nypoxem|c kesp|ratory

Ia||ure
Curus n. Sessler, Mu, lCC, lCCM
Crhan Muren rofessor of Medlclne
vlrglnla CommonwealLh unlverslLy PealLh SysLem
ulrecLor, CenLer for AdulL Crlucal Care
Medlcal College of vlrglnla PosplLals
csessler[vcu.edu
nypoxem|c kesp|ratory Ia||ure
Curtis N. Sessler, MD, FCCP, FCCM
ACCP Pulmonary Board Review Course
San Antonio, TX
August 29, 2013
No potential conflicts of interest to disclose
nypoxem|c kesp|ratory Ia||ure
Gas Lxchange
Lmclency dependenL upon
Alveolar venulauon (v)
ulmonary blood ow
(C)
MaLchlng of v and C
lmpalrmenL resulLs ln
hypoxemla or hypercapnla
Measure pC
2
and pCC
2
by
arLerlal blood gas analysls
Netter
8|ood Gas A|teranons |n
Var|ous Causes of nypoxem|a
Mechanism PaO
2
PaCO
2
PA-aO
2

on RA
PA-aO
2
on
100%O
2
High altitude ! ! N N
Alveolar
hypoventilation
! # N N or #
Decreased ventilation
vs perfusion
! ! , N, or
#
# corrects
Diffusion block ! N or ! # corrects
Right-to-left shunt ! N or ! # #
Consensus Cr|ter|a for AkDS & ALI
Chest kad|ograph|c Ieatures of AkDS
uluse bllaLeral
lnlLraLes
aLchy, conuenL
Alveolar, ground-glass
ln conLrasL Lo CPl, no
promlnence of..
Cardlomegaly
leural euslon
Wldened vascular
pedlcle
Chest C1 Demonstrates Dependent
Dens|nes |n AkDS
AkDS: 8er||n Dehn|non
Category Criterion
Timing Within 1 week of clinical insult or new/worsening
respiratory sx
Chest Imaging Bilateral opacities not fully explained by effusions,
lobar/lung collapse, or nodules
Origin of edema Not fully explained by cardiac failure or fluid
overload. Objective measure to rule out hydrostatic
edema
Oxygenation: Mild 200 mm Hg < PaO2/FIO2 < 300 mm Hg*
Oxygenation: Moderate 100 mm Hg < PaO2/FIO2 < 200 mm Hg**
Oxygenation: Severe PaO2/FIO2 < 100 mm Hg**
* PEEP or CPAP > 5 cm H2O; ** PEEP > 5 cm H2O
JAMA 2012;307:2526-33
AkDS: athophys|o|ogy
SysLemlc lnammauon
Acuvauon of complemenL and coagulauon sysLems,
sumulauon of lnammaLory cells, release of pro-
lnammaLory medlaLors
SequesLrauon of neuLrophlls ln mlcrovasculaLure,
mlgrauon lnLo alrspaces
LndoLhellal and eplLhellal dlsrupuon
AkDS: athophys|o|ogy
Lxudauon of proLeln-rlch uld from mlcro-
vasculaLure lnLo lnLersuual space and alveoll
ulsrupuon of surfacLanL, reduclng lung compllance
and promoung aLelecLasls
erslsLenL lnammauon, brouc repalr
lallure of hypoxlc vasoconsLrlcuon resulung ln shunL
and severe hypoxemla
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Management of AkDS
! 1reaL underlylng condluon
! SupporL oxygenauon and venulauon
Mechanlcal venulauon, avold / mlnlmlze baroLrauma and
oxygen LoxlclLy
use lung proLecuve venulauon / low udal volumes
ressure or volume? 8ecrulLmenL? Plgher LL?
! Supporuve (non-venulaLory) Lherapy
! Conservauve uld managemenL
! CorucosLerolds?
! ManagemenL of severe hypoxemla
Management of AkDS
! 1reaL underlylng condluon
! SupporL oxygenauon and venulauon
Mechanlcal venulauon, avold / mlnlmlze baroLrauma and
oxygen LoxlclLy
use lung proLecuve venulauon / low udal volumes
ressure or volume? 8ecrulLmenL? Plgher LL?
! Supporuve (non-venulaLory) Lherapy
! Conservauve uld managemenL
! CorucosLerolds?
! ManagemenL of severe hypoxemla
Lung !"#$%&'(% Mechan|ca| Venn|anon
for AkDS
! Lung ln[ury ls
heLerogeneous, buL wlLh
funcuonal
comparLmenLs:
normal lung (8) - poLenual
for overdlsLenuon
ALelecLauc, buL recrulLable
lung (C) - poLenual for
cycllc recrulLmenL /
collapse
uensely consolldaLed
lung (A) - poorly
recrulLable
Moloney & Griffiths Br J Anaesth 2004; 92:261-70
Venn|ator Assoc|ated Lung In[ury:
More than [ust 8arotrauma?
voluLrauma
CverdlsLenuon of alveoll
ALelecLrauma
Shear sLress of cycllc collapse-recrulLmenL of alveoll
MosL pronounced near xed sLrucLures
8loLrauma
Lung elaborauon and sysLemlc release of lnammaLory
cells and medlaLors
Lower 1|da| Vo|ume Venn|anon for
ALI and AkDS
AkDS Network. N Lng| I Med 2000, 342:1301
! Randomized trial of
conventional TV (11.8
ml/kg) vs low TV (6.2
ml/kg) ventilation in
861 patients with ALI
*p < .01

