Adult Respiratory Distress

Syndrome Update 2016

Scott B. Helberg, MD, MBA

Pulmonary & Critical Care Medicine
About the Speaker

Undergraduate
BS in Business Administration
BS in Mortuary Science
MBA with emphasis in consultancy
Medical School
Sanford School of Medicine (University of South Dakota)
Residency
University of New Mexico (Internal Medicine)
Fellowship
University of New Mexico (Pulmonary/Critical Care)
Relevant Work Experience
Executive Director, Residential Care Facility for the Chronically Ill
Public Health (Primary/Specialty Medical Care Indigent)
Hospitalist (Acute and Critical Care)
Pulmonologist/Intensivist
Disclosures
I have no financial disclosures
Goals and Objectives
Understand the risk factors for ARDS
Define ARDS and the impact of the Berlin Criteria
Discuss the role of mechanical ventilation in
profound hypoxemia
Understand the role of neuromuscular blockade in
the management of ARDS
Discuss the role of prone positioning in the
treatment of ARDS
Define how timing of tracheostomy effects
outcomes
List ineffective or harmful therapies in ARDS
Grading of Recommendations
1 = Strong Recommendation
2 = Weak Recommendation

A = Good evidence from randomized trials

B = Moderate strength evidence from small
randomized trial(s) or upgraded observational trials
C = Low strength evidence, well-done observational
trials with control randomized controlled trials
D = Very low strength evidence, downgraded
controlled studies or expert opinion
INTRODUCTION
Introduction
Distinct type of hypoxemic respiratory failure
Abnormality of both lungs

Acute, diffuse, inflammatory lung injury

Increased pulmonary vascular permeability
Increased lung weight
Loss of aerated tissue

Pathology
Diffuse alveolar damage
Alveolar edema with or without focal hemorrhage, acute
inflammation of the alveolar walls, and hyaline
membranes
Microscopy of ARDS

Normal Alveoli
Microscopy of ARDS

ARDS
Microscopy of ARDS

ARDS
Common Causes of ARDS
DIRECT
Aspiration of gastric contents
Infectious pneumonia
Inhalation of toxic gas or aerosol
Lung contusion
Near-drowning
Fat emboli

INDIRECT
Bacterial sepsis
Especially gram-negative
Trauma of a non-thoracic origin
Multiple fractures
Multiple blood transfusions
Pancreatitis
Opiate and other drug overdose
Heroin, methadone, barbiturates, salicylates
Disseminated intravascular coagulation
Other infectious causes
Snake bite
Cardiopulmonary bypass
Introduction
Case-fatality rate decreased during the 1990s
Still exceeds 30%

No drug has proven beneficial in the prevention or

management of ARDS

Mainstay of therapy
Supportive
Improving gas exchange
Preventing complications
Introduction
Diagnosis of ARDS
Chest X-ray
Accuracy of portable chest radiograph to detect ARDS is
limited

CT Scan
High PPV and moderate NPV
Upper-lobe-predominant ground-glass attenuation
(95.2%/47.5%)
Central-predominant ground-glass attenuation
(92.3%/51.4%)
Central airspace consolidation (92.0%/50.0%)
Mortality Prediction and the Berlin Criteria

INTRODUCTION
Definition of ARDS
1994 to 2012
American-European Consensus Conference (AECC)

