ARDS - trauma
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Lungs might be affected by trauma, chemicals, infections. patients show in respiratory failure.
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ARDS - trauma
- 1. Acute Respiratory Distress Syndrome. Case presentation Dr. Adel Hassan Sen. Consult. Anesthesiologist HOD Anesthesia & ICU. Kalba Hospital, MOH. 31st March 2014
- 3. F. 35ys , 300 Kgs, Lt. TIBIA/FIBULA Fx (Impacted In place). 8th D -in pat. w.- after admission, sudden severe hypoxia PH 7.22 PaCO2 =72 mmhg PaO2=43 mmhg HCO36 , Unconscious. Anesthesia on duty was called to IPW. Supported ventilation shifted pt. to ICU. Management started as will be discussed later.
- 4. Acute Respiratory Failure • Failure in one or both gas exchange functions: oxygenation and carbon dioxide elimination • In practice: PaO2<60mmHg or PaCO2>46mmHg • Derangements in ABGs and acid-base status
- 5. Acute Respiratory Failure • Hypercapnic v Hypoxemic respiratory failure • ARDS and ALI
- 6. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Problem VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 7. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Problem VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 8. Hypercapnic Respiratory Failure Alveolar Hypoventilation Brainstem respiratory depression Drugs (opiates) Obesity-hypoventilation syndrome PI max Central Hypoventilation Neuromuscular Disorder nlPI max Critical illness polyneuropathy Critical illness myopathy Hypophosphatemia Magnesium depletion Myasthenia gravis Guillain-Barre syndrome
- 9. Hypercapnic Respiratory Failure (PAO2 - PaO2) Alveolar Hypoventilation V/Q abnormality PI max increasednormal Nl VCO2 PaCO2 >46mmHg Not compensation for metabolic alkalosis Central Hypoventilation Neuromuscular Disorder VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 10. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding
- 11. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding • Increased dead space ventilation • advanced emphysema • PaCO2 when Vd/Vt >0.5 • Late feature of shunt-type • edema, infiltrates
- 12. Hypercapnic Respiratory Failure V/Q abnormality Increased Aa gradient Nl VCO2 VCO2 V/Q Abnormality Hypermetabolism Overfeeding • VCO2 only an issue in pts with ltd ability to eliminate CO2 • Overfeeding with carbohydrates generates more CO2
- 13. Hypoxemic Respiratory Failure Is PaCO2 increased? Hypoventilation (PAO2 - PaO2)? Hypoventilation alone Respiratory drive Neuromuscular dz Hypovent plus another mechanism Shunt Inspired PO2 High altitude FIO2 (PAO2 - PaO2) No NoYes Is low PO2 correctable with O2? V/Q mismatch No Yes Yes
- 14. The Case of Patient ES 77F s/p MVC. Injuries include multiple L rib fxs, L hemopneumothorax s/p chest tube placement, L iliac wing fx. PMH: atrial arrhythmia, on coumadin. INR>2 HD#1 RR 30s and shallow. Pain a/w breathing deeply. Placed on BiPAP overnight PID#1 BiPAP 80%: 7.45/48/66/32/+10
- 15. Hypoxemic Respiratory Failure Is PaCO2 increased? Hypoventilation (PAO2 - PaO2)? Hypoventilation alone Respiratory drive Neuromuscular dz Hypovent plus another mechanism Shunt Inspired PO2 High altitude FIO2 (PAO2 - PaO2) No NoYes Is low PO2 correctable with O2? V/Q mismatch No Yes Yes
- 16. Hypoxemic Respiratory Failure V/Q mismatch V/Q mismatch DO2/VO2 Imbalance PvO2>40mmHg PvO2<40mmHg DO2: anemia, low CO VO2: hypermetabolism
- 17. Hypoxemic Respiratory Failure V/Q mismatch SHUNT V/Q = 0 DEAD SPACE V/Q = ∞ Atelectasis Intraalveolar filling Pneumonia Pulmonary edema Pulmonary embolus Pulmonary vascular dz Airway dz (COPD, asthma) Intracardiac shunt Vascular shunt in lungs ARDS Interstitial lung dz Pulmonary contusion
- 18. Hypoxemic Respiratory Failure V/Q mismatch SHUNT V/Q = 0 DEAD SPACE V/Q = ∞ Atelectasis Intraalveolar filling Pneumonia Pulmonary edema Pulmonary embolus Pulmonary vascular dz Airway dz (COPD, asthma) Intracardiac shunt Vascular shunt in lungs ARDS Interstitial lung dz Pulmonary contusion
- 19. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • Severe ALI • B/L radiographic infiltrates • PaO2/FiO2 <200mmHg (ALI 201-300mmHg) • No e/o L Atrial P; PCWP<18
- 20. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • Develops ~4-48h • Persists days-wks • Diagnosis: – Distinguish from cardiogenic edema – History and risk factors
- 24. Inflammatory Alveolar Injury Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
- 25. Inflammatory Alveolar Injury Fluid in interstitium and alveoli Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
- 26. Inflammatory Alveolar Injury Fluid in interstitium and alveoli • Impaired gas exchange • Compliance • PAP Pro-inflmm cytokines (TNF, IL1,6,8) Neutrophils - ROIs and proteases damage capillary endothelium and alveolar epithelium
- 27. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Exudative phase Fibrotic phaseProliferative phase Diffuse alveolar damage
- 28. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Direct Lung Injury • Infectious pneumonia • Aspiration, chemical pneumonitis • Pulmonary contusion, penetrating lung injury • Fat emboli • Near-drowning • Inhalation injury • Reperfusion pulmonary edema s/p lung transplant
- 29. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Indirect Lung Injury • Sepsis • Severe trauma with shock / hypoperfusion • Burns • Massive blood transfusion • Drug overdose: ASA, cocaine, opioids, phenothiazines, TCAs. • Cardiopulmonary bypass • Acute pancreatitis
- 30. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome Complications • Barotrauma • Nosocomial pneumonia • Sedation and paralysis persistent MS depression and neuromuscular weakness
- 31. Hypoxemic Respiratory Failure Acute Respiratory Distress Syndrome • 861 patients, 10 centers • Randomized • Tidal Vol 12mL/kg PDW, PlatP<50cmH2O • Tidal Vol 6mL/kg PDW, PlatP<30cmH2O • NNT 12 • 31% mortality v 39.8% • 65.7% breathing without assistance by day 28 v 55% • Significantly more ventilator-free days • Significantly more days without failure of nonpulmonary organs/systems