Mortality

Vent-free days

Organ failure-
free days

Barotrauma
*
*
*
AkDSNet kecommendanons for
Mechan|ca| Venn|anon |n AkDS
volume - AsslsL ConLrol Mode
1ldal volume (vL) = 8 ml/kg 8W*
8educe vL by 1 ml/kg unul vL = 6 ml/kg
SeL lnsplraLory ow > pL demand (usually > 80L/mln)
Ad[usL 88 and vL Lo achleve plaL & pP goals
Alm for plaL < 30 cm P
2
C
Alm for pP = 7.3-7.43 by lncreaslng 88 (Lo 33 lf
necessary) and addlng blcarbonaLe
* PBW = predicted body weight: M = 50 + 2.3[height (inches) - 60],
F = 45.5 + 2.3[height (inches) - 60]
N Engl J Med 2000; 342:1301
uesnon 1
Whlch of Lhe followlng udal volumes ls approprlaLe Lo
venulaLe a 6 fooL Lall man wlLh 6 ml/kg of predlcLed
body welghL?
A. 470 ml
8. 320 ml
C. 370 ml
u. 620 ml
Un||ze Strateg|es to Improve Lung
rotecnve Venn|anon
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Un||ze Strateg|es to Improve Lung
rotecnve Venn|anon
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PETA
People for the Ethical
Treatment of Alveoli
uesnon 2
SLudles and surveys lndlcaLe whlch of Lhe followlng
regardlng Lhe use of lung proLecuve venulauon for
A8uS ln medlcal cenLers?
A. MosL pauenLs recelve udal volumes < 6.3 ml/kg 8W
8. aCC2 averages 33 mmPg
C. MosL pauenLs recelve pressure conLrol venulauon
u. hyslclan unwllllngness Lo rellnqulsh venulaLor
conLrol ls an lmporLanL barrler Lo lnluaung lung
proLecuve venulauon
8arr|ers to rov|d|ng Lung-rotecnve
Venn|anon: AkDSNet kN & k1 Surveys
8arrlers Lo lnluaung Lv
hyslclan unwllllngness Lo rellnqulsh venulaLor conLrol
hyslclan lack of recognluon of ALl/A8uS
hyslclan percepuons of conLralndlcauons
8arrlers Lo conunulng Lv
Concerns over pauenL dlscomforL, Lachypnea
Concerns over hypercapnla, acldosls, hypoxemla
Rubenfeld et al. Crit Care Med 2004; 32:1289-93
Low 1|da| Vo|ume Venn|anon (L1VV):
Use a rotoco|
230 pauenLs wlLh ALl ln 8alumore lCus
1he day aer ALl dlagnosed
vL < 6.3 ml/kg 8W ln 46
vL < 8.3 ml/kg 8W ln 81
lacLors assoclaLed wlLh use of L1vv
use of wrluen proLocol (C8 6.0, 1.3-27.2)
Serum PCC3 < 22 (C8 0.3, 0.1-0.9)
Umoh et al. Crit Care Med 2008; 36: 1463-1468
AkDSNet kecommendanons for
