Acute respiratory distress syndrome

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  • 1. INSUFICINCIA RESPIRATRIAAGUDA CONCEITOS BSICOSETIOPATOGENIA DIAGNSTICO TRATAMENTOCarlos Darcy Alves Bersot TSA.SBAMD RESPONSVEL PELO CET H.F.LAGOA Mdico Anestesiologista do Hospital Federal da Lagoa - SUS Mdico Anestesiologista do Hospital Universitrio Pedro Ernesto-UERJ

2. INSUFICINCIA RESPIRATRIA AGUDACONCEITO:DISTRBIO RESPIRATRIO CARACTERIZADOPOR REDUO DA:CAPTAO DEO2 ;ELIMINAO DO CO2OFERTA DE O2 AOS TECIDOSRISCO DE VIDA 3. CAUSAS DE INSUFICINCIA RESPIRATRIA AGUDA Distrbios:Vias areasParnquima PulmonarCirculao PulmonarParede Torcica - CaixaFunes Neuromusculares 4. CAUSAS DE INSUFICINCIA RESPIRATRIA AGUDA Distrbios das Vias Areas Asma Bronquite Crnica/Enfisema- Agudizado Obstruo das Vias AreasA nvel de:FaringeLaringeTraquia e Bronquios 5. CAUSAS DE INSUFICINCIARESPIRATRIA AGUDADisfuno do Parenquima PulmonarSndrome de Angustia Respiratria AgudaIsuficincia Cardaca CongestivaPneumoniasPneumonite AlrgicaAspiraoPs-operatrio 6. CAUSAS DE INSUFICINCIARESPIRATRIA AGUDADisfuno da Parede TorcicaTraumatismo e pneumotraxEsmagamento ou Fratura da Arcada Costal- Flail Chest 7. CAUSAS DE INSUFICINCIARESPIRATRIA AGUDADisfuno do Circulao PulmonarEmbolia Pulmonar AgudaShunts 8. CAUSAS DE INSUFICINCIA RESPIRATRIA AGUDA Disfunes NeuromuscularesHipnoanalgsicos/Sedativos/BNMSndrome de Guillain-BarrBotulismoLeso da ColunaMiastenia GravisPoliomieliteAcidente Vascular Enceflico - AVC 9. INSUFICINCIA RESPIRATRIAAGUDASinais e SintomasDispniaCianoseAnsiedade/Agitao/Confuso Mental/DelrioTaquipniaTaquicardiaHipertenso ArterialArritmias CardacasTremorDispnia / Cefalia 10. INSUFICINCIA RESPIRATRIAAGUDADiagnsticoDiagnstico Clnico Sinais e SintomasDiagnstico Laboratorial Gasometria Arterial e Venosa 11. INSUFICINCIA RESPIRATRIAAGUDATratamentoSUPORTE RESPIRATRIOManter a tenso de O2 prximo de90 mmHgVentilao Mecnica- IndicaoIntubao orotraqueal/TraqueostomiaRespiradoresSuporte ao PacienteComplicaes 12. FISIOPATOLOGIA DA SARA(Sndrome de Angustia Respiratria Aguda)_ 13. Sndrome de Angustia Respiratria AgudaINTRODUO : SNDROME CARACTERIZADA POR:Hipoxemia Resistente a OxigenoterapiaPadro Radiogrfico de Infiltrado difusoAusncia de Evidencia Clnica ou Radiolgica deInsuficincia Cardaca 14. Sndrome de Angustia Respiratria AgudaONSETARTERIALCHEST LEFT ATRIAL OXYGENATION RADIOGRAPH PRESSURE ACUTEAcutePaO2/FiO2 300Bilateral PWP 18 mmHg orLUNG mmHg with orpulmonaryabsence of left heart INJURYwithout positive infiltrates failure end expiratory pressure (PEEP)ARDSAcutePaO2/FiO2 200 BilateralPWP 18 mmHg or no mmHg PEEP pulmonary evidence of left heart infilitrates failureAmericanEuropean Consensus Conference definitions of acute lung injury and acute respiratory distress syndrome .Mmodified with permissionfrom Canonico and Brigham 15. CAUSAS DE SARALeso Direta do PulmoLeso Indireta do PulmoPneumoniasCausas comuns -Sepsis Aspirao de contedo GstricoTrauma Severo No PulmonarContuso PulmonarEmbolias - GordurosaChoqueAfogamentos Transfuses Sangneas.Inalao de FumaaBypass em Cirurgia CardacaEdema de ReperfusoIntoxicaes por DrogasAps TransplantesPancreatite AgudaTransfuses de Hemoderivados 16. Sndrome de Angustia Respiratria AgudaUnidade Alvolo-CapilarUma Barreira ? 17. Sndrome de Angustia Respiratria Aguda Barreira Aveolo-Epitelial 18. Sndrome de Angustia Respiratria Aguda Adhesion Molecules on the Alveolar capillary membrane. ICAM SelectinasCaderinas Ocludinas 19. Sndrome de Angustia Respiratria AgudaMicrograph of intestinal ischemia-reperfusion elicited lung inflammation stained for ICAM-1 (blue),neutrophils (pink) and fluorosceinlabed albumin to delinate the vascular space (green). Systemicinflammation induces marked lung leukocyte retention, neutrophil-endothelial cell interaction andfluid and protein extravasation. Image courtesy of D. Carden, V. Specian and R. Specian. 