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Stretch Injury Alters capillary transmural pressures Changes in transmural pressure causes breaks in capillary endo and epithelium Increases leak of proteinacious material Promotes Atelectasis Rodents ventilated with three modes: High Pressure (45 cmH2O), High Volume Low Pressure (negative pressure ventilator), High Volume High Pressure (45 cmH2O), Low Volume (strapped chest and abdomen) Dreyfuss,D ARRD 1988;137:1159 Bài giảng hồi sức cấp cứu.Dung tích của phổi Ventilator induced lung injury HFOV Caring for the Baby in Adults Baby Lung Sitting on Top of a Consolidated Lung Tidal Volumes of 610 mlkg based on weight Tidal Volumes of 2050 mlkg based on open lung units Histology is similar to infant lung injury
Ventilator Induced Lung Injury Ventilator Induced Lung Injury • Barotrauma • Volutrauma • Stretch Injury • Biochemical Injury VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Barotrauma • Air leaking into pleural space • Air leaking into interstitial space (PIE) • Tearing at Bronchio-Alveolar Junction as lung is recruited and allowed to collapse • Most occurs in dependent lung zones (transition zone) VIASYS Healthcare, Inc Effect of 45 cmH2O PIP Control 20 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Stretch Injury • Alters capillary transmural pressures • Changes in transmural pressure causes breaks in capillary endo and epithelium • Increases leak of proteinacious material • Promotes Atelectasis VIASYS Healthcare, Inc Ventilator Induced Lung Injury Stretch Injury Alveolar Space A-C Membrane VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Rodents ventilated with three modes: • High Pressure (45 cmH2O), High Volume • Low Pressure (negative pressure ventilator), High Volume • High Pressure (45 cmH2O), Low Volume (strapped chest and abdomen) Dreyfuss,D ARRD 1988;137:1159 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Volutrauma • Caused by cycling of the lung (change in surface area), independent of pressure required • Alters Surfactant function • Promotes Atelectasis • Increases capillary leak of proteinacious material • Promotes Atelectasis Dreyfuss,D ARRD 1988;137:1159 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Hyaline Membrane Disease is not really a disease, it’s the result of volume cycling the lungs • CMV produces consolidation, over inflation and hyaline membrane formation • HFOV uniformly inflates the lung without hyaline membrane formation Meredith K, JAP 1989; 66:2150 VIASYS Healthcare, Inc Ventilator Induced Lung Injury Premature baboon model Coalson J Univ Texas San Antonio VIASYS Healthcare, Inc Ventilator Induced Lung Injury VIASYS Healthcare, Inc Ventilator Induced Lung Injury Control animal histology Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury HFOV animal histology Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury CMV animal histology Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • HFOV Stimulates Significantly Less Neutrophil Activity Than CMV • Neutrophil Activity Has a Role in the Genisis of ARDS, Releasing Active Oxygen Species, Proteinases and Arachidonic Acid Metabolites Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • HFOV produces less inflammatory markers than CMV Imai Y, AJRCCM 1994; 150:1550 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Activation of alveolar macrophages and pro-inflammatory cytokines play a pivotal role in Ventilator Induced Lung Injury Takata M, AJRCCM 1997; 156:272 VIASYS Healthcare, Inc Risk Factors for ARDS • • • • • • • • • Trauma Shock Syndromes - Sepsis, Cardiogenic Gastric Aspiration Burns Diffuse Pneumonias Near Drowning Drug Overdose Metabolic Events - Pancreatitis, Uremia Systemic Mediator Release Associated Diseases – Disseminated Intravascular Coagulopathy – Cardiopulmonary Bypass Anaphylaxis – Extrapulmonary Infection Transfusion Reaction VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Pre Lavage Pressure Control Ventilation Weiler N et al, 1999, personal communication Paw 13 cmH2O PEEP cmH2O VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Pre Lavage Pressure Control Ventilation Paw 23 cmH2O PEEP 15 cmH2O Weiler N et al, 1999, personal communication VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Post Lavage Pressure Control Ventilation Weiler N et al, 1999, personal communica Paw 13 cmH2O PEEP cmH2O VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Post Lavage Pressure Control Ventilation Paw 23 cmH2O PEEP 15 cmH2O Weiler N et al, 1999, personal communication VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Post Lavage Pressure Control Ventilation Paw 33 cmH2O PEEP 25 cmH2O Weiler N et al, 1999, personal communication VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Post Lavage HFOV Paw 23 cmH2O Weiler N Heinrichs W, et al 1999 VIASYS Healthcare, Inc “Open up the lung up and keep it open!” Burkhard Lachmann, 1992 VIASYS Healthcare, Inc [...]