1 65 ARDS
2
3 ARMA by ARDS Network 1 12ml/kg 6ml/kg RCT ARDS
4 Low Tidal Volume Amato Stewart Brochard Brower ARMA Lower Higher Lower Higher Lower Higher Lower Higher Lower Higher N 29 24 60 60 58 58 26 26 432 429 VT(ml/kg) 6.1 11.9 7.2 10.8 7.1 10.3 7.3 10.2 6.2 11.8 P plat 30.1 36.8 22.2 28.5 25.7 31.7 24.9 30.6 26 34 28 38% 71% NR NR NR NR NR NR NR NR 45% 71% 50% 47% 47% 38% 50% 46% 31% 40%
5 ALI/ARDS 2 a. 1 10ml/kg (6 8ml/kg ): 12ml/kg 30cmH2O : 35cmH2O b. FiO2 PEEP FiO2 1.0 PaO2 PEEP (5cm H2O) 3-5cmH2O ( 20cmH2O) PaO2>60mmHg FiO2 0.4 0.6 High PEEP ALVEOLI, LOV, Express Study PEEP ARDS c. ARDS
6 ALI/ARDS 2 a. NPPV b. HFOV c. IRV d. APRV PEEP
7 Lung Protective Ventilatory Strategy ARMA lower tidal protocol PEEP RM APRV ECMO
8 VALI: Ventilator-associated lung injury " Oxygen toxic effects : FiO2 " Barotrauma " Volutrauma ARMA " Atelectrauma " Biotrauma Open Lung Approach
9 high grade 2009 H1N1 AARC Preparing for Pandemic(H1N1) Influenza Webcast
10 Refractory hypoxemia " PaO2/FiO2 100 on PEEP 15 cm H2O " Rescue Tx : Recruitment maneuvers, prone position, inhaled vasodilator, HFOV, ECLS " "
11 Refractory hypoxemia " High PEEP " Recruitment maneuver " APRV " Prone position " HFOV " ino " ECMO/iLA
12 Ashbaugh ARDS (1967) PEEP " " " " " X " " (IRDS) " " (PEEP)
13 Q: PEEP 0 (ZEEP) ARDS
14 ALI/ARDS 2 a. 1 10ml/kg (6 8ml/kg ): 12ml/kg 30cmH2O : 35cmH2O b. FiO2 PEEP FiO2 1.0 PaO2 PEEP (5cm H2O) 3-5cmH2O ( 20cmH2O) PaO2>60mmHg FiO2 0.4 0.6 High PEEP ALVEOLI, LOV, Express Study PEEP ARDS c. ARDS
15 Higher PEEP vs. ower PEEP: Summary ARDS-Net ALVEOLI LOV Study Group Express Study Group Journal NEJM 2004 JAMA 2008 JAMA 2008 n 549 983 767 PEEP(24h) 14.7 vs 8.9 15.6 vs 10.1 14.6 vs 7.1 PEEP(72h) 12.9 vs 8.5 11.8 vs 8.8 13.4 vs 6.7 Primary end point Other outcome 28 28
16 Barotrauma higher PEEP Lower PEEP p-value ARDS-Net ALVEOLI 10 11 0.51 LOV Study Group 11.2 9.1 0.33 Express Study Group 6.8 5.8 0.57
17 Express: the Expiratory Pressure Study ARDS ( ) Non-ARDS ( ) ARDS ( ) Higher PEEP Non-ARDS ( ) Lower PEEP JAMA. 2008;299(6):646-655
18 Higher vs Lower Positive End-Expiratory Pressure Systematic Review and Meta-analysis high PEEP high PEEP Briel et al. JAMA. 2010;303(9):865-873
19 PEEP PEEP
20 Optimal PEEP " FiO2/PEEP " PEEP " (low-flow)pressure-volume " PEEP " ARMA
Teaching case 1: Influenza + Drug-induced ARDS 21 PEEP Intubation CYC 650mg m-psl1g 2g oseltamivir FOY sivelestat PSL60mg MEPM 1g CPFX 600mg Extubation FOY 40mg m-psl1g VCM MEPM 1g SMX/TMP Camostat PSL 50mg MFLX 400mg 10 1517 20 24 20 17 15 10 8 6 PEEP 4 4
22 Ideal lung protective ventilation
23 PEEP
Concept of Baby lung 24
25 " " FiO2 " " " Biotrauma!
26 Recruitment maneuver : PEEP : pressure for opening pressure for maintaining
27 Recruitment Maneuver " CPAP : 40-50 cmh2o, 30-60 sec " eg) 40/40 method : CPAP 40cmH2O x 40 sec " pressure control ventilation " PEEP 15-30 cmh2o " 40-60 cmh2o " Amato s Maximum recruiting strategy
28 Amato s Maximum Recruitment Strategy 60cmH2O Borges JB et al. Am J Respir Crit Care Med Vol 174. pp 268 278, 2006
29 CT -PEEP RM - " ARDS " PEEP " 24% 45cmH2O Gattinoni L. et al. N Engl J Med 2006;354:1775-86.
30 PEEP high PEEP Caironi, Gattinoni et al. Am J Respir Crit Care Med Vol 181. pp 578 586, 2010
31 Systematic Review " " " desaturation " " Am J Respir Crit Care Med Vol 178. pp 1156 1163, 2008
32 Lung protective PEEP titration Sipmann, Amato et al. Recruitment decremental PEEP incremental PEEP
Recruitment maneuver + Decremental PEEP trial 33
Teaching case 2 : ARDS 34 Recruitment maneuver + Decremental PEEP trial Intubation Vt = 450ml PS+SIMV 1.0 0.6 0.5 0.4 0.35 0.4 NPPV trial SBT Extubation 10 18 16 14 12 10 8 6 400 300 Atelectasis BF 200 100 P/F ratio Pneumothorax Drainage 0
35 Recruitment maneuver + Decremental PEEP trial 40/40 AaDO2
Teaching case 3 : ARDS 36 recruitment maneuver Fluid resuscitation AaDO2 RM RM RM FiO2 0.7 0.5 0.45 0.3 day 1 day 3 intubation PEEP 8 8 8 12
Teaching case 4 : ARDS PEEP titration? (Open Lung Tool ) 37 19 19 17 15 13 PEEP 11 9 7 0 595 VTe 0 35 Cdyn 0 on servo i by Maquet
ALI/ARDS 2 38
39 APRV: Airway Pressure Release Ventilation CPAP Release
40 APRV: ------High MAP------ Biphasic positive pressure ventilation/bi-level I/E recruitment APRV slow and continuing recruitment maneuver
41 APRV: ( ) " " " " (WOB) " /
Teaching case 5 : 誤嚥性肺炎 ARDS 42 APRV: Airway Pressure Release Ventilation mpsl 1g MEPM mpsl 125 A-aDO2 500 CTRX 気胸 TAZ/PIPC DRPM 60 PSL 50 40 20 10 CRP 25 CRP 気切 400 20 300 15 A-aDO2 200 10 100 5 0 0 1 5 10 15 SIMV+PSV(PEEP 10 20 ) 25 30 35 APRV Phigh 25 11 CPAP
44 Sponge lung ARDS
45 ARDS MOF Ferring M, Vincent J-L. Eur Respir J 1997; 10: 1297 1300
46 " ALI/ARDS 1 " " " RM