Ventilator associated lung injury: Difference between revisions
(updates)
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==Differential Diagnosis==
==Differential Diagnosis==
* [[Acute respiratory distress syndrome|ARDS]]
* [[Acute respiratory distress syndrome|ARDS]]
* [[Pulmonary Edema]]
* Cardiogenic [[Pulmonary Edema]]
* Acute exacerbation of idiopathic [[pulmonary fibrosis]]
* [[Pneumonia]]
* [[Pneumonia]]
* [[PE]]
* [[PE]]
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* Equipment failure  
* Equipment failure  
==Evaluation==
==Evaluation==
===== Check for [[Deterioration after intubation (DOPE)]]=====
===== Overview =====
* D - Displacement of tube → Attach end-tidal CO2 to verify and check depth (cm at lip)
*VALI does NOT need to be distinguished from [[Acute respiratory distress syndrome]]''' because evaluation and management are the same.<ref name="NEJM">Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.</ref>
* O - Obstruction of tube/circuit → Use suction catheter to remove mucus plug, or make sure patient not biting down
*Both VALI and ARDS are a diagnosis of exclusion.
* P - Pneumothorax → Verify via ultrasound, CXR, or needle thoracostomy (high suspicion)
*Check for [[Deterioration after intubation (DOPE)]] and exclude other etiologies.
* E - Equipment failure → Connect to BVM
 
* S - Stacked breaths → Auto-PEEP especially in COPD/Asthma → Disconnect from ventilator
=====Imaging=====
*CXR
*Echocardiography
 
=====Labs=====
*BNP - below 100 pg/mL favors ARDS, but higher levels neither confirm heart failure nor exclude ARDS<ref name="Lev">Levitt JE, Vinayak AG, Gehlbach BK, et al. Diagnostic utility of B-type natriuretic peptide in critically ill patients with pulmonary edema: a prospective cohort study. Crit Care 2008; 12:R3.</ref>
*CBC
 
===== Other=====
*Noninvasive respiratory sampling – the lower respiratory tract can be sampled via tracheobronchial aspiration or mini-bronchoalveolar lavage (mini-BAL). Tracheobronchial aspiration is performed by advancing a catheter through the endotracheal tube until resistance is met and then applying suction


'''VALI does NOT need to be distinguished from [[Acute respiratory distress syndrome]]''' because evaluation and management are the same.<ref name="NEJM">Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.</ref>
* CXR
* CBC
* Chem 10
* UA
* LFT
* Lipase
* PT/PTT
* Influenza (seasonal)
* Blood cultures
* Lactate
* Consider bedside echo
* Consider ABG/VBG
* Consider BNP
==Management==
==Management==
'''Prevention is key with ventilator lung protective settings.  
'''Prevention is key with ventilator lung protective settings.  
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* Supportive care  
* Supportive care  
===== Ventilator Lung Protective Settings =====
===== Ventilator Lung Protective Settings =====
* '''Mode''': AC (Assist Control). - Fully supported mode (rather than partially supported) on either volume (better studied) or pressure control (both acceptable).  
{| class="wikitable"
* '''Tidal volume:''' 6ml/kg of predicted body weight (PBW)  
|-
* '''RR''': 12-14bpm  
! Variable !! Setting
* '''PEEP''' - cm H2O
|-
* '''I:E''' - 2
| Mode || Assist Control (AC) - Fully supported mode (rather than partially supported) on either volume (better studied) or pressure control (both acceptable).  
* '''Plateau pressure:''' ≤30 cm H2O
|-
| Tidal Volume || 6ml/kg of predicted body weight (PBW)  
|-
| Respiratory Rate || 12-14bpm
|-
| PEEP || 5cm H20
|-
| I:E || 2
|-
| Plateau Pressure || ≤30 cm H2O
|}




