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Ventilator induced surfactant dysfunction

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Presentation by Dr Papadakos
Scribe Knowledge Resources
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Ventilator induced surfactant dysfunction

  1. 1. Ventilator-InducedSurfactant Dysfunction PJ Papadakos MD FCCM FCCP FAARC Director Critical Care Medicine Professor Anesthesiology, Surgery and Neurosurgery University of Rochester Professor Respiratory Care Genesee Community College
  2. 2. Conflict of Interest DisclosurePeter Papadakos MD FCCM Has no real or apparent conflicts of interest to report.
  3. 3. 20 year collaboration Rotterdam and now Berlin
  4. 4. Basic PhysiologyThe Base of Good Care In all trauma patients
  5. 5. Pulmonary Surfactant
  6. 6. Pulmonary Surfactant was initially identified as a lipoprotein complex that reduces surface tension at the air- liquid interface of the lung
  7. 7. Lipids Levels of total phospholipids decrease over time with cyclic opening and closing especially phosphatidylcholine and phosphatidylglycerol, which are essential for lowering surface tension at the alveolar capillary membrane. Tsangaris l. et al Eur Respir J 2003, 21:495-501
  8. 8. Lung Mechanics change with Lung Collapse
  9. 9. Shear Forces
  10. 10. Eskaros and Papadakos Respiratory Monitoring in Millers Anesthesia 7thEdition
  11. 11. The cycle opening and closing of Alveolar Units Deplete Surfactant and lead to further collapse through clumping.
  12. 12. Key to ImmunologyAnd host defence
  13. 13. Lung host defence mechanisms the lung is constantly challenged by inhaled pathogens Pollutants an particles
  14. 14. of a family of proteins known as collectins.
  15. 15. Surfactant Proteins A and SP-D potentially bind several receptors, including Toll receptors
  16. 16. INCREASED SUCTION FORCES ACROSS ALVEOLAR WALLSURFACTANT INACTIVATION HIGH PERMEABILITY EDEMADECREASEDSURFACTANTACTIVITYINCREASED SURFACE TENSION AT ALVEOLAR WALL
  17. 17. NosocomialPneumonia
  18. 18. Medicare and Insurance Guidelines
  19. 19. Nosocomial Pneumonia Head of Bed Up Suctioning Mouth and Subglotic Mouth Care Oral intubation and Special ET tubes Hand washing and gowns Low gastric volumes Humidification
  20. 20. Presence of atelectasis Leads to impairment of host defense  promotes nosocomial pneumonia
  21. 21. Nosocomial Pneumonia True Protection
  22. 22. Curr Opin Crit Care 10, 2004: 18-22
  23. 23. Surfactant Rplacement 1988
  24. 24. Therapy in Children
  25. 25. Early surfactant with brief ventilation Vs selective surfactant and MV for preterm with or at risk for RDS Is associated with -less need MV -lower incidence of BPD -fewer air leak syndromes
  26. 26. Which is better ? Natural or synthetic surfactant Both surfactants are effective in the treatment & prevention of RDS Early improvement with natural surfactant – i) Requirement for ventilator support ii) Fewer pneumothoraces iii) Fewer deaths Natural surfactants a desirable choice
  27. 27. Beractant Survanta Poractant a Curosurf Colfosceril palimitate Exosurf Neosurf Source Bovine lung Porcine lung Synth Bovine liquid Prophylaxis Yes Yes Yes Yes Treatment Yes Yes Yes Yes Initial dose 4 cc/kg 2.5 cc/kg 5cc/kg 5 cc/kg Vial size 4 / 8 ml 1.5 ml 5 ml 3 / 5 ml Storage 2-8 C 2-8 C 2-8 C -10C Max. doses 4 3 2 3 Getting ready Warm at room temp for 10 min Wait for 30 min Slowly warm to room temp
  28. 28. Implementation of surfactant treatment during CPAP (INSURE) Reduces the need for MV Decreased need for surfactant Relative risk for BPD of 0.51* (95% CI 0.26 to 0.99) An option to more effectively treat RDS, particularly in a care setting where transfer is necessary to provide MV
  29. 29. Adult Replacement
  30. 30. Permissive Atelectasis
  31. 31. Many Thanks

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