Dr.

Rakesh Chintalapudi
email : rakesh1959@gmail.com

ACUTE RESPIRATORY
DISTRESS SYNDROME

12/09/2021 1
 PRESENTER :
Dr. Rakesh Chintalapudi

MODERATER :

12/09/2021
Dr. Radha Madhavi
2
 Acute Respiratory Distress Syndrome

? ?
Adult Respiratory Distress Syndrome

? ?
New Born Respiratory Distress
Syndrome
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 ARDS
Term first introduced in 1967
Synonyms
–Shock lung
–Da Nang Lung
–Traumatic wet lung

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 Definition

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 The 1994 North American-European
Consensus Conference (NAECC)
criteria:

Onset - Acute and persistent

Radiographic Criteria - Bilateral Pulmonar

nfiltrates consistent with the presence of
dema.

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 (NAECC) criteria:

Oxygenation criteria -
Impaired
oxygenation regardless of the
PEEP
concentration, with a Pao2 / Fio2
ratio
 300 torr (40 kPa) for ALI and 
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 (NAECC) criteria:

xclusion Criteria - Clinical evidence of Le

trial Hypertension or a Pulmonary - artery
theter Occlusion Pressure > 18 mm Hg .

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 Aetiology

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 Direct Insult
C
• Aspiration
O Pneumonia
M
M
O
• Pneumonia
N

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 L Direct Insult
E
S • Inhalation Injury
S
• Pulmonary
C contusions
O • Fat Emboli
M
M • Near Drowning
O • Reperfusion
N
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 Indirect Insult
C Sepsis
O
M
M Severe Trauma
O
N Shock
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 L Indirect Insult
E
S Acute Pancreatitis
S Cardio Pul. Bypass
C
T R A L I
O DIC
M Burns
M
O Head Injury
N Drug Over dosage
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 Pathophysiology

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Basic Insult is Damage to Lung

Lung Unit – the Alveoli

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 NORMAL ALVEOLUS

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INJURED
ALVEOLUS

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 Phases Of ARDS
• Acute - Exudative,
inflammatory : capillary
congestion, neutrophil
aggregation, capillary
endothelial swelling, epithelial
injury; hyaline membranes by
72 hours
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 Phases Of ARDS
• Sub-acute - proliferative:
proliferation of type II
pneumocytes (abnormal
lamellar bodies with decreased
surfactant) , fibroblasts intra-
alveolar, widening of septae
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 Phases Of ARDS
• Chronic - fibrosing alveolitis :
remodeling by collagenous
tissue, arterial thickening,
obliteration of pre-capillary
vessels; cystic lesions
( > 10 days)
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 Overall Picture
Increased pulmonary shunt.
Increased dead space
ventilation.
Hypoxemia Hypoxemia
Reduced pulmonary complian
Increased work of breathing.
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 Overall Picture

Respiratory failure
requiring
mechanical ventilation.

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 Diagnosis
Plasma BNP
(< 100 pg/ml)
2 D Echo
Pulm. artery Cath.

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 Diagnosis
Pulmonary edema,
Diffuse alveolar
hemorrhage
Acute interstitial
pneumonia
Idiopathic acute
eosinophilic Pneumonia

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 Exudative phase

Diagnosis
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 Fibrotic phase

Diagnosis
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Therapy
 Ventilatory Strategy

Non Ventilatory Strategy

Supportive Measures

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 Ventilatory Strategy

The NIH 816

A R D S NET
Recommendations
“Lung Protective
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 VOLUME PRESSURE

Two powerful Bombs

Two poor Victims
Ventilatory-based Strategies in
the

Management of ARDS/ALI
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 Modes

• Both Volume cycled ventilation (VCV)

and Pressure controlled ventilation (PCV)
modes can be used with lung protective
strategy depending upon whether it is
more important to control airway
pressures or to control tidal volume .

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 Modes
• However, choosing appropriate ventilatory
goals
(VT and airway pressure) is far more
important than the particular mode.

• In general, fully supported modes of

ventilation (e.g. A/C) are favored over
partially-supported modes
( SIMV + PSV OR SIMV only) particularly
early in the course of the disease.
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Low Tidal volume Strategy

(6-8 ml/kg predicted body

weight)

Plateau pressure ≤ 30 cm H2O

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 Open Lung Concept
with alveolar recruitment with
PCV

High PEEP Strategy :

Prevention of VILI :
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 Recruitment Maneuvers :

Ventilation In Prone Position :

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FiO2 < 0.6

IR PCV

HFOV

APR
Ventilation 36
 Open Lung Concept

The open lung concept is physiologically

based on the Law of Laplace. Adhering
to the principles of the open lung
concept, pressure controlled ventilation
may improve patient
out come during Mechanical Ventilation
P = 2T/R
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 What is Open Lung Concept ?