Revision as of 05:48, 2 August 2016

Background

  • Abbreviation: VALI
Terminology
  • An acute lung injury that is suspected to have developed during mechanical ventilation is termed ventilator-associated lung injury (VALI).
  • If it can be proven that the mechanical ventilation caused the acute lung injury it is termed ventilator-induced lung injury (VILI).
  • VALI is the appropriate term in most clinical situations because it is virtually impossible to prove causation outside of the research laboratory.
Epidemiology
Pathogenesis
  • VALI is alveolar injury caused by overexpansion of alveoli (volutrauma), repeated alveolar collapse and expansion (RACE), and cyclic atelectasis.
  • Eventually, in serve VALI/ARDS alveoli edema/bleeding and loss of surfactant can cause complete alveoli collapse. [2]

Clinical Features

  • Indistinguishable from ARDS.
Clinical signs
  • Hypoxemic - or requiring a greater fraction of inspired oxygen (FiO2) to maintain the same arterial oxygen tension.
  • Tachypneic
  • Tachycardic
  • VALI may also be associated with multiple organ dysfunction syndrome (MODS).[3]
Imaging
  • CXR - increased bilateral interstitial or alveolar opacities of any severity.
  • Computed tomography (CT) - heterogeneous consolidation and atelectasis, as well as focal hyperlucent areas that represent overdistended lung.[4]

Differential Diagnosis

Evaluation

Overview
Imaging
  • CXR
  • Echocardiography
Labs
  • BNP - below 100 pg/mL favors ARDS, but higher levels neither confirm heart failure nor exclude ARDS[6]
  • CBC
Other
  • Noninvasive respiratory sampling – the lower respiratory tract can be sampled via tracheobronchial aspiration or mini-bronchoalveolar lavage (mini-BAL). Tracheobronchial aspiration is performed by advancing a catheter through the endotracheal tube until resistance is met and then applying suction

Management

Prevention is key with ventilator lung protective settings. Management is the same as ARDS:

  • Continue mechanical ventilation.
  • Apply lung protective settings.
  • Treat underlying causes.
  • Supportive care
Ventilator Lung Protective Settings
Variable Setting
Mode Assist Control (AC) - Fully supported mode (rather than partially supported) on either volume (better studied) or pressure control (both acceptable).
Tidal Volume 6ml/kg of predicted body weight (PBW)
Respiratory Rate 12-14bpm
PEEP 5cm H20
I:E 2
Plateau Pressure ≤30 cm H2O


Also see Ventilator Management

Disposition

  • Admit to ICU

See Also

Mechanical Ventilation Pages

External Links

LITFL - VALI

References

  1. ↑ Gajic O, Dara SI, Mendez JL, et al. Ventilator-associated lung injury in patients without acute lung injury at the onset of mechanical ventilation. Crit Care Med 2004; 32:1817.
  2. ↑ Rouby JJ, Brochard L (2007). "Tidal recruitment and overinflation in acute respiratory distress syndrome: yin and yang.". Am J Respir Crit Care Med 175 (2): 104–6. doi:10.1164/rccm.200610-1564ED. PMID 17200505.
  3. ↑ Plötz FB, Slutsky AS, van Vught AJ, Heijnen CJ. Ventilator-induced lung injury and multiple system organ failure: a critical review of facts and hypotheses. Intensive Care Med 2004; 30:1865.
  4. ↑ International consensus conferences in intensive care medicine: Ventilator-associated Lung Injury in ARDS. This official conference report was cosponsored by the American Thoracic Society, The European Society of Intensive Care Medicine, and The Societé de Réanimation de Langue Française, and was approved by the ATS Board of Directors, July 1999. Am J Respir Crit Care Med 1999; 160:2118.
  5. ↑ Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342:1301.
  6. ↑ Levitt JE, Vinayak AG, Gehlbach BK, et al. Diagnostic utility of B-type natriuretic peptide in critically ill patients with pulmonary edema: a prospective cohort study. Crit Care 2008; 12:R3.
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