ARDS Berlin DEFINITION.pptx

ards

1. ARDS- BERLIN DEFINITION DR PRASHANT BHATIA

2. Guru Brahma Gurur Vishnu Guru Devo Maheshwaraha Guru Saakshat Para Brahma Tasmai Sree Gurave Namaha Meaning:Guru is verily the representative of Brahma, Vishnu and Shiva. He creates, sustains knowledge and destroys the weeds of ignorance. I salute such a Guru.

3. Stages of ARDS Exudative (acute) phase Proliferative phase Fibrotic phase

4. Stages Acute, exudative phase rapid onset of respiratory failure after trigger diffuse alveolar damage with inflammatory cell infiltration hyaline membrane formation capillary injury protein-rich edema fluid in alveoli disruption of alveolar epithelium Expansion of interstitium with macrophages and inflammation Hyaline Membranes Alveolar Filling

5. Proliferative phase: persistent hypoxemia development of hypercarbia fibrosing alveolitis further decrease in pulmonary compliance pulmonary hypertension Chronic phase / Recovery phase obliteration of alveolar and bronchiolar spaces and pulmonary capillaries gradual resolution of hypoxemia improved lung compliance resolution of radiographic abnormalities

6. ARDS causes Direct Lung Injury : a) PNA and aspiration of gastric contents or other causes of chemical pneumonitis b) pulmonary contusion, penetrating lung injury c) fat emboli d) near drowning e) inhalation injury f) reperfusion pulm edema after lung transplant

7. ARDS causes Indirect lung injury a) sepsis b) severe trauma w/ shock hypoperfusion c) drug over dose d) cardiopulmonary bypass e) acute pancreatitis f) transfusion of multp blood products

8. WHAT IS A DEFINITION A definition is a thorough description of the meaning of a lexical unit

9. WHY DEFINITION FACILITATES RESEARCH PATHOGENESIS AMPLIFIED AND NOTIFIED COMPARISION OF VARIOUS CLINICAL TRIALS EARLY INSTITUTION OF STANDARDISED CARE OUTCOME PROGNOSTICATION MEASURE THE IMPACT (ECONOMIC, SOCIAL) ETC

10. DEFINITION OF ALI/ARDS AMERICAN-EUROPEAN CONSENSUS CONFERENCE 1994 ALI CRITERIA Timing: acute onset Oxygenation: PaO ₂/FIO₂≤ 300 MM Hg (regardless of peep) Chest Radiograph: bilateral infiltrates seen on frontal chest radiograph Pulmonary artery wedge:≤ 18 mm Hg when measured or no clinical evidence of left atrial hypertension

11. DEFINITION OF ALI/ARDS ARDS CRITERIA Timing: acute onset Oxygenation: PaO ₂/FIO₂≤ 200 MM Hg (regardless of peep) Chest Radiograph: bilateral infiltrates seen on frontal chest radiograph Pulmonary artery wedge:≤ 18 mm Hg when measured or no clinical evidence of left atrial hypertension

12. MURRAY LIS No Lung Injury Score 0 Mild To Moderate Lung Injury Score 1-2.5 Severe Lung Injury > 2.5

13. DELPHI CONSENSUS DEFINITION PEEP (>10) PaO ₂/FIO₂≤ 200 MM Hg RADIOGRAPHIC CRITERIA > 2 QUADRANTS QUANTITATIVE PULMONARY COMPLIANCE ABNORMALITIES OR PREDISPOSING CONDITION NON CARDIOGENIC PULMONARY OEDEMA CHARACTERISATION EITHER BY PAC OR TTE

14. OXYGENATION INDEX OI = MAP × FIO₂ × PaO ₂ /100 OI > 30 HAS BEEN ASSOCIATED WITH POOR OUTCOME

15. HETEROGENITIES INCITING CAUSE PHASE TIMING RELATIVE TO ONSET OF MECHANICAL VENTILATION VARIABILITY IN MECHANISM

16. RELIABILITY AND VALIDITY RELIABILITY INTEROBSERVER INTRAOBSERVER VALIDITY FACE CONTENT CRITERION CONCURRENT PREDICTIVE CONSTRUCT CONVERGENT DISCRIMINANT

17. Face Validity Do the diagnostic criteria appear to describe the disease entity in question Criterion Validity Do the diagnostic criteria correlate with gold standard Predictive Validity Does this predict a certain outcome or response to therapy

18. HYPOXEMIA VARIES WITH FIO₂ EFFECT OF PEEP CONFOUNDING FACTORS ATELECTASIS LOW C.O SHUNT VENTILATORY SETTINGS TIME PERIOD

19. EFFECT OF SHUNT

20. INFILTRATES INTEROBSERVER VARIABILITY EFFECT OF HIGH MEAN AIRWAY PRESSURE CT SCAN IS RELIABLE

21. LEFT ATRIAL HYPERTENSION PAOP MEASUREMENT-INTEROBSERVER RELIABILIY TRANSMITTED AIRWAY PRESSURES FLUID RESUSCITATION

22. ACUTE ONSET SPECIFICATION OF TIMELINES OF ‘ACUTE’

23. HYPOXEMIA PaO ₂/FIO₂≤ 201- 300 WITH PEEP/CPAP≥5 PaO ₂/FIO₂≤ 200 WITH PEEP/CPAP≥5 PaO ₂/FIO₂≤ 100 PEEP/CPAP≥10 TIMIMING ACUTE ONSET WITHIN 1 WEEK OF A KNOWN CLINICAL INSULT OR NEW/WORSENING RESPIRATORY SYMPTOMS Mild Moderate Severe ORIGIN OF OEDEMA RESPIRATORY FAILURE NOT EXPLAINED BY CARIAC FAILURE OR FLUID OVERLOAD RADIOLOGIC ABNORMALITIES BILATERAL OPACITIES BILATERAL OPACITIES OPACITIES INVOLVING AT LEAST THREE QUADRANTS ADDITIONAL PHYSIOLOGIC DERANGEMENTS N/A N/A VEcorr >10L/MIN OR Crs ≤ 40 ml/cm H₂ О ARDS

24. RECURITABLE LUNGS 30-40 cm H₂O AIR WAY PRESSURE FOR 30-40 SECS PEEP BY 10 cm H₂O TO A MAXIMUM OF 20 cm H₂O POTENTIAL HIGH POTENTIAL LOW SpO ₂> 5% MARGINAL EFFECT PaCO ₂ PaCO ₂ Compliance Compliance

25. RESCUE THERAPIES High peep levels Lung recruitment maneuvers High frequency ventilation Airway pressure release ventilation Prone positioning Extracorporeal life support

26. NONVENTILATORY STRATEGIES Neuromuscular Blocking Agents Inhaled Nitric Oxide ECLS Conservative Fluid Management Corticosteroid Therapy Nutritional Supplementation Therapy

27. We are constantly misled by the ease with which our minds fall into the ruts of one or two experiences. Sir William Osler

28. THANK YOU