... Phospholipid levels • Improved lung mechanics • All Conventional Ventilator Strategies • Resulted in Death or Decreased Surfactant Performance Froese A, ARRD 1993; 148:569 VIASYS Healthcare, Inc Ventilator Induced Lung Injury VIASYS Healthcare, Inc Ventilator Induced Lung Injury Control animal histology Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury HFOV animal histology... of 20-50 ml/kg based on open lung units • Histology is similar to infant lung injury VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Adult Acute Respiratory Failure – Atelectasis – Overdistended airways and alveoli – Cellular accumulation – Hyaline Membranes Lamy ARRD 1976; 114:267 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Adult ARDS late stage lung structural changes • Enlarged... Suchyta MR, ERS 1997 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • HFOV with Surfactant as Compared to CMV with Surfactant in the Premature Primate – HFOV resulted in • Less Radiographic Injury • Less Oxygenation Injury • Less Alveolar Proteinaceous Debris Jackson C AJRCCM 1994; 150:534 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • High Lung Volume Strategies with HFOV • Extended... Metabolites Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • HFOV produces less inflammatory markers than CMV Imai Y, AJRCCM 1994; 150:1550 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Activation of alveolar macrophages and pro-inflammatory cytokines play a pivotal role in Ventilator Induced Lung Injury Takata M, AJRCCM 1997; 156:272 VIASYS Healthcare, Inc Risk... Inc Pulmonary Injury Sequence • There are two injury zones during mechanical ventilation • Low Lung Volume Ventilation tears adhesive surfaces • High Lung Volume Ventilation overdistends, resulting in “Volutrauma” • The difficulty is finding the “Sweet Spot” Froese AB, Crit Care Med 1997; 25:906 VIASYS Healthcare, Inc Ventilator Induced Lung Injury Twenty Years of One Year Follow Up of Lung Function... Inc Ventilator Induced Lung Injury CMV animal histology Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator Induced Lung Injury • HFOV Stimulates Significantly Less Neutrophil Activity Than CMV • Neutrophil Activity Has a Role in the Genisis of ARDS, Releasing Active Oxygen Species, Proteinases and Arachidonic Acid Metabolites Sugiura M, JAP 1994; 77:1355 VIASYS Healthcare, Inc Ventilator. .. Emphysematous Changes • Fibrosis • Pulmonary Vascular Obliteration • Chronic Lung Disease VIASYS Healthcare, Inc Ventilator Induced Lung Injury • Biochemical Injury • Biochemical agents (mediators) attack the lung • Recruit fibrotic proliferation cells to the lung • Atelectasis promotes release of chemical mediators • Mediators released in the lung can attack other organ systems • Cells • Macrophages • Endothelial.. .Ventilator Induced Lung Injury Premature baboon model Coalson J Univ Texas San Antonio VIASYS Healthcare, Inc Alveolar Edema and Hyaline Membrane VIASYS Healthcare, Inc Hemorrhage and Edema VIASYS Healthcare, Inc Adult ARDS • HFOV - Caring for the Baby in Adults • Baby Lung Sitting on Top of a Consolidated Lung • Tidal Volumes of 6-10 ml/kg based on weight... etc VIASYS Healthcare, Inc ARDS Pulmonary Injury Sequence • Phase 2 Proliferative (Day 5-10) • Proliferation of Type 2 Cells • Fibroblast Migration • Interstitial Collagen Formation • Increased Dead Space • Decreased Compliance • Increased Pulmonary Vascular Resistance VIASYS Healthcare, Inc ARDS Pulmonary Injury Sequence • Phase 3 Fibrotic (Day 10-14) • Lung Destruction • Emphysematous Changes •... Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Pre Lavage Pressure Control Ventilation Weiler N et al, 1999, personal communication Paw 13 cmH2O PEEP 5 cmH2O VIASYS Healthcare, Inc Lung Inflation Patterns Multi-Scan CT (10 scans/sec) 30 kg Pig Pre Lavage Pressure Control Ventilation Paw 23 cmH2O PEEP 15 cmH2O Weiler N et al, 1999, personal communication VIASYS Healthcare, Inc Lung