ARDS: An Evidence-based Update. By Mac Sweeney.
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Rob mac Sweeney dissects the current evidence base that governs our diagnosis and management of ARDS. Distressing results.
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ARDS: An Evidence-based Update. By Mac Sweeney.
- 1. ARDS An Evidence Based Update Rob Mac Sweeney SMACCgold 2014 rob@criticalcarereviews.com / @critcarereviews
- 2. Disclosure • Research funding from Northern Ireland Health and Social Care Research and Development Board • Research into ARDS biomarkers References • http://www.criticalcarereviews.com/index.php/smacc-2014
- 3. ARDS An Evidence Based Update Rob Mac Sweeney SMACCgold 2014 rob@criticalcarereviews.com / @critcarereviews
- 4. A Condition That…. 1. can’t diagnose 2. of limited use 3. no specific treatment for 4. people don’t die from ……….. doesn’t actually exist
- 8. Causes Pulmonary • Pneumonia • Pulmonary contusion • Inhalational injury • Aspiration • Fat embolism • Near Drowning Extra-Pulmonary • Extra-pulmonary sepsis • Trauma • Burns • Acute Pancreatitis • Massive Transfusion • Drug overdose
- 9. Acute Respiratory Distress Syndrome
- 10. Acute Respiratory Distress Syndrome
- 11. Original Description • Case Series of 12
- 12. Original Description • Syndrome of • Severe Dyspnoea • Tachypnoea • Cyanosis refractory to oxygen therapy • Loss of lung compliance • Benefit with PEEP • Possible benefit with steroids • Diffuse alveolar infiltration
- 15. Acute Lung Injury 300 – 200 mmHg < 200 mmHg ALI ARDS 40 – 26.6 kPa < 40 kPa
- 17. Acute Respiratory Distress Syndrome < 300 mmHg < 200 mmHg mild moderate severe < 40 kPa < kPa 26.6 < 100 mmHg < kPa 13.3
- 20. Autopsy Timing Clinical Utility Prediction Definition
- 21. Autopsy Clinical Utility Prediction Definition Timing Oedema Timing
- 22. Autopsy Clinical Utility Prediction Definition Radiograph Infiltrates Timing Oedema PaO2/FiO2 Oedema Origin
- 23. Autopsy Clinical Utility Prediction Definition OOxyxyggeennaatitoionn Timing Oedema PaO2/FiO2
- 24. Autopsy Clinical Utility Prediction Definition Infiltrates Timing Oedema PaO2/FiO2 Infiltrates Infiltrates
- 25. Autopsy Clinical Utility Utility Definition Infiltrates Timing Oedema PaO2/FiO2 Infiltrates
- 26. Autopsy Clinical Utility Utility Definition Temporality Temporary Temporality Timing Oedema PaO2/FiO2 Infiltrates
- 27. Autopsy Clinical Utility Utility Definition Clinical Reality Clinical Use Temporary Reality Timing Oedema PaO2/FiO2 Infiltrates
- 28. Autopsy Clinical Utility Utility Definition Temporary Clinical Recognition Consequence Recognition Reality Timing Oedema PaO2/FiO2 Infiltrates
- 29. Autopsy Mortality Utility Definition Temporary Reality Recognition Timing Oedema PaO2/FiO2 Infiltrates
- 30. Autopsy Mortality Utility Definition Cause Temporary Severity Cause Recognition Reality Timing Oedema PaO2/FiO2 Infiltrates
- 31. Autopsy Mortality Utility Definition Prediction Cause Prediction Temporary Severity Recognition Reality Timing Oedema PaO2/FiO2 Infiltrates
- 32. Autopsy Mortality Utility Definition Cause Prediction Temporary Severity Reality Recognition Timing Oedema PaO2/FiO2 Infiltrates
- 33. Autopsy Mortality Utility Definition DAD Cause Prediction Temporary Diffuse Alveolar Damage Reality Recognition Timing Oedema PaO2/FiO2 Infiltrates
- 35. 50%
- 37. One in Two
- 38. DAD ARDS
- 39. DAD ARDS
- 40. Pneumonia No Lesion Abscess COPD DAD ARDS
- 41. COPD Cancer Pneumonia No Lesion Abscess DAD ARDS
