16. Lung Tissue Disorders - Airleaks + PARDS

Question 1

what are the 4 types of pulmonary air leaks?

Answer 1

• Pneumothorax
• Pneumomediastinum
• Pneumopericardium
• Pulmonary interstitial emphysema (PIE)

Question 2

1. Pulmonary air leak syndromes were common complications of ______ ________ in ________ _____ with _______ _______ _______ before the use of ________.
2. what are 4 newborn ventilator strategies used today with air leaks?

Answer 2

1. mechanical ventilation, premature infants with respiratory distress syndrome, surfactant
2. Minimize volutrauma and barotrauma, Permissive hypercapnia, High frequency ventilation, Non invasive ventilation

Question 3

1. premature infants at what age are at an increased risk for air leaks?
2. what are 2 most frequent risk factors?
3. what 3 parameters in MV can cause air leaks if they are high?
4. what do term babies occasionally develop shortly after birth? what increases the risk that this can occur at birth?

Answer 3

1. < 1000g
2. PPV and mechanical ventilation
3. Positive end-expiratory pressure, Peak inspiratory pressures, Prolonged inspiratory time
4. spontaneous airleak, PPV at birth

Question 4

1. what is a pneumothorax?
2. can also be what?
3. what should we be aware of?
4. what is the most reliable indicator that a pneumo is present in neonates?

Answer 4

1. Leakage of air into the pleural space
2. tension pneumo
3. cardiovascular effects
4. transillumination

Question 5

1. what is a pneumomediastinum?
2. where does the gas originate from?
3. the gas can track from _____ to the ______ or _____.

Answer 5

1. Leakage of air into the mediastinum
2. Gas may originate from the lungs, trachea, central bronchi, oesophagus, and peritoneal cavity
3. mediastinum to the abdomen or neck

Question 6

1. what is a pneumopericardium?
2. where does this gas come from?
3. what can this condition lead to?

Answer 6

1. Air enters the pericardial cavity and gets trapped in the pericardial sac
2. Air from the lungs, pneumomediastinum
3. cardiac tamponade

Question 7

1. what is the definition of Pulmonary Interstitial Emphysema (PIE)?
2. this is a result of what?
3. when is this condition commonly seen?
4. what procedure can cause this condition if done incorrectly?

Answer 7

1. Collection of gases in the interstitial tissue surrounding alveoli and airways
2. Result of alveolar and terminal bronchiolar rupture
3. overdistention and air trapping in premature patients
4. Unilateral surfactant administration

Question 8

what 8 things may commonly be seen on a CXR of a patient who has PIE?

Answer 8

• Air trapping and alveolar hyperinflation
• Depressed diaphragm
• Atelectasis
• May show focal or generalized problem areas
• Fine bubbly appearance extending from the hilum to the pleura
• Pneumomediastinum
• Pneumothorax
• Pneumopericardium

Question 9

1. what is considered the best treatment for airleak syndromes?
2. how can these syndromes be avoided? (hint 5)

Answer 9

1. PREVENTION
2. Ensure PPV pressure are monitored and minimized, Lowest mechanical ventilator pressures (PIP, PEEP), Permissive hypercapnia, Radiologic confirmation of the adequacy of PEEP and lung volume, High-frequency ventilation

Question 10

1. what type of ventilation has been considered helpful in treating pulmonary airleaks in infants?
2. what type of intubation strategy can be considered in neonates?

Answer 10

1. High-frequency ventilation (HFJV)

2. Selective intubation of the unaffected or less affected lung may allow the injured lung time to heal

Question 11

1. how should a pneumo initially be drained? what should be left in place after this?
2. how is a pneumopericardium drained?
3. what 2 airleaks can NOT be drained and should be resolved on their own?

Answer 11

1. Needle thoracentesis for pneumothorax then chest tube left in place
2. Pericardiocentesis
3. pneumomediastinum and PIE

Question 12

1. PARDS is acute lung injury characterized by?…..

2. what 2 things are also seen in these patients?

