Materi Kuliah Ards

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    Childrens Hospital of MichiganChildrens Hospital of Michigan

    ACUTE RESPIRATORYDISTRESS SYDROME

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    ISTI!AH !AI

    Adult Respiratory

    Distress SyndromeTransfusion LungPost Perfusion LungShock LungTraumatic Wet Lung

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    ORI"IA! DE#IITIO Ac$te respirator% distress

    C%anosis refractor% to o&%gentherap%

    Decreased l$ng co'pliance

    Di($se in)ltrates on chestradiograph

    Di*c$lties+ lac,s speci)c criteria

    contro-ers% o-er incidence and'ortalit%

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    RE.ISIO O# DE#IITIOS

    /011+ fo$r2point l$ng in3$r% score !e-el of PEEP

    PaO45 #iO4ratio

    Static l$ng co'pliance Degree of chest in)ltrates

    /006+ consens$s conference

    si'pli)ed the de)nition

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    /006

    COSESUS Ac$te onset'a% follo7 catastrophic e-ent

    8ilateral in)ltrates on chestradiograph

    PA9P : /1 '' Hg

    T7o categories+

    Ac$te !$ng In3$r% 2 PaO45#iO4ratio :;

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    #ACTORS PECETUS

    Shoc,

    Aspiration of gastric contents

    Tra$'a

    Infections

    Inhalation of to&ic gases and f$'es

    Dr$gs and poisons

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    STA"ES

    Ac$te= e&$dati-e phase rapid onset of respirator% fail$re after

    trigger

    di($se al-eolar da'age 7ithin>a''ator% cell in)ltration

    h%aline 'e'?rane for'ation

    capillar% in3$r%

    protein2rich ede'a >$id in al-eoli

    disr$ption of al-eolar epitheli$'

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    STA"ES

    S$?ac$te= Proliferati-e phase+ persistent h%po&e'ia

    de-elop'ent of h%percar?ia

    )?rosing al-eolitis f$rther decrease in p$l'onar%

    co'pliance

    p$l'onar% h%pertension

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    STA"ES

    Chronic phase o?literation of al-eolar and ?ronchiolar

    spaces and p$l'onar% capillaries

    Reco-er% phase grad$al resol$tion of h%po&e'ia

    i'pro-ed l$ng co'pliance resol$tion of radiographic a?nor'alities

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    MORTA!ITY

    6

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    PATHO"EESIS

    Inciting e-ent

    In>a''ator% 'ediators

    Da'age to 'icro-asc$lar endotheli$' Da'age to al-eolar epitheli$'

    Increased al-eolar per'ea?ilit% res$ltsin al-eolar ede'a >$id acc$'$lation

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    Patogenesis

    D$a 'e,anis'e +

    Aspirasi ?ahan ,i'ia ata$ inhalasi gas?er?aha%a langs$ng to,si, terhdp epitel al-eolar

    epitel r$sa, dan ter3adi pening,atan

    per'ia8I!ITAS

    EDEMA ITERSTISIA!

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    BERUSABA PADA MEM8RAA!.EO!OBAPI!ER

    PEI"BATA PERMIA8I!ITAS

    EDEMA ITERSTESIA!

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    DUA MEBAISME ITU MEMPE"ARUHI +

    2 TRASPORT "AS 'en$r$n

    2 TIM8U! HIPOBSEMIA2 "A"A! APAS

    2 PO4 : < ''Hg

    2 PCO4 < ''Hg2 RR ;6 &5'nt

    2 T. : cc5,g ??

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    ORMA! A!.EO!US

    Type I cell

    Endothelial

    Cell

    RBCs

    Capillary

    Alveolar

    macrophage

    Type II

    cell

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    ACUTE PHASE O# ARDS

    Type I cell

    Endothelial

    Cell

    RBCs

    Capillary

    Alveolar

    macrophage

    Type II

    cell

    Neutrophils

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    Kerusakan

    alveoli saat

    ards

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    PATHOPHYSIO!O"Y

    A?nor'alities of gas e&change

    O&%gen deli-er% and cons$'ption

    Cardiop$l'onar% interactions

    M$ltiple organ in-ol-e'ent

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    Sign and s%'pto'