- 42. COPD Cancer Pneumonia No Lesion Abscess DAD ARDS
- 43. COPD Cancer Pneumonia No Lesion Abscess DAD ARDS
- 44. COPD Cancer Pneumonia No Lesion Abscess DAD ARDS
- 45. COPD Cancer Pneumonia No Lesion Abscess DAD ARDS
- 46. COPD Cancer Pneumonia No Lesion Abscess DAD PE Bleeding Fibrosis PO TB ARDS
- 47. DAD ARDS
- 48. DAD NON - DAD ARDS
- 49. ARDS NON - ARDS
- 50. ARDS NON - ARDS Therapy General
- 51. ARDS NON - ARDS Therapy DAD Specific
- 53. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
- 54. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
- 55. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
- 56. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
- 57. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) 5. doesn’t actually exist (half the time)
- 58. ARDS – A Condition That…. 1. can’t diagnose (we can’t agree to diagnose) 2. of limited use (doesn’t change management) 3. no specific treatment for (getting to it) 4. people don’t die from (mostly) …….doesn’t actually exist (half the time)
- 61. Therapeutic Evidence- Base ? DAD Severity Mortality Temporary Function Clinical Timing Oedema PaO2/FiO2 Infiltrates
- 62. ECMO Drugs Haemodynamics Ventilatory Adjuncts Ventilation
- 63. Tidal Volume • 861 ARDS patients (P/F < 300 cm H20) • 6 ml/kg & Pplt ≤ 30 cm H20 versus • 12 ml/kg & Pplt ≤ 50 cm H20 • 9% absolute risk reduction in 28 day mortality
- 64. Tidal Volume • 150 critically ill mechanically ventilated patients • 6 ml/kg vs 10 ml/kg Development of ARDS • 2.6% versus 13.5%; p = 0.01
- 65. Tidal Volume • 400 patients undergoing major abdominal surgery • 10-12 ml/kg & ZEEP & no recruitment versus • 6-8 ml/kg & PEEP 6-8 cm H20 & RM • Postoperative Respiratory Support • 5% vs 17% • RR 0.29 (95% CI 0.14 to 0.61)
- 66. Oscillate • 548 ARDS patients • PaO2/FiO2 < 200 cmH20 • Fi02 > 0.5 In-hospital mortality • HFOV 47% vs Control 35% (RR 1.33; 95% CI 1.09 to 1.64; P = 0.005)
- 67. Oscar • 548 ARDS patients • PaO2/FiO2 < 200 cmH20 • PEEP > 5 cmH20 30 day mortality • HFOV 41.7% vs Control 41.1% • Difference 0.6%, 95% CI −6.1 to 7.5
- 68. ECMO Drugs Haemodynamics Ventilation
- 69. ECMO Drugs Haemodynamics Ventilatory Adjuncts Ventilation
- 70. ACURASYS Study • 340 ARDS patients • PaO2/FiO2 < 150 mmHg Adjusted Mortality at Day 90 • NMB: 31.6% vs placebo: 40.7% • HR 0.68 (95% CI 0.48 to 0.98; P = 0.04)
- 71. PROSEVA Study • 466 ARDS patients • PaO2/FiO2 < 150 cmH20 28 day mortality • Prone: 16% vs Control 32.8% Unadjusted 90-day mortality • Prone: 23.6% vs supine 41.0%
- 72. Prone Ventilation • 4 RCTS • 1,573 patients In the most hypoxaemic • 486 patients • PaO2/FiO2 < 100 mmHg • absolute mortality reduction 10% (6% to 21%)
- 73. NMBs ECMO Drugs Prone Ventilatory Adjuncts Ventilation
- 74. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 75. FACTT Study • 1000 patients with ALI • 0 ml vs 7000 ml fluid balance at day 7 60 Day Mortality • Conservative: 25.5% vs liberal 28.4% 95% CI difference −2.6 to 8.4 %, P=0.3
- 76. FACTT Study • 1000 patients with ALI • 0 ml vs 7000 ml fluid balance at day 7 60 Day Mortality • Conservative: 25.5% vs liberal 28.4% 95% CI difference −2.6 to 8.4 %, P=0.3
- 77. FACTT Study • 1000 patients with ALI • 0 ml vs 7000 ml fluid balance at day 7 60 Day Mortality • Conservative: 25.5% vs liberal 28.4% 95% CI difference −2.6 to 8.4 %, P=0.3
- 78. ECMO Fluids CVC Fluids Ventilatory Adjuncts Ventilation
- 79. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 80. Drugs
- 81. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X