Mechan|ca| Venn|anon |n AkDS
volume - AsslsL ConLrol Mode
1ldal volume (vL) = 8 ml/kg 8W*
8educe vL by 1 ml/kg unul vL = 6 ml/kg
SeL lnsplraLory ow > pL demand (usually > 80L/mln)
Ad[usL 88 and vL Lo achleve plaL & pP goals
Alm for plaL < 30 cm P
2
C
Alm for pP = 7.3-7.43 by lncreaslng 88 (Lo 33 lf
necessary) and addlng blcarbonaLe
* PBW = predicted body weight: M = 50 + 2.3[height (inches) - 60],
F = 45.5 + 2.3[height (inches) - 60]
N Engl J Med 2000; 342:1301
Lung rotecnve Venn|anon for AkDS:
Var|anons
volume vs pressure LargeLed venulauon?
8ecrulLmenL maneuvers?
Pow much LL?
ressure vs Vo|ume-1argeted
Venn|anon |n AkDS?
no large, recenL (low vL) 8C1s comparlng only
pressure vs volume-Largeung
oLenual advanLages of pressure-Largeung
Laslly ad[usL lnsplraLory ume
8euer pauenL-venulaLor synchrony
Avold reglonally excesslve Lransalveolar pressure
oLenual advanLages of volume-Largeung
Avold h udal volume, slmpllfy lmplemenLauon
MacIntyre & Sessler. Respir Care 2010; 55:43-55
Marini & MacIntyre Chest 2011; 140:286-294
kecru|tment Maneuvers
Wlde varleLy of proposed approaches
40 cm P2C pressure for 40 seconds
8amp up and down of pressure
Many oLhers
uemonsLraLed Lo lmprove oxygenauon
1ranslenL beneL alone
8ecommended prlor Lo lncreaslng LL
Clearly beneclal for lnLervenuons LhaL promoLe loss of
alrway pressure / LL (l.e. sucuonlng)
kecru|tment Maneuvers |n AkDS:
Meta-ana|ys|s
Hodgson et al. Cochran Collaboration 2009
7 sLudles (n = 1170 sub[ecLs) wlLh recrulLmenL maneuver
3 sLudles venulauon slmllar beLween groups
Cxygenauon lmproved slgnlcanLly for shorL perlod ln 4/3
no eecL on morLallLy, baroLrauma, blood pressure
arameLer 88, p value
28d Mortality 0.73 (0.46, 1.17), p = 0.20
Barotrauma 0.50 (0.07, 3.52) p = 0.5
Blood pressure 0.9 mm Hg (-4.28, 6.08), p = 0.73
Lung kecru|tment w|th LL
Lu et al. Crit Care 2006; 10:R95
1
5

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Dark gray = normal, light gray = poorly aerated, red = nonaerated
Cxygenanon vs LL (Day 3)
from 4 n|gh vs Low LL kC1s
150
200
250
300
5 10 15 20
Brower
Meade
Mercat
Talmor
PEEP (cm H
2
O)
P
a
O
2
/
F
i
O
2