Criteria
Acute onset of hypoxemia defined by partial pressure of
arterial oxygen/fraction of inspired oxygen (PaO2/FiO2,
or P/F) ratio of > 200, with
New bilateral infiltrates
Not attributable to heart failure as defined by pulmonary
capillary wedge pressure (PCWP) (as measured by a
Swan-Ganz catheter) of not more than 18 mmHg (or
absence of suspected left atrial hypertension/cardiogenic
pulmonary edema if PCWP was not available)
Definition of ARDS
2012
European Society of Intensive Care Medicine
Expert panel to improve the reliability and validity of the ARDS definition
Berlin Criteria
Criteria
Defining three categories of ARDs severity on the basis of P/F ratio
300 and >200 mild ARDS (previously acute lung injury)
100-200 moderate ARDS
<100 severe ARDS
Defining acute onset of bilateral infiltrates as within 7 days of exposure to an
ARDS risk factor or worsening respiratory symptoms
More definitive chest radiograph criteria were provided
Bilateral infiltrates consistent with pulmonary edema and not fully explained by
effusion, lobar/lung collapse, or nodules
Use of CT scan allowable
Use of the PCWP for defining cardiogenic pulmonary edema was
removed
If a risk factor for ARDS is not identified
Some objective criteria of cardiac function
Minimum use of PEEP of at least 5 cm H2O on mechanical
ventilation (or delivered by NIV only in the mild ARDS category)
assessing the severity of oxygenation impairment using the P/F ratio
Implications of Berlin Criteria
Derived and validated
Variable which did not improve severity prediction were
excluded
Lung compliance, radiographic severity, levels of PEEP,
and exhaled minute ventilation

Categorizing severity directed attention to most

afflicted group

Allowed for mortality prediction

Mild 27%
Moderate 32%
Severe 47%
MANAGEMENT OF HYPOXEMIA
Management of Hypoxemia
Options for improving arterial oxygen saturations
Use of high fractions of inspired oxygen (FiO2)
Decrease oxygen consumption
Improve oxygen delivery
Manipulate mechanical ventilator support

Risk of high fractions of FiO2

Absorptive atelectasis
Three gasses hold alveoli open (nitrogen, carbon dioxide and
oxygen)
At 50% FiO2 with small tidal volumes
Nitrogen is washed out (into venous system and released)
When oxygen is absorbed, little other gas to keep alveoli open
Oxygen toxicity
Oxygen damage from toxic oxygen species (free radicals) occurs
within hours
Destroys type I alveolar cells
Proliferate type II alveolar cells exudative stage increase
edema
Fluid build up increased V/Q mismatch shunt
Goal is 50-60% range as soon as possible
Early versus Late Intubation
Large multi-ICU prospective cohort study 2006-2011

457 patients with ARDS

106 (23%) not intubated at time of diagnosis

Non-intubated patients had lower morbidity and severity of

illness
However, mortality at 60 days was the same (36%) in both
groups
Of 106 non-intubated patients
56% required intubation within 3 days
Late intubation group had significantly higher 60-day mortality
(56%) when compared to the early intubation group (36%; p <
0.03) and patients never requiring intubation (26%; p = 0.002)
Increased mortality in the late intubation group persisted at 2-
year-follow-up
Adjustments for baseline clinical and demographic
differences did not change the results
MECHANICAL VENTILATION
Low Tidal Volume Ventilation

MECHANICAL VENTILATION
ARDS Net (Low Tidal Volume Ventilation)
ARMA Trial
Compared 12 ml/kg (ideal body weight) and 6 ml/kg
Significant reduction in mortality with low tidal volume
ventilation
38% to 31%

Meta-analysis of six randomized trials (2009)

Low tidal volume ventilation had significantly improved
28 day mortality (27.4 versus 37%) and hospital
mortality (34.5 versus 43.2 percent) when compared to
conventional mechanical ventilation
Low Tidal Volume Ventilation (LTVV)
More recent studies have applied low tidal volume
ventilation to at risk patients
Surgical patients

A trial of intraoperative low-tidal-volume ventilation

in abdominal surgery, NEJM (2013)
Prophylactic protective ventilation
Improved clinical outcomes in intermediate- and high-
risk patients undergoing abdominal surgery
Concerns for LTVV
Low tidal volume ventilation is well tolerated and
not associated with any clinically important adverse
outcomes

