ACUTE RESPIRATORY

DISTRESS SYNDROME

Childrens Hospital of Michigan

ISTILAH LAIN
Adult Respiratory
Distress Syndrome
Transfusion Lung
Post Perfusion Lung
Shock Lung
Traumatic Wet Lung

Childrens Hospital of Michigan

ORIGINAL DEFINITION
Acute respiratory distress
Cyanosis refractory to oxygen
therapy
Decreased lung compliance
Diffuse infiltrates on chest
radiograph
Difficulties:
lacks specific criteria
controversy over incidence and
mortality

Childrens Hospital of Michigan

REVISION OF DEFINITIONS
1988: four-point lung injury score
Level of PEEP
PaO2 / FiO2 ratio
Static lung compliance
Degree of chest infiltrates

1994: consensus conference

simplified the definition

Childrens Hospital of Michigan

1994
CONSENSUS

Acute onset

may follow catastrophic event

Bilateral infiltrates on chest

radiograph
PAWP < 18 mm Hg
Two categories:
Acute Lung Injury - PaO2/FiO2 ratio <
300
ARDS - PaO2/FiO2 ratio < 200
Childrens Hospital of Michigan

FACTORS PENCETUS

Shock
Aspiration of gastric contents
Trauma
Infections
Inhalation of toxic gases and fumes
Drugs and poisons

Childrens Hospital of Michigan

STAGES
Acute, exudative phase
rapid onset of respiratory failure after
trigger
diffuse alveolar damage with
inflammatory cell infiltration
hyaline membrane formation
capillary injury
protein-rich edema fluid in alveoli
disruption of alveolar epithelium
Childrens Hospital of Michigan

STAGES
Subacute, Proliferative phase:
persistent hypoxemia
development of hypercarbia
fibrosing alveolitis
further decrease in pulmonary
compliance
pulmonary hypertension

Childrens Hospital of Michigan

STAGES
Chronic phase
obliteration of alveolar and bronchiolar
spaces and pulmonary capillaries

Recovery phase
gradual resolution of hypoxemia
improved lung compliance
resolution of radiographic abnormalities
Childrens Hospital of Michigan

MORTALITY
40-60%
Deaths due to:
multi-organ failure
sepsis

Mortality may be decreasing in recent

years
better ventilatory strategies
earlier diagnosis and treatment
Childrens Hospital of Michigan

PATHOGENESIS
Inciting event
Inflammatory mediators
Damage to microvascular endothelium
Damage to alveolar epithelium
Increased alveolar permeability results
in alveolar edema fluid accumulation

Childrens Hospital of Michigan

Patogenesis
Dua mekanisme :
Aspirasi bahan kimia atau inhalasi gas
berbahaya langsung toksik terhdp epitel alveolar

epitel rusak dan terjadi peningkatan

permiaBILITAS

EDEMA INTERSTISIAL
Childrens Hospital of Michigan

 KERUSAKAN PADA MEMBRAN

ALVEOLOKAPILER

PENINGKATAN PERMIABILITAS

EDEMA INTERSTESIAL
Childrens Hospital of Michigan

 DUA MEKANISME ITU MEMPENGARUHI :

- TRANSPORT GAS menurun
- TIMBUL HIPOKSEMIA
- GAGAL NAPAS
- PO2 < 50 mmHg
- PCO2 > 50 mmHg
- RR > 34 x/mnt
- TV < 5 cc/kg bb
Childrens Hospital of Michigan

NORMAL ALVEOLUS
Type I cell
Alveolar
macrophage
Endothelial
Cell

RBCs

Type II
cell
Capillary

Childrens Hospital of Michigan

ACUTE PHASE OF ARDS

Type I cell
Alveolar
macrophage
Endothelial
Cell

RBCs

Type II
cell
Capillary
Neutrophils

Childrens Hospital of Michigan

Kerusakan
alveoli saat
ards
Childrens Hospital of Michigan

Childrens Hospital of Michigan

PATHOPHYSIOLOGY

Abnormalities of gas exchange

Oxygen delivery and consumption
Cardiopulmonary interactions
Multiple organ involvement

Childrens Hospital of Michigan

Sign and symptom

ABNORMALITIES OF GAS EXCHANGE
Increased capillary permeability
Interstitial and alveolar exudate
Surfactant damage
Diffusion defect and right to left shunt

Childrens Hospital of Michigan

Sign and symptom

Status mental menurun

Takikardi
Takipnea dan dyspnea
Sianosis, pucat
Retraksi notot napas
Ronchi basah pada edema pulmonal
kardiogenik
Analisa gas darah
Childrens Hospital of Michigan

