ards - ADJUNCTS IN TREATMENT OF ARDS Dr AKASHDEEP SINGH...

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ADJUNCTS IN TREATMENT OF ARDS Dr. AKASHDEEP SINGH DEPARTMENT OF PULMONARY AND CRITICAL CARE MEDICINE PGIMER CHANDIGARH
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ABJUNCTS IN TREATMENT OF ARDS 1. Ventilatory Strategies other than Lung Protective Strategy. - Prone Ventilation - Liquid Ventilation - High Frequency Ventilation - Tracheal Gas Insufflation - Extracorporeal Gas Exchange 2. Hemodynamic Management – Fluids, Vasopressors. 3. Selective Pulmonary vasodilators. 4. Surfactant replacement therapy. 5. Anti-inflammatory Strategies. a) Corticosteroids. b) Cycloxygenase & lipoxygenase inhibitors. c) Lisofylline and pentoxifylline. 6. Antioxidants – NAC : Procysteine 7. Anticoagulants.
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PRONE VENTILATION Effect on gas exchange Improves oxygenation – allows decrease Fio 2 ; PEEP - Variable - not predictable response rate – 50-70% Proposed mechanism – how it improves oxygenation 1) Increase in FRC 2) Improved ventilation of previously dependent regions. (a) Difference in diaphragmatic movement - supine : dorsal and ventral portion move symmetrically - prone : dorsal > ventral
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PP L -3.0 +2.8 P PL -1.0 +1.0 Supine prone P PL at dorsal Higher Less TP pressure Lower More Result Atelactasis opening c) Decrease chest wall compliance in p.p Redistribution of tidal volume to atelactatic dorsal region. c) Weight of heart may affect ventilation. 1. Improvement in Cardiac output 2. Better clearance of secretions 3. Improved lymphatic damage
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CONTRAINDICATION - Unresponsive cerebral hypertension - Unstable bone fractures - Left heart failure - Hemodynamic instability - Active intra abdominal pathology TIMING ARDS > 24 hrs./ 2 nd day FREQUENCY Usually one time per day DURATION 2 to 20 hrs/day. OUTCOME Improvement in oxygenation No improvement in survival POSITIONING ACHIEVED BY Circ Olectric, bed (Late 1970s). Manual 2 step Light weight portable support frame (Vollman prone positioner)
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NO. OF PERSONS 3-5 POSITION OF ABDOMEN allowed to protude ; partial/complete restriction POSITION OF HEAD Head down/ Head up position. ADEQUATE SEDATION +/- NMBA COMPLICATIONS - pressure sore - Accident removal of ET; Catheters - Arrhythmia - Reversible dependent odema (Face, anterior chest wall) Gattinoni et al, in a MRCT evaluated the effect of 7 hr / day prone positioning x 10 day improvement in oxygenation, no survival benefit NEJM 2001, Vol 345 No 8 568-573
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In ARDs there is increased surface tension which can be eliminated by filling the lungs with liquid (PFC). Perflurocarbon: Colourless, clear, odourless, inert, high vapour pressure Insoluble in water or lipids MC used – perflubron ( Perfluoro octy bromide ) (Liquivent) Bromide radiopaque ANIMAL EXPERIENCE Improved - Compliance - Gas exchange (dose dependent) - lung function - Survival Anti-inflam. properties Decrease risk of nosocomial pneumonia. Reduces pulm. vascular resistance.
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This note was uploaded on 12/03/2011 for the course MEDICINE 350 taught by Professor Dr.aslam during the Winter '07 term at Medical College.

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ards - ADJUNCTS IN TREATMENT OF ARDS Dr AKASHDEEP SINGH...

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