Concerns
Auto-PEEP
Theory Higher RR used to maintain minute ventilation
during LTVV may create auto-PEEP
Subgroup analysis reveals negligible quantities of auto-
PEEP between two ventilation groups
Sedation
Work of breathing and asynchrony may increase need for
sedation
Post-hoc analysis showed no significant differences in
the percentage of days patients received sedatives,
opioids, or neuromuscular blockage between the two
ventilation groups
Potential Mechanisms of Protection
Barotrauma
High pressures to lungs resulting in injury
Volutrauma
High tidal volumes inducing lung stretch resulting in injury
Hemodynamics
Less over distention improving venous return
Atelectrauma
Lack of maintenance of open lung units has the potential to
exacerbate lung injury from opening and closing of lung units
Studies show higher PEEP in moderate ARDS improved
outcomes
Biotrauma
Activation of cellular signaling cascades resulting in lung
inflammation from stretching lung unit
Implementation
Goal plateau airway pressure checked q4 hours and
after every PEEP or tidal volume change
Goal plateau airway pressure is 30 cm H2O (ARMA Trial)
Goal plateau airway pressure in practice is < 28 cm H2O
Decreases alveolar over distension and makes it unlikely to
induce lung strain
Goal for PaO2 is between 55 and 80 mmHg
SpO2 between 88-95%
Permissive hypercapnia allowed

2016 multicenter international prospective cohort study

(3,022 patients)
ARDS recognized in 60% patients
< 66% received a tidal volume of 8 mL/kg PBW
Spontaneous Breathing in ARDS
Complete inactivity of the diaphragm results in disuse
atrophy and muscle weakness
Ventilator-induced diaphragmatic dysfunction (VIDD)
Occurs in as little as 18-24 hours of MV
Can contribute to difficulty weaning and poorer prognosis

Experimental studies Assist-control ventilation or

pressure support ventilation can reduce VIDD
Timing of allowing spontaneous breathing has been debated

Experimental lung injury models in ARDS

Reduced markers of lung inflammation and epithelial cell
damage
Improved tidal ventilation gas exchange and oxygen delivery
Increased systemic blood flow
Spontaneous Breathing in ARDS
2005 Study by Neumann et al.
Partial ventilator support with airway pressure release
ventilation (APRV) compared to standard ventilation
Promoted alveolar recruitment in distal peri-diaphragmatic
areas
Improved ventilation/perfusion matching and gas
exchange
Increased oxygen delivery
Limited to those with mild to moderate ARDS

2013 Study by Yoshida and co-workers

Spontaneous breathing in a model of severe lung injury
caused
High transpulmonary pressure
Worsened oxygenation and lung damage
Caused local injury by internal redistribution of volume
Considerations in Spontaneous Breathing
Real transpulmonary pressures becomes the sum
of the pressure generated by the ventilator and by
the patient's respiratory muscles
Pressure targeted modes
Pressure assist/control ventilation and pressure support
ventilation
True driving pressure is higher than the airway pressure
(Paw)
Volume controlled ventilation
Transpulmonary pressure and tidal volumes are kept
constant irrespective of muscular pressure

Currently ongoing large multicenter randomized

controlled study
Early Spontaneous Breathing in Acute Respiratory
Distress Syndrome (BiRDS)
Not Standards of Care
Proportional assist ventilation
Neurally adjusted ventilator assist
Noisy pressure support ventilation
PEEP in ARDS
ARDS characterized by a major loss in lung volume
Alveolar flooding
Atelectasis
Consolidation
PEEP is used to reverse hypoxemia and atelectasis
Goal of PEEP is to recruit (or maintain recruitment
of ) atelectatic or flooded lung

Three large multicenter randomized trails have

tested higher versus lower PEEP while limiting tidal
volumes in all patients
ALVEOLI Trial (Assessment of Low tidal Volume and
elevated End-expiratory volume to Obviate Lung Injury)
ExPress Trial (Expiratory Pressure)
LOVS Trial (Lung Open Ventilation Study)
PEEP in ARDS Trial Results
No significant improvement in mortality
Express trial found an improvement in ventilator-
free days

Meta-analysis of the trials

Modest reduction in mortality for patients with moderate
and severe ARDS in the higher PEEP arms
Physiological Consequences of PEEP
Increase end-expiratory lung volume (EELV)
Highly recruitable patient
Substantial part of increased EELV due to reopening of
previously collapsed lung tissue (recruitment)
Poorly recruitable patient
Most of the increase is generated by inflation of
previously open lung tissue
Leads to overdistention risk of volutrauma
Effectiveness of PEEP based on patient characteristics

