. Predisposing: alcoholism, severe sepsis, genetic predisposition Direct or indirect, outcome is similar
  3. 不一定想到 , 想到不一定判斷的出
  4. 一開始的缺氧不是好的預測指標 , 但 severe hypoxia for days 則是
  5. TNF, IL1,IL8 Tissue factor, plasminogen activator inhibitor 1
  6. 近年重要觀念 : 不均勻 , 體重大於預期 ( 可能大於 20%), 呼吸器會導致傷害 , 雖然一開始不明顯
  7. taken at the end of inspiration. A=0, B=15, C=15 x3, D= 15*5 F=0*1, G = 0*3, H =0*5
  8. 用的是預期體重
  9. 目前唯一對 mortality 有效的方法
  10. 高低的分界是 9%
  11. 不論哪一組 , 都大約有 24% 的肺無法打開