Management of persistent hypoxemic respiratory failure in the icu garpestad
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Management of persistent hypoxemic respiratory failure in the icu garpestad
- 1. Management of Persistent Hypoxemic Respiratory Failure in the ICU Erik Garpestad, M.D. Director, MICU Tufts Medical Center
- 14. Ware, L. B. et al. N Engl J Med 2000;342:1334-1349 Radiographic and Computed Tomographic (CT) Findings in the Acute, or Exudative, Phase (Panels A and C) and the Fibrosing-Alveolitis Phase (Panels B and D) of Acute Lung Injury and the Acute Respiratory Distress Syndrome
- 18. Barotrauma
- 19. Tobin, M. J. N Engl J Med 2001;344:1986-1996 Lung Injury Caused by Mechanical Ventilation in a 31-Year-Old Woman with the Acute Respiratory Distress Syndrome Due to Amniotic-Fluid Embolism
- 21. Tobin, M. J. N Engl J Med 2001;344:1986-1996 Respiratory Pressure-Volume Curve and the Effects of Traditional as Compared with Protective Ventilation in a 70-kg Patient with the Acute Respiratory Distress Syndrome
- 23. The Acute Respiratory Distress Syndrome Network, N Engl J Med 2000;342:1301-1308 Summary of Ventilator Procedures
- 24. The Acute Respiratory Distress Syndrome Network, N Engl J Med 2000;342:1301-1308 Main Outcome Variables
- 25. The Acute Respiratory Distress Syndrome Network, N Engl J Med 2000;342:1301-1308 Probability of Survival and of Being Discharged Home and Breathing without Assistance during the First 180 Days after Randomization in Patients with Acute Lung Injury and the Acute Respiratory Distress Syndrome
- 30. Pressure Volume Curve in ARDS LIP Volume Pressure UIP 1 2 3 1 2 3 1 2 3 1 2 3 Too much VT Too little PEEP
- 31. PEEP 5 PEEP 10 PEEP 15 PEEP 5 By keeping intrathoracic pressure positive throughout the respiratory cycle atelectatic lung can be re-expanded or recruited. Shunt decreases and PaO2 increases. PaO2 = 60 PaO2 = 100 PaO2 = 220
- 33. Amato M et al. N Engl J Med 1998;338:347-354 Actuarial 28-Day Survival among 53 Patients with the Acute Respiratory Distress Syndrome Assigned to Protective or Conventional Mechanical Ventilation
- 35. The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. N Engl J Med 2004;351:327-336 Summary of Ventilator Procedures in the Lower- and Higher-PEEP Groups
- 36. The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. N Engl J Med 2004;351:327-336 Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP
- 37. The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network. N Engl J Med 2004;351:327-336 Main Outcome Variables
- 40. Borges J et al. N Engl J Med 2006;355:319-322 Computed Tomographic Images Obtained at the End-Expiratory Pause in a Patient with Pneumocystosis and the Acute Respiratory Distress Syndrome
- 41. Gattinoni L et al. N Engl J Med 2006;354:1775-1786 Enrollment and Study Protocol
- 42. Gattinoni L et al. N Engl J Med 2006;354:1775-1786 Frequency Distribution of Patients According to the Percentage of Potentially Recruitable Lung (Panel A) and CT Images at Airway Pressures of 5 and 45 cm of Water from Patients with a Lower Percentage of Potentially Recruitable Lung (Panel B) and Those with a Higher Percentage of Potentially Recruitable Lung (Panel C)
- 49. Supine Prone Dependent Atelectasis
- 51. The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. N Engl J Med 2006;354:2213-2224 Kaplan-Meier Estimates of the Probability of Survival and of Survival without the Need for Assisted Ventilation during the First 60 Days after Randomization
- 52. The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network. N Engl J Med 2006;354:2564-2575 Probability of Survival to Hospital Discharge and of Breathing without Assistance during the First 60 Days after Randomization
- 69. High Frequency Ventilation Modes From UptoDate, Ostenholzer and Hyzy
- 71. Increased Mean Pressures = Improved oxygenation From Mehta et al Critical Care 2001
- 73. Gas Transport in HFOV From UptoDate, Ostenholzer and Hyzy
- 82. Preventing Derecruitment after Proning Demory et al Crit Care Med 2007
Editor's Notes
- Figure 1. Radiographic and Computed Tomographic (CT) Findings in the Acute, or Exudative, Phase (Panels A and C) and the Fibrosing-Alveolitis Phase (Panels B and D) of Acute Lung Injury and the Acute Respiratory Distress Syndrome. Panel A shows an anteroposterior chest radiograph from a 42-year-old man with the acute respiratory distress syndrome associated with gram-negative sepsis who was receiving mechanical ventilation. The pulmonary-artery wedge pressure, measured with a pulmonary-artery catheter, was 4 mm Hg. There are diffuse bilateral alveolar opacities consistent with the presence of pulmonary edema. Panel B shows an anteroposterior chest radiograph from a 60-year-old man with acute lung injury and the acute respiratory distress syndrome who had been receiving mechanical ventilation for seven days. Reticular opacities are present throughout both lung fields, a finding suggestive of the development of fibrosing alveolitis. Panel C shows a CT scan of the chest obtained during the acute phase. The bilateral alveolar opacities are denser in the dependent, posterior lung zones, with sparing of the anterior lung fields. The arrows indicate thickened interlobular septa, consistent with the presence of pulmonary edema. The bilateral pleural effusions are a common finding.1415 Panel D shows a CT scan of the chest obtained during the fibrosing-alveolitis phase. There are reticular opacities and diffuse ground-glass opacities throughout both lung fields, and a large bulla is present in the left anterior hemithorax. Panels C and D are reprinted from Goodman16 with the permission of the publisher.
