Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
.pdf
ARDS Causes and Pathophysiology
DIRECT LUNG INJURY
SYSTEMIC INFLAMMATION
•
Pneumonia
•
Aspiration pneumonitis
•
Drowning
•
Thoracic trauma/pulmonary contusion
•
Smoke or toxic inhalation
•
Fat emboli
•
Reperfusion injury (post lung transplant)
•
Severe sepsis
•
Transfusion reaction (TRALI)
•
Shock
•
Pancreatitis
Pathophysiology:
• Proteinaceous fluid fills alveoli
• Neutrophils flood alveolar space
• Hyaline membranes form on epithelial
basement membrane
• Microthrombi form
• Fibrosis develops (late stage)
Treatment:
1. Ventilation Strategies
2. Prone positioning
3. Neuromuscular Blockade
4. ECLS/ECMO
5. Corticosteroids
6. Inhaled Pulmonary Vasodilators
https://t.me/medicina_free
ARDS: Ventilation
Mode: Volume Control
Tidal volume (Vt): Initial Vt at 6ml/kg PBW à target 4-8 ml/kg PBW
Plateau pressure: ≤ 30 cm H2O, Driving pressure (Pplat - PEEP) target < 15 cm H2O
PEEP: target higher PEEP in mod/severe ARDS, based on FiO2-PEEP Tables SpO2:
target 88-93% or PaO2 55 - 80 mmHg (avoid hyperoxia – ↑s harm)
CO2: permissive hypercapnia allowed, target pH > 7.25
• Deep sedation to achieve the above parameters
• Lung Recruitment Maneuvers: Don’t use routinely (evidence of ↑ mortality). Can be
considered.
• High frequency oscillation: Do not use
Fi0
2
0.3
-0.4
0.4
0.5
0.6
0.7
0.8
0.9
PEEP
5-88
-14
8
-16
10
-20
10
-20
14
-22
16
-22
1. Am J Respir Crit Care Med Vol 195, Iss 9, pp 1253–1263, May 1, 2017
2. CMAJ 2021 May 25;193:E761-8. doi: 10.1503/cmaj.202661
No need to memorize this table!
FYI only!
https://t.me/medicina_free
ARDS Treatment Modalities Summary
High PEEP
Recommended for in mod/
sev ARDS. Mortality benefit in moderate-severe (ARDS,
ALVEOLI, LOV, EXPRESS trials )
Prone positioning
Strong recommendation for severe ARDS. Mortality benefit if P/F < 150 (PROSEVA
trial). Duration > 12hrs per day.
Neuromuscular blockade
No mortality benefit. Consider in severe ARDS after optimizing PEEP and ventilator
settings. Reduces ventilator desynchrony, improves (ACURASYS, ROSE trials)
Inhaled INO
No mortality benefit. May improve oxygenation by improving VQ mismatching and
reducing shunting. Bridge therapy.
Diuresis
Decreases duration on ventilator.
ECMO
No clear mortality benefit, acts as a bridge therapy. (EOLIA trial). See next slide.
Steroids
No benefit for ARDS. May be clinically indicated depending on underlying cause (
ie.
Covid
pneumonia, concern of COP)
Statins
No benefit. Not indicated.
High frequency oscillation
Strong recommendation against routine use. May increase mortality
31
https://t.me/medicina_free
ECMO Respiratory Considerations
Consider ECMO
Do NOT Consider ECMO
•
Severe ARDS
•
Hypercapneic respiratory failure
•
Bridge to lung transplantation
•
Primary graft dysfunction after lung transplantation
•
Status asthmaticus
Absolute
•
Disseminated malignancy
•
Known severe brain injury
•
Prolonged CPR without adequate tissue perfusion
•
Severe chronic organ dysfunction
•
Severe chronic pulmonary hypertension
•
Non-recoverable advanced comorbidity (ie. CNS
damage or terminal malignancy)
32
Call for ECMO referral if:
• P/F < 80 mmHg for > 6 hours OR P/F < 50 mmHg for > 3 hours
• PaCO2 > 60 mmHg for > 6 hours (despite optimization of vent)
• Mechanically ventilated < 7 days
• BMI < 40 or weight < 125 kg
• Age 18 - 65
ECMO Guidelines, CCSO 2020
BONUS
Read on own
https://t.me/medicina_free
Severe COVID-19 Respiratory Failure in the ICU
Infection Control
Intubation or bronchoscopy – N95 + Standard PPE + Negative Pressure Room
Refer to local Infection Control regarding length of isolation after severe COVID19 Pneumonia (21d Ontario)
Proning
Recommended in early pandemic to improve oxygenation. COVI-PRONE (JAMA 2022) compared awake
proning to non proning, no change in rate of intubation at 30d. = PRONE if tolerated.
Intubation
Indication: usual indications (LOC, airway protection, resp failure), +/- failed trial of High flow nasal cannula
Most Experienced Provider should intubate. Recommend video laryngoscopy to increase success on 1st pass.
