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ARDSDR.T.MOHANKUMAR,MD,AB,DPPR,FCCPCHIEF&SENIORCONSULTANT,DEPARTMENTOFPULMONOLOGY&CRITICALCARE,SRIRAMAKRISHNAHOSPITAL,COIMBATORE30/07/20001DR.T.M.K-ARDSARDSDR.T.MOHANKUMAR,MD,ABDIAGNOSTICCRITERIAARDSAcutePaO2/Fio2<200mmHgBilateralinterstitialoralveolarinfiltratesPcwp<15-18mmHgALIAcute<300mmHgSamesame30/07/20002DR.T.M.K-ARDSDIAGNOSTICCRITERIAARDSALI30/0ClinicaldiagnosisRapidWithin12to48hrofthepredisposingeventAwakepatientsbecomeanxious,agitated&dyspnoeicDyspnoeaonexertionproceedingtoseverewhenhypoxemiaintervenesStiffeningoflungleadstoincreaseworkofbreathing,smalltidalvolumes,rapidrespiratoryrateInitiallyrespiratoryalkalosisRespiratoryfailure30/07/20003DR.T.M.K-ARDSClinicaldiagnosisRapid30/07/2ClinicaldisordersassociatedwithARDSDirectlunginjuryAspirationofgastriccontentsPulmonarycontusionToxicgasinhalationNeardrowningDiffusepulmonaryinfectionIndirectlunginjurySeveresepsisMajortraumaHypertransfusionAcutepancreatitisDrugoverdoseReperfusioninjuryPostcardiacbypass/lungtransplants30/07/20004DR.T.M.K-ARDSClinicaldisordersassociatedClinicaldisordersassociatedwithARDSFREQUENTCAUSESSEPSISBACTEREMIAWITHOUTSEPSISSYNDROME4%SEVERESEPSIS/SEPSISSYNDROME35-45%MAJORTRAUMAMULTIPLEBONEFRACTURES5-10%PULMONARYCONTUSION17-22%HYPERTRANSFUSION5-36%ASPIRATIONOFGASTRICCONTENTS22-36%30/07/20005DR.T.M.K-ARDSClinicaldisordersassociatedCLINICALMANIFESTATIONSARDSoccursinthesettingofacutesevereillnessClinicalmanifestationsmayvarySepsisandtraumamostimportantMultipleorganfailureAtelectasisandfluidfilledlungsHypoxemia/dyspnoeaFever/leukocytosis30/07/20006DR.T.M.K-ARDSCLINICALMANIFESTATIONSARDSocLaboratorystudiesTodatenolabfindingspathognomonicofARDSX-raychestshowsbilateralinfiltratesconsistentwithpulmonaryedema,maybemildordense,interstitialoralveolar,patchyorconfluentABGshowshypoxemiawithrespiratoryalkalosis.

Inlatestageshypoxemia,acidosis,hypercarbiamaybeseen.30/07/20007DR.T.M.K-ARDSLaboratorystudiesTodatenolLeukocytosis/Leukopenia/anemiaarecommonRenalfunctionabnormalities/orliverfunctionVonwillebrand’sfactororcomplementinserummaybehighAcutephasereactantslikeceruloplasminorcytokine(TNF,IL-1,IL-6,IL-8)maybehigh.30/07/20008DR.T.M.K-ARDSLeukocytosis/Leukopenia/anemiaBRONCHOALVEOLARLAVAGEInflammatorymediatorslikecytokines,reactiveoxygenspecies,leukotrienes&activatedcomplementfragmentsarefoundinthefluidCellularanalysisshowsmorethan60%ofneutrophils.AsARDSresolvesneutrophilsarereplacedwithalveolarmacrophages.AnotherinterestingfindingisthepresenceofamarkerofpulmonaryfibrosiscalledprocollagenpeptideIII(PCPIII)andthiscorrelateswithmortality.Presenceofmoreeosinophilssuggesteosinophilicpneumonia,highlymphocytecountsmaybeseeninhypersensitivitypneumonitis,sarcoidosis,BOOP,orotheracuteformsofinterstitiallungdisease.30/07/20009DR.T.M.K-ARDSBRONCHOALVEOLARLAVAGEInflammaDifferentialdiagnosisInfectiouscausesBacteria-