OXYGEN EXTRACTION
Cell

O2
Arterial
Inflow
(Q)

O2 O2
O2 O2

capillary

O2
O2 O2

Venous
Outflow
(Q)

VO2 = Q x Hb X 13.4 X (SaO2 - SvO2)

(Adapted from the ICU Book by P. Marino)
Childrens Hospital of Michigan

HEMODYNAMIC SUPPORT
Max O2
extraction

VO2

Max O2
extraction

VO2
Critical DO2

DO2

Critical DO2

DO2

Normal

Septic Shock/ARDS

VO2 = DO2 X O2ER

Abnormal Flow Dependency

Childrens Hospital of Michigan

OXYGEN DELIVERY &

CONSUMPTION
Pathologic flow dependency
Uncoupling of oxidative dependency
Oxygen utilization by non-ATP producing
oxidase systems
Increased diffusion distance for O2
between capillary and alveolus

Childrens Hospital of Michigan

CARDIOPULMONARY
INTERACTIONS
A = Pulmonary hypertension
resulting in increased RV afterload
B = Application of high PEEP
resulting in decreased preload
A+B = Decreased cardiac output

Childrens Hospital of Michigan

RESPIRATORY SUPPORT
Conventional mechanical ventilation
Newer modalities:
High frequency ventilation
Innovative strategies
Nitric oxide
Liquid ventilation
Exogenous surfactant

Childrens Hospital of Michigan

MANAGEMENT
Monitoring:
Respiratory
Hemodynamic
Metabolic/nutrition
Infections
Fluids/electrolytes
Childrens Hospital of Michigan

MANAGEMENT
Optimize VO2/DO2 relationship
Delivery O2
hemoglobin
mechanical ventilation
oxygen/PEEP

V olume of O2
preload
afterload
contractility
Childrens Hospital of Michigan

CONVENTIONAL VENTILATION
Oxygen
PEEP
Inverse I:E ratio
Lower tidal volume
Ventilation in prone position
Childrens Hospital of Michigan

RESPIRATORY SUPPORT
Goal: maintain sufficient oxygenation and
ventilation, minimize complications of ventilatory
management
Improve oxygenation: PEEP, MAP, FiO
2
Improve ventilation : change in pressure

Childrens Hospital of Michigan

Mechanical Ventilation Guidelines

American College of Chest Physicians
Consensus Conference 1993
Guidelines for Mechanical Ventilation in ARDS
When possible, plateau pressures < 35 cm H O
2

Tidal volume should be decreased if necessary

to achieve this, permitting increased pCO2

Childrens Hospital of Michigan

PEEP - Benefits
Increases transpulmonary distending pressure
Displaces edema fluid into interstitium
Decreases atelectasis
Decrease in right to left shunt
Improved compliance
Improved oxygenation

Childrens Hospital of Michigan

No Benefit to Early Application of

PEEP
Pepe PE et al. NEJM 1984;311:281-6.
Prospective randomization of intubated patients at
risk for ARDS
Ventilated with no PEEP vs. PEEP 8+ for 72 hours
No differences in development of ARDS,
complications, duration of ventilation, time in
hospital, duration of ICU stay, morbidity or mortality
Childrens Hospital of Michigan

Pressure-controlled Ventilation
(PCV)
Time-cycled mode
Approximate square waves of a preset pressure are
applied and released by means of a decelerating flow
More laminar flow at the end of inspiration
More even distribution of ventilation in patients with
marked different resistance values from one region of
the lung to another

Childrens Hospital of Michigan

Pressure-controlled Inverse-ratio
Ventilation
Conventional inspiratory-expiratory ratio is reversed
(I:E 2:1 to 3:1)
Longer time constant
Breath starts before expiratory flow from prior breath
reaches baseline auto-PEEP with recruitment of
alveoli
Lower inflating pressures
Potential for decrease in cardiac output due to increase
in MAP
Childrens Hospital of Michigan

HASIL PENELITIAN
In patients with acute lung injury and the acute
respiratory distress syndrome, mechanical ventilation
with a lower tidal volume than is traditionally used
results in decreased mortality and increases the number
of days without ventilator use

Childrens Hospital of Michigan

Prone Position
Improved gas exchange
More uniform alveolar ventilation
Recruitment of atelectasis in dorsal regions
Improved postural drainage
Redistribution of perfusion away from edematous,
dependent regions

Childrens Hospital of Michigan

THANK FOR ALL

Childrens Hospital of Michigan