9/5/2018. Conflicts of Interests. Pediatric Acute Respiratory Distress Syndrome. Objectives ARDS ARDS. Definitions. None

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1 Pediatric Acute Respiratory Distress Syndrome Conflicts of Interests Diane C Lipscomb, MD Director Inpatient Pediatric Medical Director Mercy Springfield Associate Clerkship Clinical Director University of Missouri - Columbia None Objectives ARDS Define ARDS Peds Specific Causes of ARDS The pathophysiology of ARDS Management of ARDS Outcomes of ARDS First described in 1967 Dr. Asbaugh and colleagues reviewed 11 adult and 1 pediatric patients Acute onset of tachypnea and hypoxia refractory to oxygen Loss of lung compliance Autopsy Pulmonary inflammation Edema Hyaline membrane formation ARDS Definitions Adults /100,000 person-years Pediatrics / 100,000 person years Accounts for % of PICU admissions Mortality rates % US higher incidence but lower mortality Oxygenation Index (OI) (FiO2 x mean airway pressure x 100/PaO2) Oxygenation Saturation Index (OSI) (FiO2 x mean airway pressure x 100/ SpO2) PaO2/FiO2 PaO2 mm Hg/FiO2 (decimal) 1

2 Pediatric Acute Lung Injury Consensus Conference (PALICC) Lung compliance Dead Space SIF FRC Taxonomy of ALI Panel of 27 Pediatric experts Reviewed all available literature Recommendations made for modalities to manage and treat ARDS ARDS Berlin Definition ARDS Berlin Definition Onset < 1 week from insult with new or worsening respiratory symptome Chest imaging Bilateral opacities c/w pulmonary edema Rull out effusion, collapse, nodules Origin of edema No cardiac failure No fluid overfload Oxygenation impairment Stratification ARDS depending on degree of hypoxemia ARDS Berlin Definition ARDS - Causes Mild PaO2/FiO2 >200 to <300 mm Hg Peep >5 cm H20 Moderate PaO2/FiO2 >100 < 200 mm Hg PEEP > 5 cm H20 Severe PaO2/FiO2 < 100 mm Hg PEEP > 5 cm H20 If altitude > 1000 m or 3280 feet correct for barometric pressure Nature of stimulus Trauma? Infection? Host response to stimulus Genetics Concurrent medical condition Iatrogenic factors Vent management Supportive care 2

3 ARDS - Pathophysiology ARDS - pathophysiology Type I alveolar cells 90% of alveolar surface Participate in gas exchange exposed to oxygen At risk for oxidative stress The end cell Type II alveolar cells 10% of cells Resistant to oxidative stress Pulmonary defense make surfactant, ion transport Exudative Disruption of alveolar -capillary barrier More permeable, influx of edema fluid Surfactant dysfunction, ion transport abnormal Proliferative Thrombosis,occlusion Fibrotic Clinical Progression of ARDS Impairment of oxygenation Decreased oxygen-diffusing capacity Low ventilation-perfusion (V/Q) or right to left shunt Venous passes through lungs and does not get oxygenated 3

4 ARDS - Management ARDS Noninvasive Ventilation Noninvasive Invasive Outcomes CPAP BiPAP HFNC ARDS Noninvasive Ventilation ARDS Noninvasive Ventilation Advantages Less invasive Infection Less sedation more comfortable Disadvantage Studies are mixed Some association with greater mortality if on noninvasive PaO2/FiO2 <150 (R1) Weak agreement Noninvasive Ventilation for early ARDS Weak agreement for use in immunocompromised patients Future definition of Oxygen/saturation and FiO2 ratios for direction of respiratory support Future research needs for HFNC ARDS Invasive Mechanical Ventilation Types Pressure versus volume Airway Pressure release Oscillation VDR Other? Mean Airway Pressure 4

5 Resistance Compliance Static Compliance Tidal Volume/Plateau P PEEP Measured when no gas flow Dynamic Compliance Tidal Volume/ PIP PEEP Measured during active gas flow Conventional Mechanical Ventilation ETT Cuffed - YES PEEP Inspiratory Pressures/Plateau Pressures Volumes Permissive Hypercabia Permissive Hypoxia Functional Residual Capacity Want More PEEP to mmhg may be needed Monitor cardiac compliance PEEP 5