Gmneg&pos,mycobacteriae,mycoplasma,rickettsia,chlamydiaViruses-

CMV,RSV,hantavirus,adenovirus,influenzavirusFungi-

H.capsulatum,C.immitisparasites-pneumocytiscarinii,toxoplasmagondii30/07/200010DR.T.M.K-ARDSDifferentialdiagnosisInfectioDifferentialDiagnosisNoninfectiouscausesCCFDrugs&toxins(paraquat,aspirin,heroin,narcotics,toxicgas,tricyclicantidepressants,acuteradiationpneumonitis)Idiopathic(esinophilicpneumonia,Acuteinterstitialpneumonitis,BOOP,sarcoidosis,rapidlyinvolvingidiopathicpulmonaryfibrosis)Immunologic(acutelupuspneumonitis,GoodPasturessyndrome,hypersensitivitypneumonitis)Metabolic(alveolarproteinosis)Miscellaneous(fatembolism,neuro/highaltitudepulmonaryoedema)Neoplastic

(leukemicinfiltration,lymphoma)30/07/200011DR.T.M.K-ARDSDifferentialDiagnosisNoninfeTherapy-goalsTreatmentoftheunderlyingprecipitatingeventCardio-respiratorysupportSpecifictherapiestargetedatthelunginjurySupportivetherapies30/07/200012DR.T.M.K-ARDSTherapy-goalsTreatmentoftheRespiratorySupport30/07/200013DR.T.M.K-ARDSRespiratorySupport30/07/20001SpontaneouslyBreathingPatientIntheearlystagesofARDSthehypoxiamaybecorrectedby40to60%inspiredoxygenwithCPAPPeakinspiratoryflowratesof>=70ltrs/minrequireatight-fittingfacemaskwithalargereservoirbagorahighflowgeneratorIfthepatientiswelloxygenatedon<=60%inspiredoxygenandapparentlystablewithoutCO2retentionandapparentlystable,thenwardmonitoringmaybefeasiblebutcloseobservation(15to30Min),continuousoximetry,andregularbloodgasesarerequiredContd..30/07/200014DR.T.M.K-ARDSSpontaneouslyBreathingPatienIndicationsformechanicalventilationInadequateOxygenation(PaO2<8kPaonFiO2>=0.6)RisingorelevatedPaCO2(>=6kPa)Clinicalsignsofincipientrespiratoryfailure30/07/200015DR.T.M.K-ARDSIndicationsformechanicalvenMechanicalVentilationTheAimsaretoincreasePaO2whileminimizingtheriskoffurtherlunginjury(Oxygentoxicity,Barotrauma).ThisistherealmoftheIRCUPhysician:seekspecialistadviceearlytopreventcomplications.Thegeneralprinciplesarethefollowing:Contd..30/07/200016DR.T.M.K-ARDSMechanicalVentilationTheAimsStartwithFiO2=1.0,tidalvolume6to10mlperKg,PEEP<=5cmH2Oandinspiratoryflowrates~60L/min.Subsequentadjustmentsaredonetotrytoachievearterialoxygensats.of>90%withFiO2<0.6andpeakairwaypressures<40to45cmH20ControlledMandatoryVentilation(CMV)withsedationandneuromuscularblockade(totrytosuppresstherespiratorydriveandreducerespiratorymuscleoxygenrequirement.)30/07/200017DR.T.M.K-ARDSStartwithFiO2=1.0,tidalvPEEPimprovesPaO2inmostpatientsandallowsreductionofFiO2.Increaseby2to5cmH2Oincrementsevery20minwatchingforhemodynamicdeterioration(duetoimpairedvenousreturnanddecreasedcardiacoutput).OptimalPEEPisusually10to15cmH2OInverseRatioVentilationmaydecreasepeekinflationpressuresandthusBarotrauma.Inspiratorytime:Expiratorytimeratio(I:Eratio)ofbetween1:1and4:1maybetried.Contd..30/07/200018DR.T.M.K-ARDSPEEPimprovesPaO2inmostpatTheventilatoryraterequiredtoclearCO2andnormalizepHiscommonlyhigh(20to25breaths/min).Howeverthismayresultinunacceptableairwaypressures.Anotherstrategyis’permissivehypercapnoea’whichasthenamesuggestsiscontrolledhypoventilation.PaCO2upto13kPaisgenerallywelltolerated;acidosis(pH<7.25)maybetreatedwithintravenousbicarbonate30/07/200019DR