- 82. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X Clinically Untested 1. Prostacyclin 2. Almitrine 3. Ibuprofen 4. N-Acetylcysteine 5. Mucolytics 6. Albumin
- 83. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X Clinically Untested 1. Prostacyclin 2. Almitrine 3. Ibuprofen 4. N-Acetylcysteine 5. Mucolytics 6. Albumin Next Wave 1. Statins 2. Aspirin 3. ACEI / ARB 4. Macrolides 5. Insulin 6. Vitamin D 7. Antibodies • Complement • Interleukins 8. Stem cells 9. Growth factors 10. Gene therapy
- 84. Drugs Clinically Tested 1. NMBs √ 2. Steroids ? 3. Surfactant X 4. β2 agonists X 5. Diuretics ? 6. Ketoconazole X 7. Activated Protein C X 8. Nitric Oxide X 9. Silvelestat X 10. Lisofylline X 11. Pharmaconutrients X Clinically Untested 1. Prostacyclin 2. Almitrine 3. Ibuprofen 4. N-Acetylcysteine 5. Mucolytics 6. Albumin Next Wave 1. Statins 2. Aspirin 3. ACEI / ARB 4. Macrolides 5. Insulin 6. Vitamin D 7. Antibodies • Complement • Interleukins 8. Stem cells 9. Growth factors 10. Gene therapy
- 85. ALTA Study • 282 patients with ALI • Aerosolized albuterol vs saline Ventilator-free days • albuterol 14.4 vs control 16.6 d • 95% CI difference –4.7 to 0.3 d; P = 0.087 Hospital death • albuterol 23.0% vs control 17.7% • 95% CI difference –4.0 to 14.7%, P=0.30
- 86. BALTI 2 Study • 326 ARDS patients • PaO2/FiO2 < 200 mmHg • IV salbutamol vs placebo 28 day mortality • salbutamol: 34% vs Control 23% • RR 1∙47, 95% CI 1∙03 to 2∙08
- 87. Nitric Oxide Severe ARDS • n = 329, six trials • RR 1.01; 95% CI 0.78 to 1.32; p = 0.93 Mild to Moderate ARDS • n = 740, seven trials • RR1.12, 95% CI 0.89 to 1.42; p = 0.33
- 88. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 89. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 90. ECMO CESAR STUDY • 170 patients with severe respiratory failure 6 month mortality outcome • ECMO centre 63% vs referral 47% • RR 0·69; 95% CI 0·05 to 0·97, p=0·03
- 91. ECMO ANZICS H1N1 ECMO Case Series • 2009 influenza A(H1N1) - associated ARDS • 68 patients • Median PaO2/FiO2 56 (48-63) mmHg • 71% survival
- 92. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 93. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 94. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 95. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 96. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 97. ECMO Drugs Fluids Ventilatory Adjuncts Ventilation
- 98. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies are probably negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
- 99. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies may be negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
- 100. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies may be negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
- 101. To Summarise 1. The positive studies would likely be positive in any critical care condition 2. The negative studies may be negative because they have been studied in any critical care condition (i.e. ARDS) rather than the specific condition that they are intended for (i.e. DAD)
- 102. ARDS – A Condition That…. 1. can’t diagnose 2. of limited use 3. no specific treatment for 4. people don’t die from …….doesn’t actually exist
- 103. Final Thoughts 1. ARDS studies need to be able to identify alveolar injury 2. Did the AECCC prevent us from adequately investigating some therapies? 3. Are critical care syndromes really of any use?
- 106. Autopsy Case Series • 712 Autopsies • 356 ARDS patients • 159 had DAD (45%) • 75% of severe ARDS had DAD