This document discusses various strategies for managing acute respiratory distress syndrome (ARDS). It begins by describing the pathophysiology of ARDS including pulmonary capillary leak, surfactant inactivation, and diffuse lung injury. It then discusses various ventilator strategies and adjunctive therapies for ARDS management such as recruitment maneuvers, prone positioning, high frequency oscillatory ventilation, liquid ventilation, and application of surfactant. The document emphasizes an open lung approach with low tidal volumes and higher positive end expiratory pressures to minimize ventilator-induced lung injury while maintaining adequate oxygenation and ventilation.

1. ARDS
MANAGEMENT
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO

2. Global Critical Care
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3. Pulmonary
capillary leak
Inactivation of
surfactant
Interstitial
& alveolar edema
Severe & refractory hypoxemia
SHUNTING - Stiff lungs
Alveolar atalectasis
Damage to alveolar capillary
membrane
DIFFUSE lung injury
CAUSES

4. Early pathologic features of ARDS
• Diffuse alveolar damage (DAD)
• There is minimal alveolar septal thickening,
hyperplasia of pneumocytes
• Eosinophilic hyaline membranes present

8. Links Between VILI and MSOF
Biotrauma and Mediator Injuries

9. What does surfactant do?
Alveoli
without
surfactant
Alveoli
with
surfactant

10. Cyanosis
Pao2 / Fio2 < 200
REFRACTORY HYPOXEMIA

11. Gas Extravasation
Barotrauma

12. 1 
A Portal for Gas
& Bacteria?
Microvascular
Fracture in ARDS

13. Excessive PEEP, particularly in combination with
hypovolemia, can decrease cardiac output and
oxygen delivery, and increase the risk of
barotrauma

14. Subcutaneous emphysema

16. CT scan showed Severe surgical emphysema and pneumomediasteum

20. Diseased Lungs Do
Not Fully Collapse,
Despite Tension Pneumothorax
…and
They cannot always
be fully “opened”
Dimensions of a fully
Collapsed Normal Lung

21. Tension Cysts

22. Spectrum of Regional Opening Pressures
(Supine Position)
Superimposed
Pressure Inflated 0
Alveolar Collapse
(Reabsorption) 20-60 cmH2O
Small Airway
Collapse
10-20 cmH2O
Consolidation 
Lung Units at Risk for Tidal
Opening & Closure
=
Opening
Pressure

23. How Much Collapse Depends on the Plateau
R = 100%
20
60
100
Pressure [cmH2O]
20 40 60
TotalLungCapacity[%]
R = 22%
R = 81%
R = 93%
0
0
R = 0%
R = 59%
Some potentially
recruitable units
open only at high
pressure
More Extensive
Collapse But
Lower PPLAT
Less Extensive
Collapse But
Greater PPLAT

24. Mechanical Ventilator

25. PRESSURE VOLUME CURVE

26. Recruitment Maneuvers (RMs)
Proposed for improving
Arterial oxygenation
Enhancing alveolar recruitment
All consisting of short-lasting increases in
intrathoracic pressures

27. Recruitment Maneuvers (RMs)
–Vital capacity maneuver
(inflation of the lungs up to 40 cm H2O,
maintained for 15 - 26 seconds)
–Intermittent sighs
–Extended sighs

28. Recruitment Maneuvers (RMs)
–Intermittent increase of PEEP
–Continuous positive airway pressure
(CPAP)
–Increasing the ventilatory pressures to a
plateau pressure of 50 cm H2O for 1-2
minutes

29. Other manoeuvres
• Prone positioning ventilation
• Prolonged inspiration
• Inverse ratio ventilation

30. Limit of open lung strategy
• To minimise VILI
to the less damaged alveoli
Max insp pressure
(plateau pressure 30-32cm H20)

31. Limit of open lung strategy
Max pressure remains unchanged
TV will decrease
Alveolar ventilation will decrease
Alv V: dead space vent ratio
will decrease

32. Increasing PaCO2
• Management options
Increase resp rate
Minute
volume
Delivered TV TV ml/kg Resp rate
6.4 L 640 ml 8 10
6.4 L 480 ml 6 14
6.4 L 320 ml 4 20
6.4 L 160 ml 2 40
Anatomical dead space 150ml

