A t R i t F il & A t R i t F il & Acute Respiratory Failure & Acute Respiratory Failure & ARDS ARDS ARDS ARDS Nina M. Patel, MD Nina M. Patel, MD Assistant Clinical Professor of Medicine Assistant Clinical Professor of Medicine Division of Pulmonary, Allergy & Critical Care Division of Pulmonary, Allergy & Critical Care Columbia University, College of Physicians & Surgeons Columbia University, College of Physicians & Surgeons
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A t R i t F il &A t R i t F il &Acute Respiratory Failure & Acute Respiratory Failure & ARDSARDSARDSARDS
Nina M. Patel, MDNina M. Patel, MDAssistant Clinical Professor of MedicineAssistant Clinical Professor of Medicine
Division of Pulmonary, Allergy & Critical CareDivision of Pulmonary, Allergy & Critical Carey, gyy, gyColumbia University, College of Physicians & SurgeonsColumbia University, College of Physicians & Surgeons
ObjectivesObjectivesObjectivesObjectives
Define respiratory failure & discuss typesDefine respiratory failure & discuss typesDefine respiratory failure & discuss types Define respiratory failure & discuss types of respiratory failureof respiratory failureBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationDefine ARDS, its epidemiology & basic Define ARDS, its epidemiology & basic
th h i lth h i lpathophysiologypathophysiologyDiscuss clinical aspects of ARDSDiscuss clinical aspects of ARDSDiscuss treatment of ARDS Discuss treatment of ARDS
An inability to adequately oxygenate orAn inability to adequately oxygenate orAn inability to adequately oxygenate or An inability to adequately oxygenate or ventilateventilate
PaOPaO22 < 60 mm Hg< 60 mm Hg–– PaOPaO22 < 60 mm Hg< 60 mm Hg–– PaCOPaCO22 > 45 mm Hg> 45 mm Hg
Respiratory FailureRespiratory FailureType IType I Type IIType II Type IIIType III Type IVType IV
Respiratory FailureRespiratory Failure-- Type IIType II
40% FiO2
PAO2= 100 PAO2=27 240 mm Hg 55 mm Hg
PaO2= 40 100 mm Hg
* PaO2 corrects readily with supplemental oxygen
Respiratory FailureRespiratory Failure-- Type IVType IVRespiratory FailureRespiratory Failure Type IV Type IV Hypoperfusion Hypoperfusion Cardiac output “steal”Cardiac output “steal”
0% 95%70% 95%
50% 75%
ObjectivesObjectivesObjectivesObjectives
Define respiratory failure & discuss typesDefine respiratory failure & discuss typesDefine respiratory failure & discuss types Define respiratory failure & discuss types of respiratory failureof respiratory failureBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationDefine ARDS, its epidemiology & basic Define ARDS, its epidemiology & basic
th h i lth h i lpathophysiologypathophysiologyDiscuss clinical aspects of ARDSDiscuss clinical aspects of ARDSDiscuss treatment of ARDS Discuss treatment of ARDS
Indications for Mechanical Indications for Mechanical VentilationVentilation
A idA idAvoid Avoid –– Respiratory AlkalosisRespiratory Alkalosis–– Barotrauma/VolutraumaBarotrauma/Volutrauma–– AutoAuto--PEEPPEEP
ObjectivesObjectivesObjectivesObjectives
Define respiratory failure & discuss typesDefine respiratory failure & discuss typesDefine respiratory failure & discuss types Define respiratory failure & discuss types of respiratory failureof respiratory failureBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationDefine ARDS, its epidemiology & basic Define ARDS, its epidemiology & basic
th h i lth h i lpathophysiologypathophysiologyDiscuss clinical aspects of ARDSDiscuss clinical aspects of ARDSDiscuss treatment of ARDS Discuss treatment of ARDS
ALI & ARDSALI & ARDSffDefinitionDefinition
Acute onsetAcute onsetAcute onsetAcute onsetBilateral infiltratesBilateral infiltratesP OP O /FiO/FiOPaOPaO22/FiO/FiO22–– < 300 mm Hg for ALI< 300 mm Hg for ALI–– << 200 mm Hg for ARDS200 mm Hg for ARDS
No evidence of pulmonary venous No evidence of pulmonary venous p yp ycongestioncongestion–– PCWP PCWP << 18 mm Hg18 mm Hggg
Bernard GR, Artigas A, Brigham KL, et al. AJRCC 1994;149:818-24.
ALI & ARDSALI & ARDSE id i lE id i lEpidemiologyEpidemiology
64 to 86 2 cases/100 000 person64 to 86 2 cases/100 000 person yearsyears64 to 86.2 cases/100,000 person64 to 86.2 cases/100,000 person--yearsyears~142,000 ~142,000 -- 191,000 annual cases191,000 annual casesRisk factorsRisk factors–– EtOH abuseEtOH abuse–– Poor nutritional statusPoor nutritional status–– Increased ageIncreased agegg–– Increased APACHE scoreIncreased APACHE score
Rubenfeld GD, Caldwell E, Peabody E, et al. NEJM 2005;353:1685-93.MacCallum NS; Evans TW. Curr Opin Crit Care 2005;11(1):43-9 From Hall, Schmidt & Wood, eds: Principles of Critical Care, 3rd ed. New York, McGraw-Hill 2005.
ARDSARDSCCCausesCauses
Direct Direct IndirectIndirectPneumoniaPneumoniaAspirationAspiration
PancreatitisPancreatitisBurnsBurnsAir, Amniotic fluid or FatAir, Amniotic fluid or FatLung contusionLung contusion
NearNear--drowningdrowning
Air, Amniotic fluid or Fat Air, Amniotic fluid or Fat EmboliEmboliDrug ReactionDrug ReactionTransfusion of BloodTransfusion of BloodTransfusion of Blood Transfusion of Blood ProductsProductsD.I.C.D.I.C.
From Hall, Schmidt & Wood, eds: Principles of Critical Care, 3rd ed. New York, McGraw-Hill 2005.
Coagulation Coagulation b litib litiabnormalitiesabnormalities
Ware LB, Matthay MA. NEJM 2000;342(18):1334-1349.
ARDSARDS-- HistopathologyHistopathology
Hyaline Membranes
ObjectivesObjectivesObjectivesObjectives
Define respiratory failure & discuss typesDefine respiratory failure & discuss typesDefine respiratory failure & discuss types Define respiratory failure & discuss types of respiratory failureof respiratory failureBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationDefine ARDS, its epidemiology & basic Define ARDS, its epidemiology & basic
th h i lth h i lpathophysiologypathophysiologyDiscuss clinical aspects of ARDSDiscuss clinical aspects of ARDSDiscuss treatment of ARDS Discuss treatment of ARDS
From Katzenstein AA, Askin FB: Surgical Pathology of Nonneoplastic Lung Disease, 2nd ed. Philadelphia,Saunders 1990.
ARDSARDS-- Clinical CourseClinical Course
Exudative Fibroproliferative
Resolution
ObjectivesObjectivesObjectivesObjectives
Define respiratory failure & discuss typesDefine respiratory failure & discuss typesDefine respiratory failure & discuss types Define respiratory failure & discuss types of respiratory failureof respiratory failureBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationBrief introduction to mechanical ventilationDefine ARDS, its epidemiology & basic Define ARDS, its epidemiology & basic
th h i lth h i lpathophysiologypathophysiologyDiscuss clinical aspects of ARDSDiscuss clinical aspects of ARDSDiscuss treatment of ARDS Discuss treatment of ARDS
9% red ction in9% red ction in9% reduction in 9% reduction in mortalitymortalityLower ILLower IL 6 levels6 levelsLower ILLower IL--6 levels6 levels> days without > days without nonpulmonary organnonpulmonary organnonpulmonary organ nonpulmonary organ failurefailure