20. Sndrome de Angustia Respiratria AgudaOS NEUTRFILOS NA SARA OS MACRFAGOSALVEOLARESNeutrfilos de RetenoConstitui cerca de 90%Pequenos Procedimentos CirrgicosClulas Residentes no PulmoLesado Influencia do Complemento Citocinas IL-1 & TNFNeutrfilos de InjriaOxidantes - Radicais Livres de O2Proteases - Elastases; ColagenasesProtenas Catinicas 21. Sndrome de Angustia Respiratria AgudaClinical Lung InjuryAlveolar EpithelialEpithelial Damage Damage 22. Sndrome de Angustia Respiratria AgudaAlveolar Epithelial DamageType II PneumocyteDamage Acute RespiratoryFailureDecreased Surfactant Production Right to Left ShuntAtelectasis andHyaline MembraneImpaired LungFormation, and ComplianceFinaly Fibrosis 23. Sndrome de Angustia Respiratria AgudaTratamentoSUPORTE RESPIRATRIOManter a tenso de O2 < 90 mmHgVentilao MecnicaRespiradoresSuporte ao PacienteComplicaes 24. Sndrome de Angustia Respiratria Aguda Endothelialdamage Acute respiratoryfailurePlatelet agregation Right to left shunt hyaline membraneNeurotrophil aggregation and formation, and release of mediators:finaly fibrosisOxygen radicals, proteolytic enzimes,arachdonic acid metabolites and PAF Pulmoray edema andhemorrage with severeimpairment of alveolar Alveolocapillryventilationmembrane permeabilityExudation of fluid, protein RBCs, into intersticium 25. Sndrome de Angustia Respiratria AgudaEndothelial damageEndotoxin Complement C5aRelease ofMacrophageactivation cytokines (TNF, IL-1) mobilizationNeurotrophil aggregation and release of mediators: Acute respiratoryOxygen radicals, proteolytic enzimes, failurearachdonic acid metabolites and PAFVasoconstriction V/Q mismatchingDecreased flow to selected areas 26. Sndrome de Angustia Respiratria AgudaThe Normal Alveolus (Left-Hand Side) and the InjuredAlveolus in the Acute Phase ofAcute Lung Injury and theAcute Respiratory DistressSyndrome (Right-Hand Side). 27. Sndrome de Angustia Respiratria AgudaMechanisms Important in theResolution of Acute Lung Injuryand the Acute Respiratory DistressSyndrome. 28. Sndrome de Angustia Respiratria AgudaFindings on Light Microscopy during the Acute Phase (Panel A D) andthe Fibrosing-Alveolitis Phase (Panels B and C) of Acute Lung Injury andthe Acute Respiratory Distress Syndrome. 29. Sndrome de Angustia Respiratria AgudaFindings on Electron Microscopy during the Acute Phase and theFibrosing-Alveolitis Phase of Acute Lung Injury and the Acute RespiratoryDistress Syndrome. 30. Sndrome de Angustia Respiratria AgudaRadiographic Findings in the Acute, or Exudative, Phase (Panels A and B)and the Fibrosing-Alveolitis Phase (Panel B) of Acute Lung Injury and theARDS. 31. Sndrome de Angustia Respiratria AgudaComputed Tomographic (CT) Findings in the Acute, orExudative, Phase (Panels A and B) and the Fibrosing-AlveolitisPhase (Panel B) of Acute Lung Injury and the ARDS. 32. Sndrome de Angustia Respiratria Aguda AB Severe acute lung injury induced by gemcitabine. A. Erect radiograph showing multiple small ill-defined opacities. B. AP supineradiograph 4 days after gemcitabine administration showing perihilar ground glassinterstitial pattern graduating to na alveolar pattern in the more peripheral lung. Thechanges in cardiac and mediastinal contour are mainly due to position and projection. 33. Sndrome de Angustia Respiratria Aguda HISTORY OF ALTERNATIVE VENTILATORY STRATEGIES FOR ACUTE LUNG INJURY ANDTHE ACUTE RESPIRATORY DISTRESS SYNDROME.VENTILATORY STRATEGY YEAR TYPE OF NO.STUDY PATIENTSFINDINGS STUDYHigh levels of positive1975 Observational 28 High incidenceKirby et al.end-expiratory pressureof pneumothoraxProphylactic positive1984 Phase 3 single 92No benefit in patients Pepe et al.end expiratory pressurecenter trialat risk for the ARDSProne positioning during 2000 Observationa39 Inconclusive,Nakos et al.ventilationneeds further studyLow tidal volumes2000 Phase 3 861Decreased mortality Acute espiratoryby 22 percentDistress Syndrome (as compared with traditional Network tidal volumes 34. Sndrome de Angustia Respiratria Aguda RESULTS OF CLINICAL TRIALS OF PHARMACOLOGIC TREATMENT FOR ACUTE LUNG INJURY AND THE ACUTE RESPIRATORY DISTRESS SYNDROMEVENTILATORY STRATEGY YEAR TYPE OF NO.STUDY PATIENTSFINDINGSSTUDYGlucocorticoids (during1987 Phase 3 87No benefitBernard etthe acute phase)Glucocorticoids during thefibrosing-alveolitis phase 1998 Phase 3 24 Decreased mortality, but Meduri et al. study was smallInhaled nitric oxide1999Phase 3 203No benefit Payen et al.Ketoconazole2000Phase 2 234No benefit NIH AcuteRespiratoryDistressSyndromeNetwork