    A8ORMA!ITIES O# "AS ECHA"E Increased capillar% per'ea?ilit%

    Interstitial and al-eolar e&$date S$rfactant da'age

    Di($sion defect and right to left sh$nt

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    Sign and s%'pto'

    Stat$s 'ental 'en$r$n

    Ta,i,ardi

    Ta,ipnea dan d%spnea

    Sianosis= p$cat

    Retra,si notot napas

    Ronchi ?asah pada ede'a p$l'onal,ardiogeni,

    Analisa gas darah

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    OXYEN EXTRACTION

    !O"# $ % &' X ()*+ X ,-aO" . -vO"/

    Arterial

    In0lo1

    ,$/ capillary

    O2

    O2

    O2

    O2 O2

    O2

    O2

    !enous

    Out0lo1

    ,$/

    Cell

    O2

    (Adapted from the ICU Book by P !arino"

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    HEMODYNAMIC SUPPORT

    2a% O"e%traction

    Critical 3O"

    !O"# 3O"X O"ER

    3O"

    !O"

    Normal

    2a% O"e%traction

    Critical 3O"

    A'normal 4lo1 3ependency

    3O"

    !O"

    -eptic -hoc56AR3-

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    OY"E DE!I.ERY FCOSUMPTIO

    Pathologic >o7 dependenc%

    Unco$pling of o&idati-e dependenc%

    O&%gen $tiliGation ?% non2ATP prod$cingo&idase s%ste's

    Increased di($sion distance for O4

    ?et7een capillar% and al-eol$s

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    CARDIOPU!MOARYITERACTIOS

    A P$l'onar% h%pertensionres$lting in increased R. afterload

    8 Application of high PEEPres$lting in decreased preload

    A8 Decreased cardiac o$tp$t

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    RESPIRATORY SUPPORT

    Conventional mechanical ventilation

    Neer modalities!

    "igh fre#uency ventilation

    $nnovative strategies

    Nitric o%ide

    Li#uid ventilation &%ogenous surfactant

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    MAA"EMET

    Monitoring+

    Respirator%

    He'od%na'ic

    Meta?olic5n$trition

    Infections

    #l$ids5electrol%tes

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    MAA"EMET

    Opti'iGe .O45DO4 relationship

    Deli-er% O4 he'oglo?in 'echanical -entilation

    o&%gen5PEEP

    . ol$'e of O4 preload

    afterload

    contractilit%

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    CONVENTIONAL VENTILATION'%ygen

    P&&P$nverse $!& ratio

    Loer tidal volume

    (entilation in prone position

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    RESPIRATORY SUPPORT

    )oal! maintain sufficient o%ygenation andventilation* minimi+e complications of ventilatorymanagement

    $mprove o%ygenation! P&&P* ,AP* -i'. $mprove ventilation ! change in pressure

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    Mechanical Ventilation GuidelinesAmerican College of Chest Physicians/

    Consensus Conference 0112

    )uidelines for ,echanical (entilation in ARDS

    When possi3le* plateau pressures 4 25 cm ".'

    Tidal volume should 3e decreased if necessary

    to achieve this* permitting increased pC'.

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    PEEP !ene"its

    $ncreases transpulmonary distending pressure

    Displaces edema fluid into interstitium

    Decreases atelectasis Decrease in right to left shunt

    $mproved compliance

    $mproved o%ygenation

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    No !ene"it to Ea#l$ A%%lication o"

    PEEPPepe P& et al6 N&7, 0189:200!.80;. hours

    No differences in development of ARDS*

    complications* duration of ventilation* time inhospital* duration of $C? stay* mor3idity or mortality

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    P#essu#econt#olled Ventilation

    &PCV'Time;cycled mode

    Appro%imate s#uare aves of a preset pressure are

    applied and released 3y means of a decelerating flo,ore laminar flo at the end of inspiration

    ,ore even distri3ution of ventilation in patients ith

    marked different resistance values from one region of

    the lung to another

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    P#essu#econt#olled In(e#se#atio

    VentilationConventional inspirat