6 Inspiratory Pressures/Plateau Pressures CO2 and O2? Peak Insp Pressure (PIP) Increase Resistance may Increase the PIP Plateau Pressure Resistance overcome < 32 Mean Airway Pressure Volumes 4-6 ml/kg (ideal body weight) Permissive Hypercarbia ph Monitor end organs Caution with CNS, CV dysfunction and Pulm HTN Permissive Hypoxia 88-92% SpO2 Monitor end organs Twin goals Permissive hypercarbia Open lung maintenance Optimize PEEP and minimize Tidal volumes PEEP maintain between upper and lower infection points to avoid overdistension Airway Pressure Release Ventilation APRV versus conventional Oscillation Less vent days in ARDS? Increased mortality in kids in ARDS? Insufficient data at this time Need larger RCT Careful patient selection 6

7 Oxygenation - Settings MAP Alveolar recruitment FRC Volume induced lung injury Studies mixes Oxygenation MAP FiO2 Ventilation Delta P Insp Time Hz Cuff leak Consider in mod-severe ARDS if Plateau Pressure > 28 (weak) Oscillation Outcomes Percussionaire Ventilators Neonatal / pediatric versus adult Changes in mortality Requirements for sedation and/or paralytic Effects upon cardiovascular status Decreased lung injury Recs consider for moderate to severe ARDS with plateau pressure > 28 (weak agreement) VDR Settings I time 2 secs E time 2 secs I:E 1:1 Pulse frequency Oscillatory CPAP/PEEP Demand CPAP/PEEP Convective Pressure Rise 7

8 VDR Outcomes So what do you do? Thermal injuries ARDS Refractory ARDS Summation of Ventilation Strageies Assess PAF ratios Decide invasive vs noninvasive Initiate lung protective strategies Reassess PAF ratios Decide APRV, Oscillate, VDR Reassess PAF ratios Consider ECMO ARDS what else can be done? Steroids Pulmonary Toilet Role of inflammation Early Late Increased ventilator days Increased mortality Risk of neuromuscular weakness Low dose?? Recommendation Steroids NOT recommended for pediatric ARDS Chest Vest Useful for airway clearance in patient with special needs Intermittent positive pressure ventilation Mobilizes secretions through a sequential pressure pattern Mini version of VDR VAP Oral care, bed positioning Prone Position Optimizing V/Q mismatch by reducing atelectasis in dependent portions of lungs Studies no clinical difference Associated with risk in critically larger patients Needs further studies Weak agreement reserved for most severely hypoxemic patients as rescue 8

9 Surfactant Therapy Nitric Oxide Replaces endogenous surfactant Prevent alveolar collapse, maintain pulmonary compliance, improve oxygen Infant versus adults versus pediatrics Need for more studies NOT recommended for PARDS Potent selective pulmonary vasodilator cgmp pathway Reduces Hypoxic pulmonary vasoconstriction Improves aeration to VP mismatch May improve right sided pressures Peds ARDS Initial improvements in oxygen No change at 72 hours or mortality Recommendations refractory pulmonary hypertension or RV dysfunction Bridge to ECMO Liquid Ventilation Sedation Perfluorocarbons Partial versus full Increased adversity Not Recommended Avoid patient ventilator dyssynchrony Risk of worsening barotrauma Sedation Anxiolytic, narcotics Others vacations Paralysis Use in severe cases if sedation inadequate ARDS - ECMO Nutrition Inclusion criteria A-a gradient greater than 450 mm HG peak pressures > 40 cm H20 Exclusion criteria Chronic lung disease Immunodeficiencies Syndromes associated with poor outcomes Types AV - ECMO VV - ECMO Outcomes 50% Recommendations Severe refractory cases of ARDS When start? How to feed? Type of nutrition? Attention to bowel movements 9

10 Extubation Readiness Complications Sedation vacations Pulmonary Exercises Why intubated? Leak, NIF, spont volumes VAP Pneumothorax Fluid Overload Multisystem organ failure ARDS The End?? Positioning Extubation readiness VAP Transfuse An ounce of action is worth a tone of theory Friedrich Engels, 19 th Century German Philosopher 10

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