Alveolar stability

The degree of this surfactant

damage will determine the
amount of pressure needed
to expand alveoli from
closed to open .
Poiseuille's
P =12/09/2021
2T/R 38
 Open Lung Concept

Poorly aerated
Normally aerated
Hyper inflated areas
Consolidated areas

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12/09/2021 40
 Open Lung Concept
• This combines low tidal volume
• Optimally applied PEEP to maximize
alveolar recruitment and aims to mitigate
alveolar over-distension and cyclic
Atlectasis.
• The goal of the open lung concept
procedure is to recruit alveoli and
maintain them open with the least
changes in pressure to minimize alveolar
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• Elevate PEEP to stay away from zone
of derecruitment
• Lower VT to stay away from over
distension zone (P plat < 30cm)
• Increase rate if higher MV is needed
(but use permissive hypercapnia) pH
>7.25
• Eliminate added mechanical dead space
(could increase Vd/Vt ratio with lower
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Vt’s.
 CYCLICAL ATELECTASIS
C
A – alveoli derecruitment
B – optimal recruitment inflatio
C – alveolar over distension
Optimal Volume D D – optimal inflation

A
Optimal
PEEP

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• Driving pressure = P plat – PEEP
• Goal – keep DP as low as possible
• Lower Vts & Higher PEEPs
• Keeps you out of zone A
(derecruitment) and zone C ( over
distension) - prevent VILI
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12/09/2021 45
 CYCLICAL ATELECTASIS
C
A – alveoli derecruitment
B – optimal recruitment inflati
C – alveolar over distension
Optimal Volume D D – optimal inflation

A
Optimal PEEP

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12/09/2021 47
 Predicted Body Weight
Ideal Body Weight
Calculating Predicted Body Weight

Male = 50 + 2.3 (height in inches - 60)

Male = 50 + 0.91(height in cm - 152.4)

Female = 45.5 + 2.3 (height in inches - 60)

Female = 45.5 + 0.91 (height in cm - 152.4)
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 What is Barotrauma ?

Excess PP >50 mmHg can lead to air

leaks Pneumothorax ,
Pneumomediastinum, SC Emphysema,
Pneuopericardium
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Gas
Extravasation
Barotrauma
 What is Volutrauma ?

Damage to the lung (Alveoli) caused by

Over distension by a Mechanical Ventilator
set
for an excessively high tidal Volume ( ?)

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 What is Atelectrauma ?

Low lung volume surfactant is squeezed out

leading to alveolar collapse, repeated collapse and
reopening leads to a shear stress particularly early
in the course of lung injury.

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 Recognized mechanisms of
Airspace Injury

Airway Trauma

Stretch
“Shear”

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 What is Biotrauma ?

Inflammatory products are

released secondary to mechanical
factors lead to MODS.

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 Volutrauma
Ayyoraama
Atelectrauama
Barotrauama
Biotrauma

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 V A L I
V I L I
(Heterogeneous distribution Of disease
pattern )

Healthy Lung Areas

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 Link
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ALI & MOSF
 Place on Pressure Control
Raise Peak Inspiratory pressure to 40 -60 cmH2O
10 breaths Minimal

I : E Ratio 1 : 1 or 2 : 1
PEEP 10 – 20 cm

Adjust peak Inspiratory Pressure to lowest

Pressure without loss of recruitment
Keep PEEP in range of
10 – 20 cm
Titrate ventilator P I P and
Mean Inspiratory pressure to the smallest
Possible difference
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 Recruitment Maneuvers

Sustained high airway pressure with

the goal to open collapsed lung tissue,
after which PEEP is applied sufficient
to keep the lungs open.

CPAP 40 cm H2 2O for 40 seconds

Intermittent Sighs
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 Still Confusing

How Much ?

So Let’s Review

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 Tidal Volume
How Much ?
6 to 8ml/pbw

WHAT IS THE LIMIT !