.T.M.K-ARDSTheventilatoryraterequiredChangingthepatientsposition(lateraldecubitusorproneinsteadofsupine)canimproveoxygenationbyimprovingperfusionofaeratedportionoflung.ConsiderthisinpatientswithnonuniformorpredominantlyposteriorandlowerlobeinfiltratesInhalednitricoxide(18ppm)reducespulmonaryarterypressures,intrapulmonaryshuntingandimprovesoxygenationwhilenotaffectingmeanarterialpressureorcardiacoutput.Howeverstudiesshowinganeffectonmortalityareawaited.Newermethodssuchashighfrequencyjetventilation,extracorporealgasexchange(CO2removal+-Oxygenation)andintravascularoxygenationdevices(IVOX)maybeofusebutarecurrentlynotwidelyavailable.30/07/200020DR.T.M.K-ARDSChangingthepatientspositionCardiovascularSupport30/07/200021DR.T.M.K-ARDSCardiovascularSupport30/07/20Invasivemonitoringismandatory(Arterialline,PAcatheter(Swan-Ganz)tomeasurecardiacoutputsandifavailable,continuousmixedvenousoxygensaturation)Inordertominimizepulmonaryoedema,aimtokeepPCWPlow(8to10mmHg)andsupportthecirculationwithinotropesifnecessaryTheroleofcolloidsandalbuminisrelativelyminor:theincreasedcapillarypermeabilityallowsthesemoleculestoequilibratewiththealveolarfluidwithlittleincreaseinnetplasmaoncoticpressureContd..30/07/200022DR.T.M.K-ARDSInvasivemonitoringismandatoRenalfailureiscommonandmayrequirehaemofiltrationtoachieveanegativefluidbalanceandnormalizebloodchemistry.Oxygenconsumption(VO2)inpatientswithARDSappearstobedeliverydependent.Thecurrenttrendistoaimfortargetlevelsofoxygendelivery(DO2=CardiacIndex(HbXSao2X1.34)X10)asguidedbytissueperfusion(clinicallyandserumlactate,pHifromagastrictonometer).DO2maybeincreasedbybloodtransfusion,inotropesandvasodilatorsincludingprostacyclin).30/07/200023DR.T.M.K-ARDSRenalfailureiscommonandmaSelectionofappropriateinotropesandvasodilatorscanonlybemadebyrepeatedmeasurementsofhaemodynamicparametersandcalculatingDO2andVO2whileevaluatingtheeffectsofthevariousagentsNutritionalsupportmustbechosentotrytoavoidfluidoverload.LipidmetabolismproducesmarginallylessCO2thandextrosemetabolismandthusfavourablyaffectstherespiratoryquotientbutthereiscontroversyastowhetherlipidcanexacerbatelunginjury30/07/200024DR.T.M.K-ARDSSelectionofappropriateinotrTreatmentofSepsis30/07/200025DR.T.M.K-ARDSTreatmentofSepsis30/07/20002Fever,Neutrophilleukocytosisandraisedinflammatorymarkers(CRP)arecommoninpatientswithARDSanddonotalwaysimplysepsis.HoweversepsisiscommonprecipitantofARDSAtrialofempiricalantibioticsguidedbypossiblepathogensshouldbegivenearly.EgCefotaxime.Thismaybemodifiedinlightoftheresultsofappropriatecultures.Avoidnephrotoxicantibiotics.Enteralfeedingseemstocarryalowerriskofsepsisthanparenteralfeedingandhelpsmaintaintheintegrityofthegutmucosa.Ileusiscommoninmulti-organfailure,soentralfeedingmaynotbepossible.30/07/200026DR.T.M.K-ARDSFever,NeutrophilleukocytosisMinimizinglunginjuryandtreatingthecause30/07/200027DR.T.M.K-ARDSMinimizinglunginjuryandtreLookforaprecipitantIngeneralprevention(exampleofaspirationofgastricacid)ismoreeffectivethantryingtotreatARDS.Howevertherearenoeffectivemeasuresforprophylaxisinpatientsatrisk(EgfromTrauma)Steroids:thereisnobenefitfromtreatmentearlyinthedisease.Treatmentlater(>7to14daysfromonset)especiallyinpatientswithperipheralbloodeosinophiliaoreosinophilsinbronchoalveolarlavage,improvesprognosis30/07/200028DR.T.M.K-ARDSLookforaprecipitant30/07/20Give2to4mg/Kgprednisoloneorequivalent:thedurationdependsontheclinicalresponse(1to3weeks)Othertherapiessuchasinhalednitricoxide,exogenoussurfactant,antioxidants(acetylcysteine),ketoconazole,NSAIDs,Pentoxifyllineandanticytokineantibodiesarestillunderinvestigation30/07/200029DR.T.M.K-ARDSGive2to4mg/KgprednisoloCausesofSuddendeteriorationinARDSRespiratoryCardiovascularPneumothoraxArrhythmiaBronchialpluggingCardiactamponadeDisplacedETtubeMyocardialinfarctionPleuraleffusion(Haemothorax)GIbleed(StressUlcer)Aspiration(EgNGfeed)Septicaemia30/07/200030DR.T.M.K-ARDSCausesofSuddendeteriorationCompletedtrialsReducinglungstretchingLisophyllinCorticosteroidsinlateARDSALVEOLIstudy30/07/200031DR.T.M.K-ARDSCompletedtrialsReducinglungCompletedtrials-IIFluidsandcatheterstreatmenttrial(FACTT)LowtidalvolumeversushightidalvolumeventilationKetoconazoleRoleofMODS30/07/200032DR.T.M.K-ARDSCompletedtrials-IIFluidsandWHATISNEW?ALI&GenetransferNewapproachestoenhancinglungedemaclearanceNitricoxidedonorsNewtreatmentforalteredpulmonaryvascularpermeabilityInflammatory&cytokinenetworksinARDS30/07/200033DR.T.M.K-ARDSWHATISNEW?ALI&GenetransfeWhatisnewUseofsurfactanttherapyLiquidventilationinALICPAPtrial30/07/200034DR.T.M.K-ARDSWhatisnewUseofsurfactanttARDSDR.T.MOHANKUMAR,MD,AB,DPPR,FCCPCHIEF&SENIORCONSULTANT,DEPARTMENTOFPULMONOLOGY&CRITICALCARE,SRIRAMAKRISHNAHOSPITAL,COIMBATORE30/07/200035DR.T.M.K-ARDSARDSDR.T.MOHANKUMAR,MD,ABDIAGNOSTICCRITERIAARDSAcutePaO2/Fio2<200mmHgBilateralinterstitialoralveolarinfiltratesPcwp<15-18mmHgALIAcute<300mmHgSamesame30/07/200036DR.T.M.K-ARDSDIAGNOSTICCRITERIAARDSALI30/0ClinicaldiagnosisRapidWithin12to48hrofthepredisposingeventAwakepatientsbecomeanxious,agitated&dyspnoeicDyspnoeaonexertionproceedingtoseverewhenhypoxemiaintervenesStiffeningoflungleadstoincreaseworkofbreathing,smalltidalvolumes,rapidrespiratoryrateInitiallyrespiratoryalkalosisRespiratoryfailure30/07/200037DR.T.M.K-ARDSClinicaldiagnosisRapid30/07/2ClinicaldisordersassociatedwithARDSDirectlunginjuryAspirationofgastriccontentsPulmonarycontusionToxicgasinhalationNeardrowningDiffusepulmonaryinfectionIndirectlunginjurySeveresepsisMajortraumaHypertransfusionAcutepancreatitisDrugoverdoseReperfusioninjuryPostcardiacbypass/lungtransplants30/07/200038DR.T.M.K-ARDSClinicaldisordersassociatedClinicaldisordersassociatedwithARDSFREQUENTCAUSESSEPSISBACTEREMIAWITHOUTSEPSISSYNDROME4%SEVERESEPSIS/SEPSISSYNDROME35-45%MAJORTRAUMAMULTIPLEBONEFRACTURES5-10%PULMONARYCONTUSION17-22%HYPERTRANSFUSION5-36%ASPIRATIONOFGASTRICCONTENTS22-36%30/07/200039DR.T.M.K-ARDSClinicaldisordersassociatedCLINICALMANIFESTATIONSARDSoccursinthesettingofacutesevereillnessClinicalmanifestationsmayvarySepsisandtraumamostimportantMultipleorganfailureAtelectasisandfluidfilledlungsHypoxemia/dyspnoeaFever/leukocytosis30/07/200040DR.T.M.K-ARDSCLINICALMANIFESTATIONSARDSocLaboratorystudiesTodatenolabfindingspathognomonicofARDSX-raychestshowsbilateralinfiltratesconsistentwithpulmonaryedema,maybemildordense,interstitialoralveolar,patchyorconfluentABGshowshypoxemiawithrespiratoryalkalosis.

