Ards Seminar

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PRESENTER :

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MODERATER :



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Basic Insult is Damage to Lung

Lung Unit ² the Alveoli



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Therapy



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816



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� Both Volume cycled ventilation (VCV) and

Pressure controlled ventilation (PCV) modes can be used with lung protective strategy

depending upon whether it is more important to

control airway pressures or to control tidal volume .



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� However, choosing appropriate ventilatory goals

(VT and airway pressure) is far more important than

the particular mode.

� In general, fully supported modes of ventilation (e.g.

A/C) are favored over partially-supported modes

( SIMV + PSV OR SIMV only) particularly early in

the course of the disease.



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The open lung concept is physiologically based

on the Law of Laplace. Adhering to the principles of the open lung concept, pressure

controlled ventilation may improve patient

out come during Mechanical Ventilation

P = 2T/R



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Pois euille's

P = 2T/R

Alveolar stability Alveolar stability

The degree of this surfactant The degree of this surfactant damage will determine the damage will determine the

amount of pressure needed to amount of pressure needed to

expand alveoli from closed to expand alveoli from closed to open .open .



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� This combines low tidal volume

� Optimally applied PEEP to maximize alveolar

recruitment and aims to mitigate alveolar over- distension and cyclic Atlectasis.

� The goal of the open lung concept procedure is

to recruit alveoli and maintain them open with the least changes in pressure to minimize

alveolar shear forces 5/19/2011 41



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A ² alveoli derecruitment

B ² optimal recruitment inflation C ² alveolar over distension

D ² optimal inflation Optimal Volume Optimal Volume

Optimal Optimal

PEEP PEEP

CC

BB

AA

DD



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A ² alveoli derecruitment

B ² optimal recruitment inflatio C ² alveolar over distension

D ² optimal inflation Optimal Volume Optimal Volume

Optimal PEEP Optimal PEEP

CC

BB

AA

DD



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Calculating Predicted Body Weight

Male = 50 + 2.3 (height in inches - 60)

Male = 50 + 0.91(height in cm - 152.4)

Female = 45.5 + 2.3 (height in inches - 60)

Female = 45.5 + 0.91 (height in cm - 152.4)



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Excess PP >50 mmHg can lead to air leaks

Pneumothorax , Pneumomediastinum, SC

Emphysema, Pneuopericardium



Gas

ExtravasationBarotrauma



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Damage to the lung (Alveoli) caused by Over distension by a Mechanical Ventilator set

for an excessively high tidal Volume ( ?)



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Low lung volume surfactant is squeezed out leading to

alveolar collapse, repeated collapse and reopening leads to

a shear stress particularly early in the course of lung injury.



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´Shearµ

Airway Trauma Airway Trauma

Stretch



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Inflammatory products are released secondary to mechanical factors lead to

MODS.



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Place on Pressure Control Place on Pressure Control

Raise Peak Inspiratory pressure to 40 Raise Peak Inspiratory pressure to 40 - -60 cmH2O 60 cmH2O 10 breaths Minimal 10 breaths Minimal

Adjust peak Inspiratory Pressure to lowest Adjust peak Inspiratory Pressure to lowest

Pressure without loss of recruitment Pressure without loss of recruitment

Titrate ventilator P I P and Titrate ventilator P I P and

Mean Inspiratory pressure to the smallest Mean Inspiratory pressure to the smallest

Possible difference Possible difference

I : E Ratio 1 : 1 or 2 : 1I : E Ratio 1 : 1 or 2 : 1

PEEP 10 PEEP 10 ² ² 20 cm 20 cm

Keep PEEP in range of Keep PEEP in range of

10 10 ² ² 20 cm 20 cm



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� Perfluorocarbon have excellent oxygen and carbon

dioxide carrying capacity (50 ml O 2 /dl and 160-210

ml CO 2 /dl, respectively).

� They are clear, odorless, inert fluids which are

immiscible in aqueous and most other solutions

� 2 types of techniques : TLV -- PLV

� TOTAL LIQUID VENTILATION

� PARTIAL LIQUID VENTILATION

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� Virtually all the other commercially available

perfluorocarbon are liquids (the exception being

perfluorocyclohexane, which sublimes at 51 C.

� Liquid breathing

� Eye surgery

� Imaging

� Artificial blood

� Decompression sickness

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Partial Liquid

Ventilation

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Surface Tension lowered Surface Tension lowered



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Aggressive search for and treatment of

Infectious complications is necessary

Appropriate time window for corticosteroid

administration between early acute injury

and established post aggressive fibrosis .



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Ards Seminar