Ventilator Mgmt
Identical to ARDS strategies (refer to those slides)
Dexamethasone
6 mg po/IV x 10 days if requiring O2 (
↓ mortality ↓ need for mechanical ventilation)**
Remdesivir
200 mg IV x 1 then 100 mg IV x 4 days if requiring low flow O2
-
May ↓ deaths in moderately ill (on low flow O2) , most trials done before routine steroids and Tocilizumab
Toc ili zumab
400 mg IV if requiring HFNC, NIV or IMV. If on low flow O2 + systemic inflammation (CRP > 75)
and worsening despite 24
-48h of steroids. Must be within 14 days of Covid diagnosis.
-
↓mortality in meta-analysis
Baricitinib
4 mg PO daily x 14d. If on appropriate steroid therapy or CI to steroids and NOT on IL
-6 therapy
VTE prevention
Prophylactic dosing in critically ill patients (HFNC/NIV/IMV)
Do not pick on MCQ:
Colchicine, IFN, Vit D, hydroxychloroquine, ivermectin, lopinavir/ritonavir, neutralizing Abs,
Paxlovid
Not recommended. Antibiotics not required unless high suspicion co-infection
33
https://t.me/medicina_free
OUTLINE
• Shock and Sepsis
• Respiratory failure
• Weaning from Mechanical Ventilation
• ICU Delirium, Sedation, Analgesia,
Sleep
• Targeted temperature management,
neuroprognostication, DNC, neuro
ICU
• Toxicology
• Extra slides for your reference:
– Acute hypoxia in the ICU
– Gas trapping
– Maternal cardiac arrest
– Liver failure guidelines
– Hyperthermia & Hypothermia
– Toxic ol og y Bo nus Sl id es
– Bonus MCQs
https://t.me/medicina_free
Weaning from
Mechanical Ventilation
35
Assess readiness for extubation
1. Adequate cough
2. Minimal secretions, ability to manage secretions
3. Awake/Alert, following commands, no sedation
4. No increased risk of airway obstruction – post-op
swelling resolved, ETT cuff leak present
Assess readiness for weaning from ventilator
1. Reversal of underlying reason for intubation
and ventilation
2. Improvement of oxygenation
(PaO2 > 60 mmHg, FiO2 < 40%, PEEP < 8)
3. Ability to perform work of breathing
(Normal/compensated Co2, pH, adequate
cardiac function, adequate diaphragm
function)
1. Boles et al., Eur Respir J 2007; 29: 1033–1056
DOI:10.1183/09031936.00010206
2. Fan et al., Ann Am Thorac Soc Vol 14, No 3, pp 441–443, Mar
2017. DOI: 10.1513/AnnalsATS.201612-993CME
https://t.me/medicina_free
Ventilator Weaning and Extubation: Best Practices
36
1. Fan et al., Ann Am Thorac Soc Vol 14, No 3, pp 441–443,
Mar 2017. DOI: 10.1513/AnnalsATS.201612-993CME
Liberation Protocol
For patients intubated > 24hrs, standardised liberation protocols, nurse/RT driven
Spontaneous Breathing Trials
Should occur
daily, if meeting screening criteria to perform
Early mobility
For patients intubated > 24hrs, protocolized rehabilitation to aid early mobilization
Sedation Liberation
Use protocols to minimize sedation use
Cuff Leak and steroids
If high risk
(traumatic intubation, intubated > 6d, reintubation, female, large ETT)
of post-
extubation
stridor perform cuff leak. If fail and otherwise ready for extubation give
steroids at least 4hrs before extubation (usually 24hrs before)
Prevention of post
-extubation
respiratory failure
If high risk (>65 + cardiac/resp disease) use NIV
If low/mod risk use HFNC instead of COT (conventional O2 therapy)
https://t.me/medicina_free
Spontaneous Breathing Trial (SBT)
• Mimics patient’s own ability to breathe independently
• Perform on PSV for 30 minutes
– PSV 5/5 vs. 0/0 vs. 5/0 à variable practices
– Toro nt o stan da rd iz ed p ra ct ic e is 0 /0
• Failure of SBT à tachypnea, increased work of
breathing, tachycardia, hypotension, desaturation
– Always ask ‘why’, and try to correct underlying cause of failure
• Rapid shallow breathing index (RSBI) à respiratory rate (breaths/min)/tidal volume
(L/min)
– RSBI > 105 is a predictor of extubation failure
37
Yang and Tobin. NEJM 1991;324:1445-50.
Meade et al. Chest 2001;120(6):400S-24S.
T-piece trial
(JAMA 2019):
- T-piece for 2 hours vs. PS 8/0
for 30 mins
- Successful extubation higher
for PS SBT over T-piece SBT
https://t.me/medicina_free
MCQ #2 –2023
A 56 year old male presents with ARDS secondary to
acute smoke inhalation during a condominium fire.
He is intubated on arrival to the ED and transferred
to the ICU. He is diagnosed with ARDS and his ABG
PaO2 on day 3 is 87, despite deep sedation, INO and
paralysis. His vent settings are as follows: ACVC Vt
4ml/kg, PEEP 14, FiO2 100%, pPlat 30, driving
pressure 14.
• What is the next best step?
a) Give methylprednisolone 125 mg daily
b) Reduce PEEP to 10 and repeat an ABG
c) Diurese with Lasix 40 mg IV BID
d) Place patient in prone positioning for 16 hrs
38
https://t.me/medicina_free
Соседние файлы в папке Библиотека им академика М.И. Перельмана