33. Increasing PaCO2
• Permissive hypercapnia
•Tracheal gas
insuflation
•Reduce
•dead space

34. Increasing PaCO2
As alveolar ventilation decreases
will require increasing FIO2
Otherwise will result
in alveloar hypoxia and arterial
hypoxaemia

35. Liquid
Ventilation
More clinical trials are req. to demonst.
efficacy.

36. • Inert
• No odor
• No color
• Low surface tension
• Carry large amount of O2 & CO2
Perfluorocarbon
(PFC)

37. Medication:
Morphine sulfate
(0.1mg/kg/dose), pavulon
(0.1 mg/kg/dose)
Rimar (30 ml/kg)
Ventilation settings:
Ti 5 sec, hold 10 sec, Te 5
sec (3-6 cycles/min)
CO2 eleminated by
increase tidal volume
O2 managed by change O2
content and FRC

39. ON START OF GAS
VENTILATION
ONE HOUR AFTER
PLV
48 HOUR AFTER PLV 3 WEEKS AFTER PLV
Partial liquid ventilation with perflubron in premature infants with severe
respiratory distress syndrome

40. High-frequency Oscillatory Ventilation
• Active expiration Pressurised circuit

41. High-frequency Ventilation

42. 35cm
H20
90 cm
3-9 hz
0.1-3ml/kg

43. 43
Pressure transmission HFOV
P
T
proximal
trachea
alveoli
Due to the attenuation of the
pressure wave
by the time it reaches the alveolar
region
it is reduced down to .1 - 5 cmH2O

44. BRONCHOTRON
VENTILATOR
CONVENTIONAL
( = LOW FREQUENCY )
VENTILATION UNIT
PULSATION
( = HIGH FREQUENCY )
VENTILATION UNIT

45. However …
Risks of barotrauma and hemodynamic compromise with high frequency
ventilation can approximate those of conventional ventilation

46. KINETIC THERAPY
MEDISCUS AIR CUSHION
BED PULMONAIR
MEDISCUS TRAUMA BED
ROTOREST

48. APPLICATION OF SURFACTANT
CUROSURF - SURVANTA
ALVEOLFACT
50 – 200 mg/kgBW
BY ENDOTRACHEAL OR ENDOBRONCHIAL ROUTE

49. APPLICATION OF SURFACTANT
• PREVENT END-EXPIRATORY COLLAPSE OF
ALVEOLI
• RECRUITMENT OF ATELECTATIC LUNG
AREAS
• IMPROVED COMPLIANCE
• IMPROVED OXYGENATION
• IMPROVED VENTILATION /PERFUSION
RATIO

50. SECRETION ELEMINATION
VIA IPPB
• BETTER DISTRIBUTION OF
MEDICATED AEROSOLS
• BRONCHOSPASMOLYTIC
• IMPROVED OXYGENATION
• SECRETOLYSIS

51. JET THERAPY
• SECRETOLYSIS ( SECRETION MOBILISATION )
• DISSOLUTION OF RESORPTIVE ATELECTASES
• IMPROVED OXYGENATION
• INTRACRANIAL PRESSURE REDUCTION

52. CLINI – JET
HIGH FREQUENCY JET VENTILATION
HFJV
 HANDY INSTRUMENT
 PRODUCES SHORT
GAS PULSES
 FOR SECRETOLYSIS
 DISSOLVE SECRETIONS
( KETCHUP EFFECT )

53. INCENTIVE SPIROMETRY
SUSTAINED MAXIMAL INSPIRATION
• ALVEOLAR RECRUITMENT
• PREVENTION OF ATELECTASES
• MUSCLE TRAINING
• COUGH PROVOCATION
• IMPROVED OXYGENATION AND VENTILATION

54. Dilates pulmonary
blood vessels and
helps reduce
shunting
REDUCTION IN INTRAPULMONARY R-L SHUNT
Nitric Oxide

55. GOOD LUCK
SAMIR EL ANSARY
ICU PROFESSOR
AIN SHAMS
CAIRO
elansarysamir@yahoo.com
Global Critical Care
https://www.facebook.com/groups/1451610115129555/#!/groups/145
1610115129555/
Wellcome in our new group ..... Dr.SAMIR EL ANSARY