Pplat: plateau or pause pressure of

30 to 35
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 PEEP
• Recruits alveoli by opening them
• Improves compliance and oxygenation
• Decreases shunt fraction and work of breathing

GOAL
• SpO2 88 to 92%
• FiO2 40 to 60%
• SpO2 90% at FiO2: 60%

PEEP is applied in 2 to 4cm increments

5to 24cm of H2o
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 How much P E E P
• PEEP/FIO2 Relation - Double the FIO2
value to know the required PEEP level and
if the chest wall compliance is low then add
4 to PEEP.
• Example - If FIO2 is 0.8 PEEP required is
8x2=16 , if the chest wall compliance is low
then add 4 to PEEP i.e. 16+4=20
FiO2 .30 .40 .40 .50 .50 .60 .70 .70 .70 .80 .90 .90 .90 1.0

PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18-
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 High Frequency
Oscillation:

A Whole Lotta
Shakin’ Goin’ On

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 H FOV
• Rapid rate
• Low tidal volume
• Maintain open lung
• Minimal volume swings

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 HFOV
• Uses mean airway pressure (mPaw) to
open lung alveoli (decrease
intrapulmonary shunt) which
ventilates above derecruitment zone on
P-V curve (set 3-5 cm above previous
mPaw)

• Uses small tidal volumes which

ventilates below the over distension
66
zone on P-V curve (set between 85-95
 HFOV

• Uses high respiratory rates of 180 –

300 bpm (set between 3-7 hertz)

• Goal to use enough m Paw to keep

Fi02 <0.60 and utilize permissive
hypercapnia (Ph > 7.20)
67
 Why - H O F V
• Delivers small pressure
swings at the alveolar level
preventing Barotrauma
• Delivers small tidal volumes
at the alveolar level
preventing Volutrauma
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 Why - H O F V

• Delivers a high level of

continuous airway pressure
preventing Atelectrauma
• Allows the use of lower levels
of FiO2 preventing oxygen
toxicity
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 High Frequency Oscillatory
Ventilation

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 High Frequency
Oscillatory Ventilation

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 High Frequency Transtracheal
Ventilation
Infra Glottic
Supra Glottic

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 Liquid Ventilation
With
Per fluorocarbons

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 Liquid Ventilation

• Perfluorocarbon have excellent oxygen and

carbon dioxide carrying capacity (50 ml O 2/dl
and 160-210 ml CO2/dl, respectively).
• They are clear, odorless, inert fluids which are
immiscible in aqueous and most other
solutions
• 2 types of techniques : TLV -- PLV
• TOTAL LIQUID VENTILATION
PARTIAL LIQUID VENTILATION
•12/09/2021 74
 Liquid Ventilation

• There are six perfluorocarbon

gases
• Perflurocyclobuta
• Tetrafluoromethane ne
• Hexafluoroethane • Perfluoro-iso-
• Octafluoropropane butane
• Perfluoro-n-
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butane
 Liquid Ventilation

• Virtually all the other commercially available

perfluorocarbon are liquids (the exception
being perfluorocyclohexane, which sublimes
at 51 C.
• Liquid breathing
• Eye surgery
• Imaging
• Artificial blood
Decompression sickness
•12/09/2021 76
 Partial Liquid
Ventilation

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Relevance 77
 Liquid
Ventilation

Surface Tension lowered

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 Non – Ventilatory
Strategies in
A R D S / ALI

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 Fluid & Hemodynamic Management

Inhaled Nitric Oxide

Prone Position

Steroids

Other Drug Therapy

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 Prone Positioning
Limits the expansion of Cephalic
& parasternal Lung regions

Relieves the Cardiac &

abdominal compression
exerted on the lower lobes
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 PRONE

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 Makes regional
ventilation/perfusion
ratios and chest Elastance more
uniform

Facilitates drainage of Secretions

Potentiates the beneficial effect
of recruitment Maneuvers .
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 Prone Positioning Relieves Lung
Compression by the Heart

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 Prone Positioning
• Absolute Contra Indications :

• Burns or open wounds on the face or

ventral body surface
• Spinal instability
• Pelvic fractures
• Life-threatening circulatory shock
• Increased intracranial pressure
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 Main complications
Facial and periorbital edema
Pressure sores
displacement of the endotracheal tube,
Airway Obstruction
Hypotension
Arrhythmias
Vomitings

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 Corticosteroid Therapy in
ARDS:

Better late than

Early & never?

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 ARDS
High dose corticosteroids in early ARDS
• Do not lessen the incidence of ARDS
among patients at high risk
• Do not reverse lung injury in
patients with early ARDS/worse
recovery
• Have no effect on mortality/even
increase mortality ratesignificantly
increase the incidence of infectious
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 Corticosteroids

Aggressive search for and treatment of

Infectious complications is necessary

Appropriate time window for corticosteroid

administration between early acute injury
and established post aggressive fibrosis .

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 Supportive Measures

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• Nutritional Care

• Deep Vein Thrombosis Prophylaxis

• General Condition -Bed Sores

prevention

• Indwelling Invasive Lines - Care

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 Take Home Message

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 Take Home Message

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 THANK YOU

Luck favors Hard work

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