Clinical trials suggest applying PEEP without

assessment of recruitability may affect improving
survival
This may explain the small effects of the previous trials
Techniques to Determine Proper PEEP
Multiple pressure-volume curves
Measurement of lung volume
Use of Poes and transpulmonary pressure
Lung ultrasound
Physiological tests based on oxygenation
Techniques to Determine Proper PEEP
Multiple pressure-volume curves
Plotting several pressure-volume curves at different
PEEP levels on the same volume axis
Measuring or estimating the volume above functional
residual capacity
Measurement of lung volume
Use of Poes and transpulmonary pressure
Lung ultrasound
Physiological tests based on oxygenation
Techniques to Determine Proper PEEP
Multiple pressure-volume curves
Measurement of lung volume
Nitrogen washout/wash-in technique
Good correlation with with helium dilution or CT scans
Direct measurement of lung volume
FRC and/or EELV at each PEEP level and calculation
of the strain
Use of Poes and transpulmonary pressure
Lung ultrasound
Physiological tests based on oxygenation
Techniques to Determine Proper PEEP
Multiple pressure-volume curves
Measurement of lung volume
Use of Poes and transpulmonary pressure
Estimate pleural pressure and then estimating transpulmonary pressure at
end-inspiration and expiration from the difference between Pplat or PEEP and
esophageal pressures
Transpulmonary pressure = Paw-Poes
EPVent Study (Esophageal Pressure directed Ventilation)
ARDS reduced chest wall compliance, edema or abdominal distension
Transpulmoanry pressure can be negative at end-expiration
Indicates closed or compressed airways or atelectatic lung
PEEP can be increased until transpulmoanry pressure becomes positive at end-
expiration to keep airways open (positive values do not assure open alveoli in the
zones distal to the sampling catheter)
Single center randomized controlled trial
Poes guided (experimental) versus ARDSNetwork (control)
Positive end-expiratory TPP experience higher PaO2/FiO2, better respiratory
system compliance and trend toward reduced 28-day mortality
Goals titration of PEEP
End-expiratory transpulmonary pressure between 0 and 10 cmH2O (reduce cyclic
alveolar collapse)
Maintaining end-inspiratory transpulmonary pressure 25 mc H2O (reduce alveolar
over distension)
Lung ultrasound
Physiological tests based on oxygenation
Techniques to Determine Proper PEEP
Multiple pressure-volume curves
Measurement of lung volume
Use of Poes and transpulmonary pressure
Lung ultrasound
Lung scoring based on the repeated examination of six
lung regions in each lung before and after increasing
PEEP
Equivalent to the pressure-volume curve methods
Physiological tests based on oxygenation
Techniques to Determine Proper PEEP
Multiple pressure-volume curves
Measurement of lung volume
Use of Poes and transpulmonary pressure
Lung ultrasound
Physiological tests based on oxygenation
High-Frequency Oscillatory Ventilation (HFOV)

Theoretically ideal for lung protection in ARDS

Effective in improving oxygenation in adults when

started early

Adults with moderate-to-severe ARDS

Instituted early versus LTVV
May increase in-hospital mortality
OSCILLATE Trial
Multicenter, prospective, non-blinded, randomized
trial
HFOV versus control (LTVV)
548 intubated pts with early moderate-severe
ARDS
Primary outcome of in-hospital mortality
47% versus 35%
Secondary outcomes
ICU mortality 45% vs 31%
28 day mortality 40% vs 29%
MV in survivors 11 days vs 10 days
Hospital days survivors 30 days vs 25 days
Multiple criticisms
BETA-2 AGONISTS
Beta-2 Agonists in ARDS
Several studies shown improved physiological outcomes

Randomized control trial

IV albuterol (15 mcg/kg/hr) versus placebo
Less lung water (9 vs 13 mL/kg)
Lower plateau airway pressure (24 vs 30 cmH2O)
Randomized control trial
Aerosolized albuterol (5 mg) or placebo q4 hours for up to 10
days
No differences in ventilator-free days or hospital mortality
Beta-agonist Lung Injury Trial (BALTI-2)
IV salbutamol vs placebo
Terminated early due to increased mortality in the salbutamol
group

