!"#$% '%()*+,$-+.

/*($+%((
0.12+-3% 4!'/05
6%((% 7,88 9/
:+-;%((-+ -; 9%2*"*1%< !1%($=%(*, > ?+*@",8 ?,+%
0%"@-1 ?=*%;< :#83-1,+. ,12 ?+*@",8 ?,+% 9%2*"*1%
A1*B%+(*$. -; ?=*",C-
D,"#8$. /*("8-(#+%(
ur. Pall
recelves honorarla from Lhe ACC for Lhls course and
SLLk
recelves honorarla from Lhe A1S for SC1A
recelves honorarla from McCraw-Plll and 1aylor-
lrancls publlshlng
has no relauonshlp Lo lndusLry
E%,+1*1C FGH%"@B%(
!I%+ $=*( (%((*-1< .-# (=-#82 G% ,G8% $-J
KL)8,*1 :,$=-)=.(*-8-C. -; !'/0
!))8. 8-M @2,8 B-8#3% B%1@8,@-1 ,( , 8#1C
)+-$%"@B% ($+,$%C.
/*("#(( $=% "-1$+-B%+(. "-1"%+1*1C 2%$%+3*1,@-1
-; *2%,8 :KK:
!))8. N12*1C( ;-+ +%"%1$ $+*,8( ;-+ 3-+% (%B%+%
!'/0
A@8*O% (,8B,C% $=%+,)*%(
/%("+*G% 3,1,C%3%1$ -; $=% "*+"#8,@-1 *1 !'/0
KL)8,*1 8-1C$%+3 -#$"-3%(
Cuesuon 1: A 43 y/o morbldly obese woman wlLh dlabeLes ls
admlued Lo Lhe hosplLal wlLh P1n1 pneumonla, she
deLerloraLes on Lhe oor and ls admlued Lo Lhe lCu and
lnLubaLed and you are presenL Lo sLablllze her on Lhe
venulaLor. She ls 3'3" Lall and welghs 123 kg.
1he lnlual LargeL 1v for LvS should be:
A) 730 cc
8) 290 cc
C) 430 cc
u) 300 cc
L) 330 cc

5
6

0
20
40
60
80
100
AudlL
4
lnLervlew 92
18 16 14 12 10 8 7 6 3 4 3 2 1 0
40
30
20
10
0
n
v1 (ml/kg 8W)
Lvldence
Adhere Lo 8esL racuce?
8runkhorsL l, Lngel C, 8agaller M, WelLe 1, 8ossalnL 8, Cerlach P,
eL al. racuce and percepuon-A nauonwlde survey of Lherapy
hablLs ln sepsls. CrlL Care Med. 2008,36(10):1-6
!EPQ!'/0R!K?? /%N1*@-1(
Timing Gas
Exchange
CXR Ppw
ALI
Acute
Onset
P/F <
300
Bilateral
infiltrates
Ppw < 18
Or no
clinical
ARDS Acute
Onset
P/F <
200
Bilateral
infiltrates
Ppw < 18
Or no
clinical
Cuesuon 2: WhaL ls Lrue of Lhe new proposed
'8erlln' denluon of A8uS?
A) Lung compllance on Lhe venulaLor ls used Lo
deLermlne severlLy
8) cwp musL be measured Lo exclude CPl
C) ALl ls subdlvlded lnLo Lhree levels of severlLy
u) A level of LL ls specled for lnLerpreung /l
L) ChesL radlograph crlLerla ellmlnaLed