Inlatestageshypoxemia,acidosis,hypercarbiamaybeseen.30/07/200041DR.T.M.K-ARDSLaboratorystudiesTodatenolLeukocytosis/Leukopenia/anemiaarecommonRenalfunctionabnormalities/orliverfunctionVonwillebrand’sfactororcomplementinserummaybehighAcutephasereactantslikeceruloplasminorcytokine(TNF,IL-1,IL-6,IL-8)maybehigh.30/07/200042DR.T.M.K-ARDSLeukocytosis/Leukopenia/anemiaBRONCHOALVEOLARLAVAGEInflammatorymediatorslikecytokines,reactiveoxygenspecies,leukotrienes&activatedcomplementfragmentsarefoundinthefluidCellularanalysisshowsmorethan60%ofneutrophils.AsARDSresolvesneutrophilsarereplacedwithalveolarmacrophages.AnotherinterestingfindingisthepresenceofamarkerofpulmonaryfibrosiscalledprocollagenpeptideIII(PCPIII)andthiscorrelateswithmortality.Presenceofmoreeosinophilssuggesteosinophilicpneumonia,highlymphocytecountsmaybeseeninhypersensitivitypneumonitis,sarcoidosis,BOOP,orotheracuteformsofinterstitiallungdisease.30/07/200043DR.T.M.K-ARDSBRONCHOALVEOLARLAVAGEInflammaDifferentialdiagnosisInfectiouscausesBacteria-

