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Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn The Department of Critical Care Medicine, The Hospital for Sick Children,

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Presentation on theme: "Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn The Department of Critical Care Medicine, The Hospital for Sick Children,"— Presentation transcript:

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2 Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Desmond Bohn The Department of Critical Care Medicine, The Hospital for Sick Children, Toronto

3 Paediatric BMT and Critical Care Sepsis Respiratory Airway obstruction Pneumonia/pneumonitis Pulmonary haemorrhage Interstitial pneumonitis ARDS Neurological Seizures Intracranial haemorrhage

4 Hepatic failure Venocclusive disease GVHD Renal failure Drug nephrotoxicity Cardiac failure Drug toxicity Paediatric BMT and Critical Care

5 ICU outcomes in paediatric BMT patients 31/176 patients admitted to ICU post BMT - 18% ARF15105 Septic shock532 Neurological disorders55 Heart failure22 Others422 n BMT BMT allogenicautologous Diaz de Heredia C Bone Marrow Transplantation 1999; 24: patients underwent mechanical ventilation - survival 46%

6 BAL in ventilated and non-ventilated in children after BMT Ben-Ari J Bone Marrow Transplantation 2001; 27:191 non-ventilated ventilated

7 Diffuse alveolar hemorrhage in pediatric BMT patients Heggen J Pediatrics 2002; 109:965

8 Diffuse alveolar hemorrhage in pediatric BMT patients Heggen J Pediatrics 2002; 109:965

9 Diffuse alveolar haemorrhage in BMT patients Presents with cough and tachypneoa No underlying infective aetiology Pulmonary haemorrhage on BAL Usually occurs following engraftment Incidence % Characterised by thrombocytopoenia but normal coagulation Treated with high dose steroids and PEEP High mortality

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11 Oxygenation Index PaO 2 /FiO 2 MAP x FiO 2 x 100 PaO 2 < 200 = ARDS >15 = severe ARDS Markers of oxygenation defect

12 Lung recruitment in ARDS

13 Froese AB, Crit Care Med 1997; 25:906 Goals: 1. Avoid Overdistention 2. Avoid Underinflation 3. Keep the lung open 4. Reduce FiO 2

14 Responses of baboons to prolonged hyperoxia Fracica PJ J Appl Physiol 1991; 71:2352 interstitial matrix alveolus PMN interstitial matrix alveolus normallethal toxicity - FiO for 110 h alveolus

15 Pulmonary oxygen toxicity Davis WB N Engl J Med 1983; 309:878 FiO for 17 hrs in healthy humans

16 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 VOLUME 342 MAY 4, 2000 NUMBER 18

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18 Infasurf Surfactant proteins B & C 42 children with ARDS Willson D Crit Care Med 1999; 27:188 Surfactant in ARDS

19 Nitric oxide in ARDS Dobyns EL J Pediatr 1999;134: hours12 hrs Change in P/F ratio from baseline Change in OI from baseline Control iNO * * * * 4 hours12 hrs

20 Nitric oxide in ARDS Dellinger RP Crit Care Med 1998; 26:15 Michael JR Am J Respir Crit Care Med 1999; 157:1372 n=177 n=40 n=30 Troncy E Am J Respir Crit Care Med 1997; 157:1483

21 Nitric oxide in ARDS 5 RCTs in adults 3 case series and 2 RCTs in pediatrics Physiological endpoints - improved oxygenation & reduction in PAP % of patients are responders No data suggests any improvement in outcome

22 Steroids in ARDS MODS ScoreOutcome Meduri GU JAMA 1998; 280:159

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24 Effect of prone position on survival in ARDS Gattinoni L N Engl J Med 2001; 345:568

25 Effect of prone position on survival in ARDS Gattinoni L N Engl J Med 2001; 345:568

26 304 patients randomised in 3 yrs Intention to treat End of study2521 ICU discharge Prone vs supine protocol End of study2722 ICU discharge *Patients with P/F < Mortality (%)SupineProne RCT of prone vs supine ventilation in ARDS/ALI Gattinoni L N Engl J Med 2001; 345:568

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28 HFOV in Paediatric ARDS CMVHFOV No. of patients2929 Duration of CMV80 ± ± 240 FiO ± ± 0.15 PEEP21 ± 522 ± 3 OI29 ± 1426 ± 10 Arnold J. Crit Care Med 1994; 22:1530

29 Algorithm for the use of HFOV MAP >5 cmH 2 O above CMV setting (25-30 cmH 2 O) High FiO 2 (>0.8) Maintain MAP for mins Attempt to decrease FiO 2 yes Decrease FiO 2 in increments to <0.6 no Increase the MAP in increments of 2 cmH 2 O Response usually at cmH 2 0

30 Oxygen extraction ratio = (CaO 2 - CvO 2 )/CaO 2 DO 2 = Q x CaO 2 Oxygen delivery/consumption VO 2 = Q x (CaO 2 - CvO 2 ). As DO 2 decreases VO 2 maintained by increased extraction.

31 Lamas (23%) Hagen (37%) Jacobe (41%) Keenan (16%) Rossi (44%) Warwick (40%) Diaz de Heredia (46%) Hayes (15%) Nichols (9%) Bojko (12%) Todd (11%) Number of Number Survival BMTsventilatedventilated patients Published outcomes in paediatric BMT patients admitted to ICU

32 AHRF: an integrated approach Pressure control ventilation (PIP <35 cmH 2 O) Prone position ventilation iNO ppm ?ECMO HFOV Negative fluid balance (furosimide)

33 Prognosis of paediatric BMT patients requiring ventilation Rossi R Crit Care Med 1999; 27:1181 n = 41

34 Prognosis of paediatric BMT patients requiring PPV Rossi R Crit Care Med 1999; 27:1181

35 Ventilation in paediatric BMT patients Hagen SA Pediatric Crit Care Med 2003; 4:206

36 Ventilation in paediatric BMT patients Hagen SA Pediatric Crit Care Med 2003; 4:206

37 Ventilation/Non-Dialytic Therapies in the Paediatric BMT Patient Acute respiratory failure requiring PPV in the BMT patient is associated with a high mortality Therapy should be focused on minimising ventilation induced lung injury Ventilation strategies that improve oxygenation may not improve O 2 delivery The development of hepato-renal failure is almost universally fatal

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