!AMA 2012 307:2326
ALl/A8uS
!EPQ!'/0SSP1"*2%1"%
8ubenfeld eL al, nL!M 2003 (daLa from Aprll-!une 2000)
!EPQ!'/0SSP1"*2%1"%
8ubenfeld eL al, nL!M 2003 (daLa from Aprll-!une 2000)
!"#$% 7.)-L%3*" '%()*+,$-+. D,*8#+%
4!7'D5
KT%"$ -; :KK:
Malo and Wood, !A 1984
PIP/PEEP 15/0 45/0 45/10
Webb HH, Tierney DF: ARRD 1974; 110: 556
Lx vlvo lungs really deaLe
1ldal volume lLself recrulLs
8uL LranslenLly wlLh ZLL
LL recrulLs buL reglonal
Collapse may conunue Lo
8e presenL
AL a sumclenLly hlgh LL recrulLmenL occurs ln Lhls model
Aer a recrulLmenL a less LL malnLalns recrulLmenL
Loss of all LL rapldly resulLs ln derecrulLmenL
!"#$%&'%( *+,-.% /,-"0
'1$%1#23
4 C+-(( G,+-$+,#3,
S 2*T#(% ,8B%-8,+ 2,3,C%
D,"$-+( !CC+,B,@1C E#1C P1H#+.
5%#$%&'%( 6-"0
*+,-.%'
4 %T%"$( -1
(#+;,"$,1$
S +%"+#*$3%1$Q
2%S+%"+#*$3%1$
U V WU WV XU
78+1$&-.&
!'/0S E#1C )+-$%"@B% B%1@8,@-1
!3,$- %$ ,8
!6'??9
WYYV
AmaLo eL al
nL!M 1998
!'/0S E#1C )+-$%"@B% B%1@8,@-1
!3,$- %$ ,8
ZK69
WYY[