- Figure 2. Lung Injury Caused by Mechanical Ventilation in a 31-Year-Old Woman with the Acute Respiratory Distress Syndrome Due to Amniotic-Fluid Embolism. The patient had undergone mechanical ventilation for eight weeks with tidal volumes of 12 to 15 ml per kilogram of body weight, peak airway pressures of 50 to 70 cm of water, positive end-expiratory pressures of 10 to 15 cm of water, and a fractional inspired oxygen concentration of 0.80 to 1.00 in order to achieve a partial pressure of carbon dioxide that was less than 50 mm Hg and a partial pressure of oxygen that was 80 mm Hg or higher. Computed tomography (CT) performed two days before the patient died revealed a paramediastinal pneumatocele in the right lung (Panel A, arrowheads) and numerous intraparenchymal pseudocysts in the left lung (Panel B, black arrow, open circle, and asterisk). At autopsy, both lungs were removed and fixed by intrabronchial infusion of formalin, alcohol, and polyethylene glycol at an insufflation pressure of 30 cm of water. Panel C shows the paramediastinal pneumatocele in the right lung (arrowheads); the horizontal broken line is the level of the CT section. Panel D shows a 1-cm-thick section of the left lung, corresponding to the CT section. Small pseudocysts are present (arrow), and two large pseudocysts (asterisk and open circle) have compressed and partially destroyed the parenchyma. The development of these lesions in a patient without a history of chronic lung disease indicates the harm that may result with the use of high tidal volumes and airway pressures. The photographs were kindly provided by Dr. Jean-Jacques Rouby, Hopital de la Pitie-Salpetriere, Paris.
- Figure 3. Respiratory Pressure-Volume Curve and the Effects of Traditional as Compared with Protective Ventilation in a 70-kg Patient with the Acute Respiratory Distress Syndrome. The lower and upper inflection points of the inspiratory pressure-volume curve (center panel) are at 14 and 26 cm of water, respectively. With conventional ventilation at a tidal volume of 12 ml per kilogram of body weight and zero end-expiratory pressure (left-hand panel), alveoli collapse at the end of expiration. The generation of shear forces during the subsequent mechanical inflation may tear the alveolar lining, and attaining an end-inspiratory volume higher than the upper inflection point causes alveolar overdistention. With protective ventilation at a tidal volume of 6 ml per kilogram (right-hand panel), the end-inspiratory volume remains below the upper inflection point; the addition of positive end-expiratory pressure at 2 cm of water above the lower inflection point may prevent alveolar collapse at the end of expiration and provide protection against the development of shear forces during mechanical inflation.
- Table 1. Summary of Ventilator Procedures.
- Table 4. Main Outcome Variables.
- Figure 1. Probability of Survival and of Being Discharged Home and Breathing without Assistance during the First 180 Days after Randomization in Patients with Acute Lung Injury and the Acute Respiratory Distress Syndrome. The status at 180 days or at the end of the study was known for all but nine patients. Data on these 9 patients and on 22 additional patients who were hospitalized at the time of the fourth interim analysis were censored.
