ALI/ARDS Update

in Mechanical Ventilation

Bambang Wahjuprajitno
Dept. of Anesthesiology & Reanimation
Medical Faculty - Univ. of Airlangga
Dept. of Intensive Care & Reanimation
Dr.soetomo General Hospital
Surabaya

The Normal Alveolus Injured Alveolus in the Acute

Phase of ALI
Ware LB, Matthay MA. N Engl J Med 2000;342:1334-1349

Three compartments of ARDS lung

Aerated normal lung susceptible to

barotrauma

Air spaces filled with exudate not

recruitable

Areas that are collapsed due to infiltration

potentially recruitable
1

3
 ARDS
Aerated normal lung
(potentially over-expanded on
mechanical ventilation)

Not recruitable
Potentially recruitable

4 Gattinoni et al.AJRCCM 1995;151:1807-1815

Consequences of alveolar collapse

Physiologic: shunt
Pathologic:
Persistent collapse (prolonged contact of
epithelial surfaces)
Inflammation, ingrowth of granulation tissue,
neovascular cross-bridge
Phasic collapse (expiratory closure & inspiratory
re-opening)
Damage to structural elements of alveolo-
bronchiolar unit, capillary stress fracture,
mechanical signal for inflammation
Tidal shearing: 20/min x 60 min x 24 h/d =
28,800/day
5

High lung permeability

volume
surfactant
inactivation
VILI:
macro-
atelectasis micro-
biologic-

Low lung tidal open/

volume collapse

6
 How does excessive mechanical
stress inflame the lung?

Airway Trauma

Stretch

Shear

Effect of Tidal Volume, PEEP and RM on Local

Cytokine Production in Rat
Mean absolut quantity of cytokine (lung fluid aspirate)

HVZP
HVZP
LVPR

LVP

LVP HVP
HVP

LVPR

High Volume, Zero PEEP (HVZP)

High Volume, PEEP (HVP)
Low Volume, Zero PEEP (LVZP) Low Volume, PEEP (LVP)
Low Volume, PEEP + Recruitment (LVPR) MIP: Macrophage Inflamm. Protein

Chiumello D, Pristine G, Slutsky AS. AJRCCM 1999;160:109-116

 Effect of Tidal Volume, PEEP and RM on
Systemic Cytokine Production in Rat
Mean serum cytokine level

HVZP HVZP

HVP
HVP
LVP LVP
LVPR
LVPR

High Volume, Zero PEEP (HVZP)

High Volume, PEEP (HVP)
Low Volume, Zero PEEP (LVZP) Low Volume, PEEP (LVP)
Low Volume, PEEP + Recruitment (LVPR) MIP: Macrophage Inflamm. Protein

Chiumello D, Pristine G, Slutsky AS. AJRCCM 1999;160:109-116

Biotrauma postulated mechanisms

Slutsky AS, Tremblay LN. Am J Respir Crit Care Med 1998;157:1721-1725

How to avoid VILI?

Recruitment of collapsed alveoli
A sustained increase in airway pressure with the
goal to open collapsed lung tissue, after which
sufficient PEEP is applied to maintain the lung
open
Hess, Bigatello, Resp Care 2002; 47: 308-318

Converting collapsed alveoli into open alveoli

Lachmann, Marini

Protective ventilation strategy

Recruitment maneuvre
12
 Low vs Traditional Vt in ARDS
The ARDS Network. N Engl J Med 2000;342:1301-1308
6 ml/kg (n=432) 12 ml/kg (n=429)

80

60

40

20

Breathing w/o
Mortality
assistance by day 28

10 center trial was stopped after 861 patients were enrolled

PEEP

Surgery by: T. Whitehead

Video by: G. Volgyesi
14 Producer: A. S. Slutsky

Survival according to PEEP levels

Barbas CSV. Crit Care Med 2003; 31(Suppl):S265-S271

15 Barbas CSV. AJRCCM 2002;165:A218
 Optimum PEEP: How?

Incremental PEEP trials

PEEP/FIO2 algorhythms
Measurements of Pflex (LIP)
Lung volume measurements
Empirical clinical approaches
Decremental PEEP trials
16

Measurement of Pflex (LIP)

Oleic acid in pig

1600
1400
1200
Volume [ml]

1000
800
600
400
200
0
0 5 10 15 20 25 30 35 40
Pressure [cmH2O]

17 From Quintel and Pelosi

ARDS
CT and PV Curve (slow inflation)

-10 0 10

#6
 ARDS
CT and PV Curve (slow inflation)

#7

ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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ARDS
CT and PV Curve (slow inflation)

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 Safe ventilation window

volume
deflection If compliance curve is available, we
Point (UIP) know:

Position of LIP

over
distension Position of UIP

Area of best compliance

inflection It is recommended that:

Point (LIP)
PEEP is just above LIP
pressure
PEEP P plateau is just below UIP

Can calculate the approximate P

required for tidal volume

73

Lung Hysteresis
(Recruitment Derecruitment)

74

Basic principles:
Continuous opening and closing cycle is
not natural, therefore mechanical
ventilation should not use this concept
in patient care

Open Lung Technique

(Open the lung and keep it open)
 Surfactant Deactivated Lung before
and After RM

Dense, liver-like atelectasis

Number of alveoli per microscope field

76

Videomiicroscopy of normal lung

77

Recruitment Maneuver of the

Surfactant Deactivated Lung

Surfactant Deactivated Lung

78
 Repetitive Alveolar Collapse and
Expansion (RACE) After RM

Unstable Alveoli
PEEP + 5 cm H2O
79

After RM and PEEP 10 cmH2O

80

Monitoring of ARM
CT scan & EIT

81
 Primary (pulmonary) ARDS
15 cm H2O
PaO2: 104 mm Hg

10 cm H2O
PaO2: 103 mm Hg

d. 53%

5 cm H2O
PaO2: 97 mm Hg
d. 56%

Prevalent consolidation
d. 59%
82

Summary

There are three compartments of the lung

in ARDS which respons differently when
mechanically ventilated

The mortality could be reduced by using

protective ventilation strategy

Open the lung-and keep it open concept

may be used cautiously as rescue therapy
when conventional method failed

83

Take this message to consider!

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Terima kasih atas perhatiannya!