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1954 !   
Engstrom anesthesia / ventilator
    
  

V  
à 1967 BY Ashbaugh et al

Synonyms:
1. on-Cardiogenic pulmonary edema
2. Adult hyaline membrane disease
3. Capillary leak syndrome
4. Stiff lung syndrome
5. Shock lung

  2 @  u 
    
    
  · 
å ü Onset ÿ Acute and persistent

å ü Radiographic criteria ÿ Bilateral pulmonary


ànfiltrates consistent with the    !

å ü Oxygenation criteria ÿ !  
   
         ð ð ð

for ALI and  for ARDS.

å ü Exclusion criteria ÿ        



    ! 
ÿ 
 
   
!! 
à à 
à  

å àncidence è   
å ARDS mortality rates - 31% to 74%

å The main causes of death are nonrespiratory


causes (i.e., die with, rather than of, ARDS).

å The cause of death in Respiratory failure


9% to 16% of patients with ARDS.

å Ô 
        
 

         
 
  
      
 
^    

AARAMETER
ALà ARDS
O SET „2 „2

mYAOXEMàA Aao2/ Fio2 < 300 Aao2/ Fio2 < 200


mm mg mm mg

CmEST XRAY B/L DàFFUSE B/L DàFFUSE


à FàLTRATES à FàLTRATES

O CARDàAC AULMO ARY ARTERY AULMO ARY ARTERY WEDGE


CAUSE WEDGE ARESSURE < 18 mm ARESSURE < 18 mm of mg.
of mg.  „   2
 „   2 „2„ 2
„2„ 2
^ 
^ 

^ardiogenic uon-^ardiogenic
â Ô 
in alveoli â A    
cells, and fluid
â Due to   accumulation in the
      alveoli
 estimated â Due   
by measuring     

pulmonary artery ë Dzotherdz systemic
wedge pressure) factors OT elevated
pulmonary capillary
pressure
^ 
^ 

^ardiogenic uon-^ardiogenic
â Aatchy infiltrates â ànfiltrates are more
appearing in the  
    â o pleural effusions
â Ô  may be present â u  
â Clinical signs and â Radiographic evidence
symptoms lag behind lags behind clinical signs
radiographic evidence and symptoms (i.e. the
(i.e          
     
    

    )
Cardiogenic on-Cardiogenic

|      ! 


  |  
  
    
|   !  
     
  !
    
| 
a    

â Aulmonary ARDS â Extrapulmonary
(Direct) ARDS (àn-direct)


  

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A 
ànsult (direct or indirect)

Activation of inflammatory cells


ë mediators

Damage to alveolar capillary membrane

àncreased permeability of alveolar capillary membrane

ànflux of protein rich edema fluid and inflammatory cells


into air spaces
Dysfunction of surfactant

A 
A 
A 
A  
 

Decreased ventilation

àmpaired diffusion

Reduced perfusion
 à à

   

â Arecipitating insult is usually evident

â Early (24 Ȃ 48hrs)


- Cough, breathlessness, fatigue

â Late (after 48hrs)


- due to worsening hypoxemia
- agitation, anxiety, confusion
 à à

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â Chest x-ray ë CT thorax:


ÿ bilateral diffuse alveolar infiltrates more on
the peripheral lung fields.
ÿ R/O Cardiogenic edema if there is
* cardiomegaly
* pulmonary artery dilatation
* batǯs wing perihilar distribution
* responding to diuretics
EO ATAL RESAàRATORY DàSTRESS SY DROME
 


    
     è
ÿ AaO2 range 55 Ȃ 60 mm of mg
ÿ ànitially respiratory alkalosis later
mixed acidosis
  Routine CBC, urea, creatinine, a, K
  Ô 
  to R/O Cardiogenic
cause.
  AAWA < 18mm of mg   ALà / ARDS
 


 
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± ormal Lung mistologyȄ


mistologyȄlarge
alveolar volumes, septal spaces
very thin, no cellular congestion.

   à
â #   è
- Chest x-ray
- mypoxemia
- AEEA
- Compliance
Score
0   no lung injury
1 Ȃ 2.5   mild to moderate lung injury
> 2.5   severe lung injury
A A 



â 
 

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ü TREATME T OF CAUSE
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ü AmARMACOLOGàCAL TREATME T
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Traditional Low Stretch


Approach Approach
  
   
  
     
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1) olume-assist-control mode
ü Tidal olume 6 vs. 12 ml/kg of BW.
ü Alateau pressure ˜ 30 vs. ˜ 50 cmm2O
2) entilator rate setting
&*+'       
  
+  )'
3) à/E ratio : 1.1 to 1.3
4) Oxygenation goal 
A " '' *  
  "  * ,'(
 Allowable combination of FiO2 and AEEA
´ ÿ=  ==

Two primary mechanistic factors


å "
  of the alveoli by high
transpulmonary pressures
å  *   
 
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2       
   
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„  r  

  Aressure control- inverse ratio


ventilation
ÿ
  Airway pressure release ventilation „
  migh frequency oscillatory ventilation

„ !  !
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2    2
  Effect on gas exchange
àmproves oxygenation Ȃ allows decrease Fio2;
AEEA
response rate Ȃ 50-70%
  Aroposed mechanism Ȃ
     
 !      
   
 
       ! ! ! 
supine : dorsal and ventral portion move
symmetrically
prone : dorsal > ventral
b) Decrease chest wall compliance in
prone position.
c) Redistribution of tidal volume to
atelactatic dorsal region.
- ! !    
 

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