n|gh LL vs Low LL |n AkDS:
Meta-ana|ys|s of Ind|v|dua| anent Data
aa
Higher
PEEP
Lower
PEEP
p Higher
PEEP
Lower
PEEP
p
Hospital death
34% 39% .049 27% 19% .07
ICU death
30% 37% .001 20% 17% .71
Pneumothorax
8% 7% .13 4% 5% .33
Vent-free days
12 d 7d .004 17d 19d .07
Rescue therapy
14% 21% <.001 4% 7% .25
Briel et al. JAMA 2010;303:865-73
ARDS No ARDS
8est LL for AkDS?
Conslder lmpacL of LL on oxygenauon, venulauon, oxygen
dellvery, rlsk of baroLrauma, exLra-pulmonary pressure
lncreaslng LL Lrlal - posluve eecLs.
8euer oxygenauon (h SpC2 and/or aC2)
8euer venulauon / compllance / recrulLmenL (l or no u
aCC2, or h or no u ln udal volume (pressure-LargeLed
mode))
lndlrecL evldence LhaL uC2 does noL worsen
l CC, 8, vC2
SLress lndex < 1
Esan et al. Chest 2010; 137:1203-1216
AkDSNet ALVLCLI Study:
Lo-LL]n|-I|C2 v n|-LL]Lo-I|C2
0
5
10
15
20
25
30
0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.8 0.9 0.9 0.9 1 1
Lo-PEEP/Hi-FiO2 Hi-PEEP/Lo-FiO2
FiO2
P
E
E
P

(
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H
2
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)

Brower et al. N Engl J Med 2004; 351: 327-36
now Much LL?
Stress Index Approach
! ConsLanL ow lnauon (volume-LargeLed AC)
! Change ln lung compllance w lnauon
Use More PEEP Use Less PEEP
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Flow
Pressure
Management of AkDS
! 1reaL underlylng condluon
! SupporL oxygenauon and venulauon
Mechanlcal venulauon, avold / mlnlmlze baroLrauma,
oxygen LoxlclLy
use lung proLecuve venulauon / low udal volumes
ressure or volume? 8ecrulLmenL? Plgher LL?
! Supporuve (non-venulaLory) Lherapy
! Conservauve uld managemenL
! CorucosLerolds?
! 8escue for severe hypoxemla
Cumu|anve I|u|d 8a|ance |n
AkDSNet kC1s
Calfee & Matthay. Chest 2007; 131:913-20
I|u|d Management Strateg|es |n ALI:
Cutcomes
arameLer Conservauve Llberal value
MorLallLy 23.3 28.4 0.30
!"#$%&'()*+)"" - ./01 .20. 033.
456*+)"" - .70/ ..02 033.
LlecLrolyLe abnl 42 19 .001
881 10 14 .06
Wiedemann H, et al. N Engl J Med 2006; 354:2564-75
8C1 comparlng conservauve and llberal sLraLegles for uld
managemenL uslng expllclL proLocols applled for 7 days ln 1000
pauenLs wlLh ALl

uesnon 3
A pauenL wlLh A8uS has blood pressure of 110/70
mmPg, urlne ouLpuL of 1 ml/kg/hr, and Cv of 7
mmPg. Accordlng Lo Lhe A8uSneL conservauve uld
managemenL algorlLhm, whlch lnLervenuon should
be performed?
A. AdmlnlsLer uld bolus
8. AdmlnlsLer dlureuc
C. 8egln dobuLamlne lnfuslon
u. 8egln vasopressor lnfuslon
I|u|d Management Strateg|es |n ALI
If anent |s nypoprote|nem|c
Cons|der A|bum|n + D|urenc
auenLs wlLh A8uS / ALl and serum proLeln < 3 mg/
dl
ConcomlLanL albumln admlnlsLrauon along wlLh
furosemlde
8euer oxygenauon
More eecuve uld removal
8euer hemodynamlc Lolerance
Martin et al. Crit Care Med 2002;30:2175-82, Martin et al Crit Care 2005;9:R74-82
Management of AkDS
! 1reaL underlylng condluon
! SupporL oxygenauon and venulauon
Mechanlcal venulauon, avold / mlnlmlze baroLrauma,
oxygen LoxlclLy
use lung proLecuve venulauon / low udal volumes
ressure or volume? 8ecrulLmenL? Plgher LL?
! Supporuve (non-venulaLory) Lherapy
! Conservauve uld managemenL
! CorucosLerolds?
! ManagemenL of severe hypoxemla
Corncostero|ds |n AkDS:
Ma[or Cutcomes |n Meta-ana|ys|s

