(Mechanical Ventilator Settings in Acute Respiratory Distress Syndrome)

.

(Acute respiratory distress syndrome, ARDS)

(ventilator-induced lung injury, VILI)

ARDS

ARDS

ARDS

.. 19941 Berlin definition acute lung injury

ARDS 1 ARDS

positive end-expiration pressure (PEEP) 12

1 The Berlin definition of ARDS

Timing 1 Chest imaging Bilateral opacities effusions, lobar/lung collapse nodules Origin of edema cardiac failure fluid

overload ( echocardiography) hydrostatic edema

Oxygenation Mild 200 mmHg

ARDS

ARDS heterogeneous process

3 3

1. (normally inflated)

nondependent

2. (recruitable) inflation pressure

3. (consolidated lung) dependent

VILI

1. volutrauma tidal volume (VT) alveoli

2. barotrauma PEEP

3. atelectrauma alveoli surfactant

4. biotrauma alveoli inflammatory cytokines

ARDS 3

1. low tidal volume 6 ./. (predicted body weight)

(plateau pressure) 30 . 1

2. positive end expiratory pressure (PEEP) 2

1

oxygenation ventilation

1. ventilation

low tidal volume, lung protective strategy (LPS)

..2000 NIH ARDS (ARMA trial)

ARDS 861 low-tidal-volume ventilator strategy (6 ./. ,

30 . ) higher tidal volume (12 ./. , 50 .

) 31.0% 39.8%

tidal volume 4

ARDS 24,5

Putensen meta-analysis 1,149

4 LPS VT

Pplat LPS

34.2 41.0 6 LPS

LPS VT Pplat 30

. Pplat VT

2 ARDS4,5

(predicted body weight, PBW)

PBW = 50 + 0.91 [( .)-152.4)] PBW = 45.5 + 0.91 [( .)-152.4)]

Volume assist/control Tidal volume (VT) VT 6 ./.

0.5 (inspiratory plateau pressure, Pplat) 4 PEEP VT

- Pplat > 30 . VT 5 4 ./.

- Pplat < 25 . VT < 6 ./. VT 1 ./.

(respiratory rate, RR)

VT RR minute ventilation RR pH 7.30-7.45 35 RR PaCO2 < 25 .

(I:E ratio)

1:1 1:3

FiO2, PEEP PaO2 PaO2 = 55-80 . SpO2 = 88-95% PEEP/FiO2

FiO2 0.3-0.4 0.4 0.5 0.6 0.7 0.8 0.9 1 PEEP 5-8 8-14 8-16 10-20 10-20 14-22 16-22 18-25

pH < 7.30 RR pH 7.30 RR = 35 pH < 7.30 RR = 35 pH < 7.15 VT ( Pplat 30 . )

pH > 7.45 RR 6 conservative fluid management strategy

central venous pressure (CVP) 4 pulmonary artery occlusion pressure 8 .

spontaneous breathing trial (SBT) SBT 1. FiO2 < 0.4 PEEP < 8 . 2. 3. 4. > 90 . 5. gag reflex

Spontaneous breathing trial pressure support 5 . PEEP 5 . T-piece HR, RR oxygen saturation 30-90 (tachycardia, tachypnea, agitation, hypoxia, diaphoresis)

1

1. (predicted body weight)

tidal volume

2. tidal volume 6 ./. tidal volume low tidal

volume Pplat 30 . tidal volume 1 ./.

4 ./. tidal volume

ARDS low tidal volume tidal volume

3. refractory hypoxemia

4. respiratory acidosis low tidal volume

35

2. oxygenation

oxygenation FiO2 PEEP FiO2 100%

24 60% oxygen toxicity

PEEP PEEP

PEEP

ARDS ..2004 ALVEOLI trail

low-tidal-volume PEEP (PEEP 1-4 8.3 3.2) PEEP

(PEEP 1-4 13.2 3.5) PEEP

7 Mercat (EXPRESS trial) ARDS 761

PEEP Pplat 28-30 . (increased recruitment strategies)

PEEP 9 .

PEEP increased recruitment strategies lung function

8 Meade (LOV trial) 983 2

Lung Open Ventilation (LOV) VT 6 ml/kg IBW

recruitment maneuver, PEEP Pplat 40 . PEEP

Pplat 30 . 9

meta-analysis Briel PEEP ARDS

10

(PEEP)

1. PEEP-FiO2 ARDS network 3

3 PEEP-FiO2 ARDS network

FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Higher PEEP (ALVEOLI)

5-14 14-16 16-18 20 20 20-22 22 22-24

Lower PEEP (ARMA)

5 5-8 8-10 10 10-14 14 16-18 18-24

2. increased recruitement strategy EXPRESS trial9 PCV VCV

mode inspired pressure Pinsp (PCV mode) VT (VCV mode) 6 ml/kg

PEEP Pplat 28-30 .

3. static pressure-volume curve PEEP Low inflection point

- (volume-pressure curve) 2 cmH2O

sedation paralytic agents

1 pressure-volume curve PEEP

4. esophageal pressure esophageal balloon

esophageal pressure pleural

pressure transpulmonary pressure (Ptp) PEEP Ptp

25 . 11

esophageal pressure pleural pressure

4 PEEP esophageal pressure11

FiO2 0.4 0.5 0.5 0.6 0.6 0.7 0.7 0.8 0.8 0.9 0.9 1.0 PLexp 0 0 2 2 4 4 6 6 8 8 10 10 PLexp,end expiratory transpulmonary

5. Stress index (SI) airway opening pressure elastance

VCV mode constant flow pressure-time wave

form PEEP 12 slope pressure-time

waveform PEEP (convex upward) elastance

recruitment alveoli (SI < 1) PEEP

slope (SI=1)

recruitment recruitment (concave upward) SI

1 overdistension

2 stress index 12

Rescue therapies ARDS

1. Recruitment maneuver (RM)

alveoli ARDS

barotraumas, cardiac arrhythmia, hypotension 2

1. CPAP 40-40 CPAP mode CPAP 40 . 40

setting PEEP 2-3 .

PEEP SpO2

2. PCV technique PCV mode Pinsp 15 . PEEP 25 .

20 FiO2 100% 2 setting PEEP

oxygenation

13

RM

RM 1 barotraumas, cardiac arrhythmia

12 8 oxygen desaturation 14 RM

2. Prone position

()

prone position Guerin severe

ARDS prone 16 15

3. Airway pressure release ventilation (APRV)

16

4. High frequency oscillatory ventilation (HFOV)

3- 5 Hz

(tidal volume) (mean alveolar

pressure)

(barotrauma)

2

17,18

5.

Partial liquid ventilation

perflurocarbon

(barotrauma)

19

Surfactant replacement therapy

Surfactant

(Compliance)

20

Inhaled Nitric Oxide

(Nitric Oxide)

(ventilationperfusion mismatch)

5 ppm

21

Extracorporeal membrane oxygenation (ECMO) and extracorporeal CO2 removal (ECCO2R)

ECMO

ECCO2R

5

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