1. Pediatric ARDS: Understanding It and Managing It James D. Fortenberry, MD Medical Director, Pediatric and Adult ECMO Medical Director, Critical Care Medicine Children’s Healthcare of Atlanta at Egleston

2. New and Improved Adult Respiratory Distress Syndrome Acute Respiratory Distress Syndrome

4. Clinical Disorders Associated with ARDS

5. The Problem: Lung Injury Other 4% Hemorrhage 5% Trauma 5% Noninfectious Pneumonia 14% Cardiac Arrest 12% Septic Syndrome 32% Infectious Pneumonia 28% Davis et al., J Peds 1993;123:35

10. ARDS:CT Scan View

15. Therapies for ARDS Innovations: NO PLV Proning Surfactant Anti-Inflammatory Mechanical Ventilation Gentle ventilation: Permissive hypercapnia Low tidal volume Open-lung HFOV ECMO IVOX IV gas exchange AVCO 2 R Total Implantable Artificial Lung ARDS Extrapulmonary Gas Exchange

18. Lung Injury Zones Atelectasis “ Sweet Spot” Overdistention

20. Lower Tidal Volumes for ARDS * * * p < .001 ARDS Network, NEJM, 342: 2000 22% decrease

21. Is turning the ARDS patient “prone” to be helpful?

25. Brief vs. Prolonged Prone Positioning in Children Oxygenation Index (OI) - Relvas et al., Chest 2003 * * **

26. High Frequency Oscillation: A Whole Lotta Shakin’ Goin’ On

27. It’s not absolute pressure, but volume or pressure swings that promote lung injury or atelectasis. - Reese Clark

29. High Frequency Oscillatory Ventilation

31. HFOV is the easiest way to find the ventilation “ sweet spot”

32. HFOV: Benefits Vs. Conventional Ventilation

33. HFOV vs. CMV in Pediatric Respiratory Failure - Arnold et al, CCM , 1994 *

37. Steroids in Unresolving ARDS * * p<.01 * - Meduri et al., JAMA, 1998

41. Inhaled NO and HFOV In Pediatric ARDS Dobyns et al., J Peds , 2000 *

42. Partial Liquid Ventilation

45. ARDS- “Mechanical” Therapies Prone positioning - Unproven outcome benefit Low tidal volumes - Outcome benefit in large study Open-lung strategy - Outcome benefit in small study HFOV -Outcome benefit in small study ECMO - Proven in neonates unproven in children

46. Pharmacologic Approaches to ARDS: Randomized Trials Glucocorticoids Fibrosing alveolitis - lowered mortality, small study Surfactant - possible benefit in children Inhaled NO - no benefit Partial liquid ventilation - no benefit

47. “…We must discard the old approach and continue to search for ways to improve mechanical ventilation. In the meantime, there is no substitute for the clinician standing by the ventilator…” - Martin J. Tobin, MD