Risk ratio / Diff in means

P value
Mortality: All 0.62 (0.43-0.91)
0.01
Mortality: Cohort 0.66(0.43-1.02)
0.06
Mortality: RCT 0.51(0.3-1.03)
0.08
Duration of MV -4.8 (-9.2 to -0.4)
.03
ICU LOS -4.1(-8.9 to 0.6)
0.09
Tang et al. Crit Care Med 2009; 37:1594-1603
Corncostero|ds |n AkDS:
Adverse Lvents |n Meta-ana|ys|s
CorucosLerolds ConLrol p value
lnfecuon 84/304 74/263 0.48
neuromyopaLhlc
compllcauons
30/173 23/142 0.62
Cl bleedlng 7/141 3/143
Pyperglycemla 30/86 22/31
All ma[or AL 93/260 82/234 0.43
Tang et al. Crit Care Med 2009; 37:1594-1603
Corncostero|ds |n AkDS:
D|scuss|on
use of low dose, longer durauon corucosLerolds ls
assoclaLed wlLh more rapld recovery and may be
assoclaLed wlLh reduced morLallLy rlsk
ConslsLenL ln randomlzed & non-randomlzed sLudles
89': ;<&%% ;'9-=";: <"'>(-(%(?=@&% A9&%='B =;;9";
no lncrease ln adverse evenLs
lf use corucosLerolds ln A8uS
Avold sLarung aer day 14
MeLhylprednlsolone 2 g/kg/d, Laper over 4 weeks
lnfecuon survelllance, avold nM8A
Sessler & Gay. Respir Care 2010; 55:175-83
Lntera| Cmega-3 Iauy Ac|d, g-L|no|en|c
Ac|d, Annox|dant Supp|ement |n ALI
revlous sLudles wlLh nuLrluonal producL conLalnlng
omega-3s, CLA, anuoxldanLs suggesLed beneL, buL awed
MulucenLer 8C1 (A8uSneL) of 8lu supplemenLauon ln 272
pauenLs w ALl
Cmega-3 supplemenLauon poLenually harmful
lewer venulaLor free days (14 vs 17.2, p = 0.02)
lewer lCu free days (14 vs 16.7, p = 0.04)
lewer non-pulm Cl days (12.3 vs 13.3, p = 0.02)
1rend for hlgher ad[usLed 60-day morLallLy (23.1 vs
17.6, p = 0.11)
Rice et al. JAMA 2011; 306:1574-81
Management of AkDS
! 1reaL underlylng condluon
! SupporL oxygenauon and venulauon
Mechanlcal venulauon, avold / mlnlmlze baroLrauma,
oxygen LoxlclLy
use lung proLecuve venulauon / low udal volumes
ressure or volume? 8ecrulLmenL? Plgher LL?
! Supporuve (non-venulaLory) Lherapy
! Conservauve uld managemenL
! CorucosLerolds
! ManagemenL of severe hypoxemla
What |s Severe AkDS?
Severe A8uS
aC2/llC2 < 60 mmPg?
<100 mmPg?
< 120 mmPg?
< 130 mmPg?
pP < 7.2?
CLher - l know lL when l see lL
lmpllcauons for venulaLory managemenL
lmpllcauons for rescue Lherapy
1herapy for L|fe-threaten|ng
nypoxem|a |n AkDS
Ventilatory
Higher PEEP
Recruitment
maneuvers
Higher mean airway
pressure
Longer Tinsp
APRV
HFOV
Non-ventilatory
Neuromuscular
blockade
Prone positioning
Inhaled pulmonary
vasodilator (iNO)
ECMO
Esan et al. Chest 2010;137:1203
Raoof et al. Chest 2010;137:1437
8est LL?
Conslder lmpacL of LL on oxygenauon, venulauon,
oxygen dellvery, rlsk of baroLrauma, exLra-
pulmonary pressure
lncreaslng LL Lrlal - posluve eecLs.
8euer oxygenauon (h SpC2 and/or aC2)
8euer venulauon / compllance / recrulLmenL (l or no u
aCC2, or h or no u ln udal volume (pressure-LargeLed