Gmneg&pos,mycobacteriae,mycoplasma,rickettsia,chlamydiaViruses-

CMV,RSV,hantavirus,adenovirus,influenzavirusFungi-

H.capsulatum,C.immitisparasites-pneumocytiscarinii,toxoplasmagondii30/07/200044DR.T.M.K-ARDSDifferentialdiagnosisInfectioDifferentialDiagnosisNoninfectiouscausesCCFDrugs&toxins(paraquat,aspirin,heroin,narcotics,toxicgas,tricyclicantidepressants,acuteradiationpneumonitis)Idiopathic(esinophilicpneumonia,Acuteinterstitialpneumonitis,BOOP,sarcoidosis,rapidlyinvolvingidiopathicpulmonaryfibrosis)Immunologic(acutelupuspneumonitis,GoodPasturessyndrome,hypersensitivitypneumonitis)Metabolic(alveolarproteinosis)Miscellaneous(fatembolism,neuro/highaltitudepulmonaryoedema)Neoplastic

(leukemicinfiltration,lymphoma)30/07/200045DR.T.M.K-ARDSDifferentialDiagnosisNoninfeTherapy-goalsTreatmentoftheunderlyingprecipitatingeventCardio-respiratorysupportSpecifictherapiestargetedatthelunginjurySupportivetherapies30/07/200046DR.T.M.K-ARDSTherapy-goalsTreatmentoftheRespiratorySupport30/07/200047DR.T.M.K-ARDSRespiratorySupport30/07/20001SpontaneouslyBreathingPatientIntheearlystagesofARDSthehypoxiamaybecorrectedby40to60%inspiredoxygenwithCPAPPeakinspiratoryflowratesof>=70ltrs/minrequireatight-fittingfacemaskwithalargereservoirbagorahighflowgeneratorIfthepatientiswelloxygenatedon<=60%inspiredoxygenandapparentlystablewithoutCO2retentionandapparentlystable,thenwardmonitoringmaybefeasiblebutcloseobservation(15to30Min),continuousoximetry,andregularbloodgasesarerequiredContd..30/07/200048DR.T.M.K-ARDSSpontaneouslyBreathingPatienIndicationsformechanicalventilationInadequateOxygenation(PaO2<8kPaonFiO2>=0.6)RisingorelevatedPaCO2(>=6kPa)Clinicalsignsofincipientrespiratoryfailure30/07/200049DR.T.M.K-ARDSIndicationsformechanicalvenMechanicalVentilationTheAimsaretoincreasePaO2whileminimizingtheriskoffurtherlunginjury(Oxygentoxicity,Barotrauma).ThisistherealmoftheIRCUPhysician:seekspecialistadviceearlytopreventcomplications.Thegeneralprinciplesarethefollowing:Contd..30/07/200050DR.T.M.K-ARDSMechanicalVentilationTheAimsStartwithFiO2=1.0,tidalvolume6to10mlperKg,PEEP<=5cmH2Oandinspiratoryflowrates~60L/min.Subsequentadjustmentsaredonetotrytoachievearterialoxygensats.of>90%withFiO2<0.6andpeakairwaypressures<40to45cmH20ControlledMandatoryVentilation(CMV)withsedationandneuromuscularblockade(totrytosuppresstherespiratorydriveandreducerespiratorymuscleoxygenrequirement.)30/07/200051DR.T.M.K-ARDSStartwithFiO2=1.0,tidalvPEEPimprovesPaO2inmostpatientsandallowsreductionofFiO2.Increaseby2to5cmH2Oincrementsevery20minwatchingforhemodynamicdeterioration(duetoimpairedvenousreturnanddecreasedcardiacoutput).OptimalPEEPisusually10to15cmH2OInverseRatioVentilationmaydecreasepeekinflationpressuresandthusBarotrauma.Inspiratorytime:Expiratorytimeratio(I:Eratio)ofbetween1:1and4:1maybetried.Contd..30/07/200052DR.T.M.K-ARDSPEEPimprovesPaO2inmostpatTheventilatoryraterequiredtoclearCO2andnormalizepHiscommonlyhigh(20to25breaths/min).Howeverthismayresultinunacceptableairwaypressures.Anotherstrategyis’permissivehypercapnoea’whichasthenamesuggestsiscontrolledhypoventilation.PaCO2upto13kPaisgenerallywelltolerated;acidosis(pH<7.25)maybetreatedwithintravenousbicarbonate30/07/200053DR.T.M.K-ARDSTheventilatoryraterequiredChangingthepatientsposition(lateraldecubitusorproneinsteadofsupine)canimproveoxygenationbyimprovingperfusionofaeratedportionoflung.ConsiderthisinpatientswithnonuniformorpredominantlyposteriorandlowerlobeinfiltratesInhalednitricoxide(18ppm)reducespulmonaryarterypressures,intrapulmonaryshuntingandimprovesoxygenationwhilenotaffectingmeanarterialpressureorcardiacoutput.Howeverstudiesshowinganeffectonmortalityareawaited.Newermethodssuchashighfrequencyjetventilation,extracorporealgasexchange(CO2removal+-Oxygenation)andintravascularoxygenationdevices(IVOX)maybeofusebutarecurrentlynotwidelyavailable.30/07/200054DR.T.M.K-ARDSChangingthepatientspositionCardiovascularSupport30/07/200055DR.T.M.K-ARDSCardiovascularSupport30/07/20Invasivemonitoringismandatory(Arterialline,PAcatheter(Swan-Ganz)tomeasurecardiacoutputsandifavailable,continuousmixedvenousoxygensaturation)Inordertominimizepulmonaryoedema,aimtokeepPCWPlow(8to10mmHg)andsupportthecirculationwithinotropesifnecessaryTheroleofcolloidsandalbuminisrelativelyminor:theincreasedcapillarypermeabilityallowsthesemoleculestoequilibratewiththealveolarfluidwithlittleincreaseinnetplasmaoncoticpressureContd..30/07/200056DR.T.M.K-ARDSInvasivemonitoringismandatoRenalfailureiscommonandmayrequirehaemofiltrationtoachieveanegativefluidbalanceandnormalizebloodchemistry.Oxygenconsumption(VO2)inpatientswithARDSappearstobedeliverydependent.Thecurrenttrendistoaimfortargetlevelsofoxygendelivery(DO2=CardiacIndex(HbXSao2X1.34)X10)asguidedbytissueperfusion(clinicallyandserumlactate,pHifromagastrictonometer).DO2maybeincreasedbybloodtransfusion,inotropesandvasodilatorsincludingprostacyclin).30/07/200057DR.T.M.K-ARDSRenalfailureiscommonandmaSelectionofappropriateinotropesandvasodilatorscanonlybemadebyrepeatedmeasurementsofhaemodynamicparametersandcalculatingDO2andVO2whileevaluatingtheeffectsofthevariousagentsNutritionalsupportmustbechosentotrytoavoidfluidoverload.LipidmetabolismproducesmarginallylessCO2thandextrosemetabolismandthusfavourablyaffectstherespiratoryquotientbutthereiscontroversyastowhetherlipidcanexacerbatelunginjury30/07/200058DR.T.M.K-ARDSSelectionofappropriateinotrTreatmentofSepsis30/07/200059DR.T.M.K-ARDSTreatmentofSepsis30/07/20002Fever,Neutrophilleukocytosisandraisedinflammatorymarkers(CRP)arecommoninpatientswithARDSanddonotalwaysimplysepsis.HoweversepsisiscommonprecipitantofARDSAtrialofempiricalantibiotics

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