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Childrens Hospital of MichiganChildrens Hospital of Michigan

MADE KARIASA,SKp.,MM.,MKep.,Sp.MB.,PG.Cert

STAFF PENGAJAR FIK UI


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Childrens Hospital of Michigan

Adult Respiratory

Distress Syndrome Transfusion Lung

Post Perfusion

Lung

Shock Lung Traumatic Wet

Lung


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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


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1988: four-point lung injury score Level of PEEP

PaO2 / FiO2 ratio

Static lung compliance

Degree of chest infiltrates

1994: consensus conference simplified thedefinition


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Acute onset

Bilateral infiltrates on chest

radiograph PAWP < 18 mm Hg

Two categories:

Acute Lung Injury - PaO2/FiO2 ratio 50 mmHg

- RR > 34 x/mnt

- TV < 5 cc/kg bb


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Type I cell

Endothelial

Cell

RBCs

Capillary

Alveolar

macrophage

Type II

cell


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Type I cell

Endothelial

Cell

RBCs

Capillary

l eolar

acropha e

Type II

cell

Neutrophils


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Kerusakan

alveoli saat

ards


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Abnormalities of gas exchange

Oxygen delivery and consumption

Cardiopulmonary interactions

Multiple organ involvement


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ABNORMALITIES OF GAS EXCHANGE Increased capillary permeability

Interstitial and alveolar exudate Surfactant damage

Diffusion defect and right to left shunt


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Status mental menurun

Takikardi

Takipnea dan dyspnea

Sianosis, pucat

Retraksi notot napas

Ronchi basah pada edema pulmonal

kardiogenik Analisa gas darah


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OXYGEN EXTR CTION

VO2 = Q x Hb X 13.4 X (SaO2 - S O2)

Arterial

Inflow

(Q) capillary

O2

O2

O2

O2 O2

O2

O2

Venous

Outflow

(Q)

Cell

O2

(Adapted from the ICU Book by P. Marino)


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Pathologic flow dependency

Uncoupling of oxidative dependency

Oxygen utilization by non-ATP producing oxidasesystems

Increased diffusion distance for O2 between capillaryand alveolus


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A = Pulmonary hypertension resulting inincreased Residual Volume afterload

B = Application of high PEEP resulting indecreased preload

A+B = Decreased cardiac output


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RESPIRATORY SUPPORT Conventional mechanical ventilation

Newer modalities:

High frequency ventilation

Innovative strategies

Nitric oxide

Liquid ventilation

Exogenous surfactant


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Monitoring:

Respiratory

Hemodynamic

Metabolic/nutrition

Infections

Fluids/electrolytes


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Optimize VO2/DO2 relationship

Delivery O2 hemoglobin mechanical ventilation

oxygen/PEEP

Volume of O2

preload afterload

contractility


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CONVENTIONAL VENTILATION

Oxygen

PEEP

Inverse I:E ratio

Lower tidal volume Ventilation in prone position


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RESPIRATORY SUPPORTGoal: maintain sufficient oxygenation and

ventilation, minimize complications of

ventilatory management Improve oxygenation: PEEP, MAP, FiO2 Improve ventilation : change in pressure


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Mechanical VentilationG

uidelinesAmerican College ofChest Physicians

Consensus Conference 1993

Guidelines for Mechanical Ventilation inARDS

When possible, plateau pressures < 35 cm

H2

O

Tidal volume should be decreased if

necessary to achieve this, permitting

increased pCO2


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PEEP - Benefits Increases transpulmonary distending

pressure

Displaces edema fluid into interstitium Decreases atelectasis

Decrease in right to left shunt

Improved compliance Improved oxygenation


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No Benefit to Early Application of

PEEP

Pepe PE et al. NEJM 1984;311:281-6.

Prospective randomization of intubated patientsat risk for ARDS

Ventilated with no PEEP vs. PEEP 8+ for 72 hours

No differences in development of ARDS,

complications, duration of ventilation, time inhospital, duration of ICU stay, morbidity or

mortality


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Pressure-controlled Ventilation

(PCV) Time-cycled mode

Approximate square waves of a preset pressure are

applied and released by means of a deceleratingflow

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


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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 priorbreath reaches baselinep auto-PEEP with

recruitment of alveoli Lower inflating pressures

Potential for decrease in cardiac output due toincrease in MAP


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HASIL PENELITIAN

In patients with acute lung injury and the acuterespiratory 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


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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


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THANK FOR ALL

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kuliah ards tamrin 14112007