mode))
lndlrecL evldence LhaL uC2 does noL worsen
l CC, 8, vC2
SLress lndex < 1
Esan et al. Chest 2010; 137:1203-1216
Longer Insp|ratory 1|me
MosL easlly accompllshed wlLh pressure-LargeLed
modes
ressure conLrolled lnverse rauo venulauon (C-l8v)
no sponLaneous breaLhs
8lLevel permlLs sponLaneous breaLhs
Alrway pressure release venulauon (A8v) ln u.S. =
long lnsplraLory ume and very shorL explraLory ume
no ouLcome 8C1s for A8v ln A8uS
A|rway ressure
ke|ease Venn|anon
AkV Concerns:
AutoLL & 1|da| Vo|ume Creep
Incomplete emptying (i.e. autoPEEP)
300
350
400
450
500
550
600
650
700
10pm 2am 6am 10am
Tidal volume
6 ml/kg IBW
pressure
flow
n|gh Irequency Csc|||anon |n AkDS:
1he U|nmate Lung rotecnve Venn|anon?
Plv proposed as a form of lung proLecuve sLraLegy
Plgh frequency osclllauon venulauon (PlCv)
Acuve lnsplraLory and explraLory phases
lrequency = 3-13 Pz, udal volumes < dead space
arameLers conLrolled: power (aecLs pressure
ampllLude), lnsplraLory ume, blas ow raLe, llC2
urlLan 8enneu 31008 luA approved for adulLs
nICV for Severe AkDS:
Not So Iast
MulucenLer 8C1 of 348
pauenLs of PlCv vs L1vv
(vL 6 ml/kg, hlgh LL) for
A8uS (aC2:llC2 < 200
mmPg)
SLopped early for harm
PlCv assoclaLed wlLh:
Plgher morLallLy (lCu, hosp)
More sedauon, nM8A
More vasopressors
Less refracLory hypoxemla
MulucenLer 8C1 of 793 uk
pauenLs of PlCv vs usual
care for A8uS (aC2:llC2 <
200 mmPg)
vL = 8.3 ml/kg, LL 11 cm
P2C
no dlerence ln:
30 day all cause morLallLy
lCu, Posp LCS
venL-free days
Ferguson et al. N Engl J Med 2013 Young et al. N Engl J Med 2013
1herapy for L|fe-threaten|ng
nypoxem|a |n AkDS
Ventilatory
Higher PEEP
Recruitment
maneuvers
Higher mean airway
pressure
Longer Tinsp
APRV
HFOV
Non-ventilatory
Neuromuscular
blockade
Prone positioning
Inhaled pulmonary
vasodilator (iNO)
ECMO
Esan et al. Chest 2010;137:1203
Raoof et al. Chest 2010;137:1437
ACUkASS
lrench mulucenLer 8C1 comparlng clsaLracurlum (ClS) or
placebo x 48h ln severe A8uS (aC2:llC2 < 130 mmPg)
ClS group deeply sedaLed (8amsay 6), paralyzed
ClS group.
Lower 90d morLallLy raLe (31.6 vs 40.7, p = 0.08)
Lower 28d morLallLy (23.7 vs 33.3, p = 0.03)
More venulaLor-free days (10.6 vs 8.3, p = 0.04)
lewer pneumoLhoraces (4 vs 11.7, p = 0.01)
no dlerence ln raLe of lCu-acqulred paresls
MorLallLy beneL llmlLed Lo pLs wlLh aC2:llC2 < 120
Papazian et al. N Engl J Med 2010; 363: 1107-16
uesnon 4
lor pauenLs wlLh A8uS, lnhaled nlLrlc oxlde has been
demonsLraLed ln randomlzed conLrolled Lrlals Lo
have whlch of Lhe followlng eecLs?
A. Plgher aC2:llC2 rauo
8. Plgher lncldence of sysLemlc hypoLenslon
C. Lower 28-day morLallLy
u. ShorLer durauon of mechanlcal venulauon
Inha|ed N|tr|c Cx|de
Endogenous vasodilator
(EDRF)
Inhalation of 2 - 40 ppm