Grade 1B
Recommend against use of beta-agonists for people with
ARDS
NEUROMUSCULAR BLOCKADE
Neuromuscular Blockers (NMBs)
Long history of use in the ICU
Previously, no protocolized use of NMBs

Multi-center trial in 2010

340 intubated patients with severe ARDS (P/F ratio of <
150)
Randomized to cisatracurium besylate versus placebo
for 48 hours
All patients received LTVV + minimum PEEP 5
Both groups received deep sedation
Adjusted 90-day in-hospital mortality rate was lower
with NMB versus placebo
No increased neuromuscular weakness was observed
Increased number of ventilator-free days
Neuromuscular Blockers (NMBs)
Possible pathways of benefit
Limiting lung injury arising from ventilator desynchrony
Increased pneumothoraxes seen in placebo group

Less biotrauma evidenced by less end-organ failure

Reduction in serum cytokines

Limits expiratory muscle function reducing respiratory

system collapse and de-recruitment
Improved compliance
Improved VA matching

Recent studies support direct anti-inflammatory effects

of blocking nicotinic acetylcholine receptor-alpha 1
PRONE POSITIONING
Prone Positioning
Prior to 2013
Known that prone positioning improved oxygenation in
ARDS
Failed to show improved mortality

Fears and concerns over prone positioning

Facial edema
Skin breakdown (pressure necrosis)
Transient desaturations
Dislodgement of line, endotracheal tubes
Hemodynamic instability
Prone Positioning
2013 Study of Prone Positioning
466 patients
Randomized patients to prone positioning for at least 16
hours/day versus standard positioning
Severe ARDS (PaO2/FiO2 < 150) and proned within 36 hours
of intubation and after 12-24 hours of stabilization
LTVV and PEEP at least 5
28-day mortality (32.8% versus 16% prone)
Benefit persisted until day 90
No significant difference in complications between groups
Except, increased rate of cardiac arrest in the supine group

Considerations
Study took place in center with experience in prone
positioning
Prone Positioning
Benefits
Improved lung ventilation perfusion matching

Improved right ventricular dysfunction

Recruitment of lower-lobe atelectatic lung units

Decreased intrapulmonary shunting

Improved maintenance of open lung units

Limiting ventilator induced lung injury

Improved secretion clearance (gravitational)

FLUID MANAGEMENT
Fluid Management
ARDS is an increased vascular permeability state
Hydrostatic versus oncotic pressures

Study of 1000 patients (FACTT Trial)

Randomized to conservative or liberal fluid management
strategy for 7 days
CVP < 4 mmHg versus CVP 10-14 mmHg
Cumulative fluid balance was -136 mL vs +6992 mL
Conservative group improved oxygenation index and lung
injury score and increased ventilator-free days (15 vs 12) and
ICU-free days (13 vs 11)
60 day mortality was unchanged
Mean CVP remained above goal

Grade 1C Recommendations are conservative fluid

management with use of albumin and furosemide
NONINVASIVE VENTILATION &
OXYGENATION
Invasive versus Noninvasive
Majority use invasive MV for ARDS

Who is appropriate for noninvasive ventilation

Hemodynamically stable
Easily oxygenation
Does not need immediate intubation
Intubation is not an option
No contraindications

Conflicting data regarding benefits and harm

Studies on NIV
Single-center trial of 83 patients
Patients requiring full face mask NIV for 8 hours
Mild to moderate disease
Randomized face mask versus helmet
Reduced need for intubation (18% vs 62%)
Higher rate of ventilator-free days
Shorter ICU stay
Lower 90-day mortality without an increase in adverse
effects

Study was stopped early so outcomes may have been

exaggerated based on effect size
Studies on NIV
Small randomized control trial of 40 patients
NIV versus high concentration supplemental oxygen
NIV arm better improvement of PaO2/FiO2
Less likely to require intubation (4.8% vs 36.8%)

Limitations
Small study (size effect imprecise)
Selection bias by physicians based on preference for NIV
Caregivers were not blinded (may influence decision to
intubate)
Exclusion criteria
Patients > 70 years old
Multiple organ failure
PaO2/FiO2 < 200
Studies on NIV
Study of hypoxemic respiratory failure
NIV versus high flow nasal cannula
Increased mortality in association with NIV

Etiology of potential harm

Higher than expected tidal volumes in NIV?