!"#$%&'%( *+,-.% /,-"0
'1$%1#23
4 C+-(( G,+-$+,#3,
S 2*T#(% ,8B%-8,+ 2,3,C%
D,"$-+( !CC+,B,@1C E#1C P1H#+.
!'/01%$ \+*,8 4ZK69 XUUU5
ZK69 ]^XJW]UW< XUUU
0
5
10
15
20
25
30
35
40
Low TV High TV
28 day mortality
!'/0Z%$J _
\
,12 9-+$,8*$.
ARDSNetwork. NEJM 342:1301, 2000
`,H*" %$ ,8a ??9 XUU^
`,H*" %$ ,8a ??9 XUU^
!AMA 2010
Cuesuon 3: lf an A8uS pauenL placed on 6 ml/kg l8W
1v ls conunuously 'doublesLacklng' Lhey are llkely
recelvlng
A. SlgnlcanLly more Lhan Lhe seL udal volume
8. Any volume up Lo Lhe seL udal volume
C. SlgnlcanLly less Lhan Lhe seL udal volume
u. no udal volume aL all
L. 1ldal volume only durlng Lhe non-sLacked
breaLhs
No Effort
Some Effort Present
Harmful Effort?
Imminent Danger?
b,B%;-+3(
Asynchrony
Inactivity
Increasing levels of effort
Stacked Breath
Stacked Breath
ohlman eL al
CCM 2009
:,),O*,1 %$ ,8a ZK69 0%)$ XUWU
8C1, pLs wlLhln 48 h of dx severe A8uS (/l < 130
on > 3 LL)
178 pLs recelved cls, 162 placebo for 48 h
no 1Cl
Muscle sLrengLh assessed by M8C score
:,),O*,1 %$ ,8a ZK69 0%)$ XUWU
Crude 90-d morLallLy
dl p=.08 buL slgnlcanL
ad[ for /l-SAS-pplaL
no dl ln M8C scores
More vlu ln cls grp
8y posL hoc analysls
survlval beneL ln Lhose
wlLh /l < 120
:,),O*,1 %$ ,8a 9%"=,1*(3c
08#$(d.a ZK69
May 20, 2013
:'?\ *1 Xe P?A( *1 D+,1"% ,12 0),*1
^ff ),@%1$( +,12-3*O%2
K1+-88%2 M*$=*1 ]f = -; *1*@,@1C 9_
:QD g WVU M*$= ,$ 8%,($ V "3 7XF :KK:
:+-1%2 ),@%1$( +%"%*B% ,$ 8%,($ Wf = -;
)+-1*1C 2,*8.
D,"$-+( !CC+,B,@1C E#1C P1H#+.
5%#$%&'%( 6-"0
*+,-.%'
4 %T%"$( -1
(#+;,"$,1$
S +%"+#*$3%1$Q
2%S+%"+#*$3%1$
!E_KFEP 4ZK69 XUU^5SSD
P
F
X
S:KK: 0$%)
?-3),+*(-1
0
4
8
12
16
20
24
PEEP
0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0
FIO2
Arterial Oxygenation: SpO
2
= 88 - 95% or
PaO
2
= 55 - 80 mm Hg
nL!M 2004
hoenlx eL al, AnesLheslology, 2009
8rlel eL al
!AMA 2010
!1 *1$%+)+%$,@-1 -; 1%C,@B% h=*C=i :KK:
$+*,8(
30 cm
\%++,C1* %$ ,8a !6'??9 XUUe
]U ),@%1$( M*$= !'/0 -1 !'/01%$ )+-$-"-8
WUQ]U G. ?\ (",1 8#1C 2%1(*$. ,))%,+%2 $- =,B%
=.)%+*1j,@-1 2#+*1C \_ %L"#+(*-1
\=%(% )$( =,2 =*C=%+ k!E ".$-d*1%(< 8%(( B%1$ ;+%%
2,.(
:)8,$ XVSXf *1 h3-+% )+-$%"$%2i )$(< X[S]U *1 h8%((
)+-$%"$%2i
'%"+#*$,G*8*$.
Camnonl L, eL.al: n Lngl ! Med 2006, 334:1773
EFb
7P`7
E#1C( ,12 :,@%1$( /*T%+
Lung may noL be LL-recrulLable
ulmonary v exLrapulmonary A8uS
ALl v A8uS
leural pressure may be qulLe posluve
CbeslLy, asclLes, abdomlnal pressure
LxplraLory muscle eorL aL end-explrauon
!Z\PS:KK:
1almor eL al, nL!M 2008
1almor eL al, nL!M 2008
?ou spend qulLe some ume wlLh venulaLor
ad[usung and sedaung. LvenLually Lhe pauenL ls
sedaLed, paralyzed and proned. WlLh Lhese
lnLervenuons you have 1v = 3 ml/kg 8W, 88 =
30, llC2 = 1.0 ln AC mode wlLh LL = 18. plaL ls
38 cm P2C wlLh SaC2 = .87.
59
0,8B,C% \=%+,)*%(
*ZF P3)+-B%( FL.C%1,@-1
CrlmLhs M!u, eL al. n Lngl ! Med 2003, 333:2683
*ZF P3)+-B%( FL.C%1,@-1
Mlchael !8, eL al. Am ! 8esplr CrlL Care Med. 1998, 137:1372
8C1 A8uS - n=40
*ZF ,12 !'/0 F#$"-3%(
Sokol J, et al. Anesth Analg 2003; 97:989
Mortality
LOS
7DF_ l 0%1(-+3%2*"( ]WUUG
1rlal sLopped aer enrollmenL of 348 of planned 1200 pauenLs
793 pauenLs randomlzed Lo elLher PlCv or convenuonal Mv
F0?PEE!\K F0?!'
C
2
CC
2
K?9F
__ K?9F l /#,8 E#3%1
uual lumen Avalon"
Cannulae avallable
useful - slngle slLe
cannulauon
27 & 31 lr
Cuesuon 4: 1he recenL 8C1 'CLSA8' evaluaung Lhe
use of LCMC for A8uS reporLed LCMC was
assoclaLed wlLh
A. lncreased morLallLy
8. Worse neurologlc ouLcome
C. lmproved ouLcome when provlded aL a speclallzed
cenLer
u. lmproved survlval buL worse neurologlc ouLcome
L. lmproved neurologlc ouLcome buL worse survlval
9-2%+1 K?9F \+*,8J ?%(,+ \+*,8
8andomlzed, prospecuve Lrlal: LCMC vs usual"
venulaLory supporL
lncluslon
usual care provlded ln 104 crlucal care cenLers across uk
All LCMC was v-v, done ln Cleneld, LelcesLer
8andomlzauon sLraued by age, hours on hlgh-level
venL supporL, SClA, dlagnosuc group (Lrauma, C8,
pneumonla)
eek C!, eL al. LanceL 2009, 374:1331-1363
?%(,+ \+*,8 '%(#8$(
LCMC (90) usual Care (90)
ueaLh or
Severe ulsablllLy (unable Lo wash or dress alone)
?es (bad) 33 46
no (good) 37 41 p=0.03