produces selective dilation of
pulmonary vessels
# ! RVEF and ! RVEDV
Rapidly inactivated by
combining with hemoglobin and
by oxidation
What |s the ko|e for
N|tr|c Cx|de |n AkDS?
Cxygenauon beneL for up Lo 4 days (3-20ppm)
no meLhemoglobln or hnC
2
unless 80ppm
Plgh acqulsluon cosL
AlLernauves lnclude aerosollzed epoprosLenol, eLc
no ouLcome beneL (survlval, durauon of mechanlcal
venulauon, lCu LCS)
8ouune use of lnhaled nC ls noL supporLed
oLenual role for lnhaled nC as rescue Lherapy for severe
refracLory hypoxemla
uemonsLraLe cllnlcally slgnlcanL beneL Lo conunue
Nebu||zed Lpoprosteno|
rone os|non|ng |n AkDS
lmproves oxygenauon ln 70 pLs
roposed mechanlsms
lncreased end-explraLory lung volume
lmproved venulauon-perfuslon
maLchlng
reglonal changes ln venulauon
8equlres personnel (4-3) and plannlng Lo
safely Lurn pauenL
oLenual for compllcauons: unlnLended
Lube/llne removal,
Lect of rone os|non|ng on
Cxygenanon |n Acute kesp|ratory Ia||ure
Gattinoni, et al. N Engl J Med 2001; 345:568-573
Change in PaO2:FiO2 from baseline to 1h to end of period to next morning
prone
supine
Guerin et al. N Engl J Med 2013
Multicenter RCT comparing prone (n = 237) and supine
(n = 229) positioning of patients with severe (PaO2:FiO2
< 150 mmHg) ARDS
> 16 hr / d prone positioning
Prone positioning associated with:
Lower 28 day mortality
Lower 90 day mortality
More patients extubated at 90 days
More ventilator-free days (at 28,
90 d)
No difference in complications
LCMC for AkDS
venovenous (vv-
LCMC) for resplraLory
fallure
8lood removed and
pumped Lhrough
oxygenaLor and
reLurned Lo clrculauon,
no cardlac supporL
Large vascular cannula,
anucoagulauon,
lnfecuon rlsk
LCMC for AkDS
LxLracorporeal Llfe SupporL (LCLS)
Large 8C1 ln uk demonsLraLed lower morLallLy and/or
dlsablllLy ln group randomlzed Lo be Lransferred Lo
LCMC cenLer (buL many oLher 8x dlerences) C""D "' &%0
E&#@"' 233F
Cnly 76 randomlzed Lo LCMC goL LCMC, groups
poorly balance (L1vv), much longer lengLh of sLay
8euer ouLcomes ln young pauenL, slngle organ fallure,
early lnluauon (MCP experlence) G">)& "' &%0 H)@> I9)? 233F
nypoxem|c kesp|ratory Ia||ure: 1he
8ouom L|ne
ldenufy A8uS uslng convenuonal parameLers
(predlsposluon / umlng, Cx8, A8C)
use lung proLecuve approach - 6 ml/kg 8W vL
Avold Lrans-alveolar pressure > 30 cmP2C, allow
permlsslve hypercapnla lf needed
Avold cycllc alveolar collapse g recrulLmenL by
applylng LL, parucularly for severe A8uS
nypoxem|c kesp|ratory Ia||ure: 1he
8ouom L|ne
Conservauve uld managemenL: alm for balanced
l = C
Conslder hlgher LL, longer lnsplraLory ume
(A8v-llLe), nM8A, prone posluonlng, or LCMC for
severe hypoxemla - movlng from leasL lnvaslve Lo
mosL lnvaslve. rove LhaL lL helps Lo conunue rx