- Figure 1. Actuarial 28-Day Survival among 53 Patients with the Acute Respiratory Distress Syndrome Assigned to Protective or Conventional Mechanical Ventilation. The data are based on an intention-to-treat analysis. The P value indicates the effect of ventilatory treatment as estimated by the Cox regression model, with the risk of death associated with the adjusted base-line score on APACHE II included as a covariate.
- Table 1. Summary of Ventilator Procedures in the Lower- and Higher-PEEP Groups.
- Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.
- Table 4. Main Outcome Variables.
- Figure 1. Computed Tomographic Images Obtained at the End-Expiratory Pause in a Patient with Pneumocystosis and the Acute Respiratory Distress Syndrome. The images were obtained under different ventilatory conditions: a positive end-expiratory pressure (PEEP) of 5 cm of water and a plateau pressure of 20 cm of water (Panel A), a PEEP of 17 cm of water and a plateau pressure of 40 cm of water (Panel B, similar to the strategy used by Gattinoni et al.), a PEEP of 25 cm of water and a plateau pressure of 40 cm of water (Panel C), and a PEEP of 25 cm of water and a plateau pressure of 60 cm of water (Panel D). The corresponding potential for recruitment (relative to the conditions in Panel A) was 35 percent for the conditions in Panel B, 67 percent for the conditions in Panel C, and 87 percent for the conditions in Panel D. At the same plateau pressures (Panels B and C), the application of a higher PEEP (25 cm of water in Panel C) improved the efficacy of the maneuver. A further increase in inspiratory plateau pressure (Panel D) revealed the full potential for recruitment.
- Figure 1. Enrollment and Study Protocol. In the study group, a recruitment maneuver was performed immediately before application of each PEEP level. In the comparison groups, patients with bilateral pneumonia were excluded from the analysis to limit the possible confounding factors caused by the partial overlapping between patients with less severe acute lung injury or ARDS and patients with bilateral pneumonia (see the Supplementary Appendix for further details). Therefore, only patients with unilateral pneumonia, who by definition did not meet the inclusion criteria for acute lung injury or ARDS, were included. The group with a lower percentage of potentially recruitable lung includes patients with potentially recruitable lung values at or below the overall median of 9 percent, and the group with a higher percentage of potentially recruitable lung includes patients with values above the median.
- Figure 2. Frequency Distribution of Patients According to the Percentage of Potentially Recruitable Lung (Panel A) and CT Images at Airway Pressures of 5 and 45 cm of Water from Patients with a Lower Percentage of Potentially Recruitable Lung (Panel B) and Those with a Higher Percentage of Potentially Recruitable Lung (Panel C). Panel A shows the frequency distribution of the 68 patients in the overall study group according to the percentage of potentially recruitable lung, expressed as the percentage of total lung weight. Acute lung injury without ARDS was defined by a PaO2:FIO2 of less than 300 but not less than 200, and ARDS was defined by a PaO2:FIO2 of less than 200. The percentage of potentially recruitable lung was defined as the proportion of lung tissue in which aeration is restored at airway pressures between 5 and 45 cm of water. Panel B shows representative CT slices of the lung obtained 2 cm above the diaphragm dome at airway pressures of 5 cm of water (left) and 45 cm of water (right) from a patient with a lower percentage of potentially recruitable lung (at or below the median value of 9 percent of total lung weight). Lung injury developed in the patient after an episode of severe acute pancreatitis (PaO2:FIO2, 296 at an airway pressure of 5 cm of water; PaCO2, 34 mm Hg; and respiratory-system compliance, 44 ml per centimeter of water). The percentage of potentially recruitable lung was 4 percent, and the proportion of consolidated lung tissue was 33 percent of the total lung weight. Panel C shows representative CT slices of the lung obtained 2 cm above the diaphragm dome at airway pressures of 5 cm of water (left) and 45 cm of water (right) from a patient in the group with a higher percentage of potentially recruitable lung. Lung injury developed in the patient after an episode of severe pneumonia (PaO2:FIO2, 106 at a PEEP of 5 cm of water; PaCO2,58 mm Hg; and respiratory-system compliance, 25 ml per cm of water). The percentage of potentially recruitable lung was 37 percent, and the proportion of consolidated lung tissue was 27 percent of the total lung weight.
- Figure 2. Kaplan-Meier Estimates of the Probability of Survival and of Survival without the Need for Assisted Ventilation during the First 60 Days after Randomization.
- Figure 3. Probability of Survival to Hospital Discharge and of Breathing without Assistance during the First 60 Days after Randomization.