Grade 2B NIV only in a select minority of

patients with sepsis-induced ARDS
PULMONARY ARTERY CATHETERS
Swan-Ganz Catheters in ARDS
The best available evidence strongly suggests that
pulmonary artery catheters do not improve
management of patients with ARDS, either with or
without shock

Grade 1A Recommends against use of PA

catheters as part of routine management of ARDS
TRACHESOTOMY
Early vs Late Tracheostomy
January 2015 Cochrane Review
All critically ill patients
Mortality in 10 days or > 10 days
8 studies and 1977 patients
Early tracheostomy had lower risk of mortality
Did not have subgroup characteristics to determine best
selection for either strategy
11 early tracheostomy to prevent 1 death in late
tracheostomy
Suggestion of benefit of time off mechanical ventilation
in the early tracheostomy group
Higher discharge from the ICU at 28 days
No significant differences in pneumonia rates
LIQUID VENTILATION
Liquid Ventilation
Oxygenation perfluorocarbon mixtures

Types of Liquid Ventilation

Total Liquid Ventilation
Special ventilator
Lungs and circuit are liquid filled
Partial Liquid Ventilation
Liquid PEEP
Lungs filled with liquid, but ventilated with a gas tidal volume
(conventional ventilator on top of a liquid FRC)

Advantages
Improve compliance and gas distribution
Lower resistance to expansion (easier to distend the lung with liquid)
Easier to open and maintain alveolar volume with liquid than gas (less
damage)
Alveoli are flushed of debris (decreases inflammation)
Perfluorocarbon decreases neutrophilic and macrophage chemotactic
and phagocytic responses

Experimental
INEFFECTIVE OR HARMFUL THERAPIES
Ineffective or Harmful Therapies
N-acetylcysteine
Procysteine
Glutamine
Antioxidants
Selenium, beta carotene, zinc, vitamin E and C
Lisophylline
Intravenous prostaglandin E1
Neutrophil elastase inhibitors
Ibuprofen
Activated protein C (Xigris)
Ketoconazole
Statins
EXTRACORPOREAL MEMBRANE
OXYGENATION
Introduction to ECMO
Partial cardiopulmonary bypass
First successful adult ECMO support was 1972
Types of ECMO
Arteriovenous (AV)
Uses patients own blood pressure to more the blood
through the circuit
Venovenous (VV)
Takes blood from a large vein and returns to a large vein
Does not support cardiac output
Venoarterial (VA)
Deoxygenated blood from a central vein and returns to
the arterial system, usually the aorta
Partial cardiac output support
CESAR Trial
Conventional ventilation versus ECMO for Severe
Adults Respiratory failure
EXTRACORPOREAL CO2 REMOVAL
Extracorporeal CO2 Removal
Veno-venous (or arterio-venous) extracorporeal
device at low blood flow rates (300-1000 mLmin)
Traditional ECMO 3-5 L/min
Flow rates are similar to renal replacement therapy
Use smaller cannulas

Adequate for substantial CO2 removal but only

minimal blood oxygenation

Facilitate ultraprotective lung ventilation

Tidal volumes <= 4 mLkg
Extracorporeal CO2 Removal Studies
Prospective cohort study [2009]
CO2 removal device to reduce tidal volume to < 6 mLkg
Observed improvement of morphological markers of lung
protection

Randomized control trial [2013]

Very log tidal volume (3 mLkg) + arterio-venous CO2 removal
versus conventional protective ventilation
79 patients
Safe, feasible and without physiologically relevant
hypercapnia/acidosis
Significant reduction in analgesic and sedative use
Increased ratio of spontaneous breathing compared with controls
Serum levels of pro-inflammatory cytokine IL-6 significantly
reduced
Overall did not reduce mechanical ventilation, ICU or hospital
stay
Post hoc analysis indicated that in most hypoxemic patients
(PaO2/FiO2 < 150)
Had significantly shorter ventilation period
Questions and Answers

THE END
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