What’s New In Pediatric ARDS.pptVIP

What’s New In Pediatric ARDS Nancy G. Hoover, MD Medical Director, PICU Walter Reed AMC New and Improved Acute Respiratory Distress Syndrome Ashbaugh, Lancet, 1967 Adult Respiratory Distress Syndrome To distinguish from neonatal HMD/RDS Acute Respiratory Distress Syndrome American-European Consensus conference, 1994 ARDS: New Definition Criteria Acute onset Bilateral CXR infiltrates PA pressure 18 mm Hg Classification Acute lung injury - PaO2 : F1O2 300 Acute respiratory distress syndrome - PaO2 : F1O2 200 Clinical Disorders Associated with ARDS Direct Injury Common Causes Pneumonia Gastric aspiration Less Common Causes Pulmonary contusion Fat emboli Near drowning Inhalational injury Indirect Injury Common Causes Sepsis Shock after severe trauma Less Common Causes Cardiopulm. bypass Drug overdose Acute pancreatitis Massive blood transfusions The Problem: Lung Injury ARDS - Pathogenesis Instigation Endothelial injury: increased permeability of alveolar - capillary barrier Epithelial injury : alveolar flood, loss of surfactant, barrier vs. infection Proinflammatory mechanisms ARDS Pathogenesis Resolution Equally important Alveolar edema - resolved by active sodium transport Alveolar type II cells - re-epithelialize Neutrophil clearance needed ARDS - Pathophysiology Decreased compliance Alveolar edema Heterogenous “Baby Lungs” Phases of ARDS Acute - exudative, inflammatory (0 - 3 days) Subacute - proliferative (4 - 10 days) Chronic - fibrosing alveolitis ( 10 days) ARDS - Outcomes Most studies - mortality 40% to 60% Majority of deaths sepsis or MOD rather than primary respiratory Outcomes similar for adults and children Mortality may be decreasing 53/68 % 39/36 % ARDS - Principles of Therapy Provide adequate gas exchange Avoid secondary injury It would seem ironic that the very existence of humans is fully dependent on a gas that, in excess quantities, is toxic and lethal Lynn D. Martin Therapies for ARDS The Dangers of Overdistention Repetitiv