73 of LCMC pLs (68/90) recelved LCMC
16 of 90 'LCMC' pLs lmproved wlLhouL LCMC (presume ln good
ouLcome group???), 3 dled before recelvlng LCMC
3 usual Care pLs wlLhdrew from sLudy before follow-up
*2 pLs dled durlng LransporL Lo LCMC cenLer*
?%(,+ \+*,8
8ecelvlng Crlucal Care servlces aL cenLral referral
cenLer (wlLh hlgher adherence Lo guldellne-based
Lherapy?) lmproves ouLcomes from severe
resplraLory fallure
Pow much aurlbuLable Lo LCMC

eek C!, eL al. LanceL 2009, 374:1331-1363
K?9F A(% l P1j#%1O, XUUYJ
7*C=8. _,+*,G8%
Canada
Aprll - !uly 2009: 213 pLs admlued Lo 38 lCus
81 mechanlcally venulaLed - 167 wlLh conrmed or probable P1n1
lnC: 13.7, PlC: 11.9, LCMC: 4.2
MorLallLy 17.3
AusLralla and new Zealand
!une - AugusL 2009: 232 pLs admlued Lo 13 lCus
80 mechanlcally venulaLed - 194 wlLh conrmed or probable P1n1
lnC (or l prosLacyclln): 32, PlC: 3 of LCMC pLs, LCMC: 31
MorLallLy: 16 (of Lhose mechanlcally venulaLed)
Kumar A, et al. JAMA 2009; 302: 1872
ANZ ECMO Influenza Investigators. JAMA 2009; 302:1888
!AMA 2011
FACTT trial objectives
To compare:

! PAC versus CVC management

AND
! Fluid conservative vs. fluid liberal
! management
! in ALI/ARDS to evaluate effects on mortality and
morbidity
nL!M 2003
D!?\\J D,"$-+*,8 $+*,8 2%(*C1
Fluid Management
C
A
T
H
E
T
E
R
Conservative
(n = 500)
Liberal
(n = 500)
PAC
(n = 500)
CVC
(n = 500)

250 patients 250 patients

250 patients 250 patients

?#3#8,@B% j#*2 G,8,1"%
-2000
0
2000
4000
6000
8000
0 1 2 3 4 5 6 7
Study Day
m
l

o
f

f
l
u
i
d
Liberal
Conservative
:!? B( ?_?< ZK69 9,. XUUV
Cuesuon 3: AL 3 Lo 3 years aer recovery from A8uS,
whlch of Lhe followlng sequelae are mosL llkely Lo
lmpalr funcuonal sLaLus?
A. 8enal fallure
8. erslsung malnuLrluon
C. neuromuscular and cognluve dysfuncuon
u. ulmonary brosls
L. upper alrway obsLrucuon
?-3)8*",@-1( -; ?+*@",8 P881%((
8esplraLory Sequelae
A8uS
Asplrauon
vA
vlLl/ 8aroLrauma
neuromuscular Sequelae
CaLabollsm
MalnuLrluon
Muscle Wasung/ALrophy
neuropaLhles
MyopaLhles
neuropsychlaLrlc Sequelae
sychologlcal malad[usLmenL
1Su
AnxleLy
uepresslon
uellrlum
Chronic Pulmonary
Dysfunction
Chronlc neuromuscular
uysfuncuon
Chronlc neuropsychlaLrlc
roblems
Perrldge eL al, nL!M 2003
-18
-16
-14
-12
-10
-8
-6
-4
-2
0
Discharge 3 mos 6 mos 12 mos
b%*C=$ C,*1 )-($S!'/0
:=.(*",8 ;#1"@-1*1C )-($ !'/0
Perrldge eL al, nL!M Aprll 2011
E-1CS\%+3 F#$"-3%(
neuromuscular dysfuncuon (weakness, Cl,
myopaLhy) ls common
Cne-Lhlrd Lo one-half of survlvors experlence
long-Lerm cognluve declLs (dellrlum, hypoxla
predlcL)
ulmonary dysfuncuon ls less llmlung Lhan
neuromuscular and cognluve lmpalrmenLs
Lxerclse capaclLy and cognluve funcuon plaLeau
aL one year posL-lllness
!"##$%&" ()* !+,-$./ 01* $. 2#$.3$,4"/ +5 6#$7384 68#" 9
#%

:%* !844* )3;<$%=* 8.% >++%* ?@@A