• ALI and ARDS
    Link:www.jci.org/articles/view/60331/pdf
    • Improving oxygenation
      • Ventilator strategies
        • NIV
          IPPV using open lung approach
          Patient positioning
          High frequency ventilation
          Partial liquid ventilation
          ECMO
      • Pharmacological strategies
        • Nitric oxide (NO)
          Surfactant replacement
          Antioxidants
          Corticosteroids
          PG E1
          Ketoconazole
    • Mortality
      • ALI 45%
        ARDS 55%
      • Steroids no benefit
    • Diagnostic criteria
      • ALI
        • Hypoxia defined by PaO₂/FiO₂ <300mmHg
          Bilateral CXR infiltrates
          PCWP <18mmHg or no clinical evidence of raised LAP
      • ARDS
        • Same criteria except PaO₂/FiO₂ <200mmHg
      • Berlin definition based on:
        Link:bcrt.ca/wp-content/uploads/2012/06/jama.2012.Berlin-ARDS.pdf
        • TIming
        • Imaging
        • Origin of oedema
        • Oxygenation
    • Use 6ml/kg Vt, high PEEP to keep lung 'open', peak pressures <40cm H₂O, I:E 1:1-1:3, RR up to 35.
    • CESAR trial
      Link:www.frcamindmaps.org/trials.html
      • Benefit from ECMO (NNT 6)
    • Phases of ARDS
      • Exudative phase
        • 24-48hrs, lungs are filled with activated cells of inflammation, leading to endothelial injury and pulmonary oedema.
      • Proliferation phase
        • 2-7 days, the lungs are remodelled by fibroblasts.
      • Fibrotic phase
        • Alveolar thickening due to fibrosis of lung parenchyma.
    • Risk factors for ARDS
      • Direct lung injury
        • Aspiration
          Toxic inhalation
          Infection
          Near drowning
          Trauma - lung contusion
      • Indirect lung injury
        • Sepsis/SIRS
          Pancreatitis
          Massive transfusion
          Multiple trauma
          Fat embolism
    • 'A syndrome of inflammation and increased permeability leading to clinical, radiological and physiological abnormalities which cannot be explained by LA or pulmonary capillary hypertension.'
    • Fluid management (FACTT trial)
      • Less ventilation days with conservative fluid management and no increase in ANY adverse events but no mortality benefit
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/5/2/52.full.pdf
    • CEACCP
      Link:ceaccp.oxfordjournals.org/content/9/5/152.full.pdf