Answer 12

1. pulmonary edema and alveolar collapse secondary to the disruption of the alveolar–capillary membrane and surfactant dysfunction
2. Hypoxemia and widespread infiltrates on CXR

Question 13

2015 Pediatric Acute Lung Injury Consensus describes criteria for meeting the diagnosis of PARDS…….. (think of the chart)

1. what does the age category refer to?
2. what is the timing required for PARDS?
3. origin of edema?
4. what is seen on a CXR?
5. NIV oxygenation status? PF and SF ratio?

Answer 13

1. exclude patients with perinatal related lung disease
2. within 7 d of a known clinical insult
3. respiratory failure not fully explained by cardiac failure or fluid overload
4. new infiltrates consistent with acute pulmonary parenchymal disease
5. full face mask bi-level ventilation or CPAP >/= 5cmH2O (PF = = 300, SF = = 264)

Question 14

2015 Pediatric Acute Lung Injury Consensus describes criteria for meeting the diagnosis of PARDS CONT …….. (think of the chart)

1. oxygenation status with MV, mild severity? moderate? severe?
2. when considering the special populations….. what is said about cyanotic heart disease in relation to oxygenation?
3. what is said about chronic lung diseases?
4. what is said about left ventricular function?

Answer 14

1. mild = 4 = OI < 8 and 5 = OSI < 7.5, moderate = 8 = OI < 16 and 7.5 = OSI < 12.3, severe = OI >/= 16 and OSI >/= 12.3
2. standard criteria above for age, timing, origin of edema and CXR with an acute deterioration in oxygenation not explained by underlying cardiac diseases
3. standard criteria above for age, timing, origin of edema and CXR consistent with new infiltrates and acute deterioration in oxygenation from baseline which meet oxygenation criteria previously mentioned
4. standard criteria for age, timing, origin of edema and CXR changes consistent with new infiltrate and acute deterioration in oxygenation which meet criteria above not explained by LVD

Question 15

what 5 strategies are used when initiating lung protective ventilation?

Answer 15

• Low tidal volumes (3-6 ml/kg if poor compliance, 5-8 ml/kg if preserved compliance)
• Pplateau < 28 cmH2O
• Permissive hypoxemia (SpO2 88-92%)
• PEEP >10 cm H2O
• Permissive hypercapnia

Question 16

1. pediatric HFOV has ____ benefit, and may cause _____ ______ in adult ARDS.
2. small RCT’s show improved what? but there was no difference in what?
3. when should HFOV be considered in PARDS?

Answer 16

1. no, potential harm
2. improved oxygenation, no difference in mortality, duration of MV, or LOS.
3. moderate to severe PARDS and Pplateau >28 cm H2O.

Question 17

1. pediatric prone positioning showed a ___ _____ reduction in severe ARDS.
2. adult systemic reviews reported improved what? was also considered what? could potentially reduce mortality when coupled with what?
3. pediatric RCT reported what? but also reported no what?
4. when should proning be considered in PARDS?
5. not considered ______ ______.

Answer 17

1. 50% mortality
2. improved oxygenation, considered safe, coupled with lung protective strategies
3. reported safety but no difference in patient outcomes
4. option in cases of severe PARDS
5. routine therapy

Question 18

1. lung recruitment maneuvers improve _________ in adults with higher what?
2. what is considered safe in ARDS and PARDS? alos helps to improve what?

Answer 18

1. oxygenation with higher lung compliance

2. incremental PEEP titration is safe and improved oxygenation

Question 19

1. nitric oxide helps to improve what? with no impact on what?
2. not considered for _______ _____.
3. when can iNO be considered? (hint 3)

Answer 19

1. oxygenation, no impact on mortality
2. routine therapy
3. patients with known pulmonary hypertension, severe right ventricular dysfunction, or as bridge to ECMO.

Question 20

1. surfactant improves overall _______. however, there is no difference in ____, _______, and ______.
2. not recommended for _____ ______.

Answer 20

1. oxygenation. No difference in MV, LOS and mortality

2. routine use

Question 21

1. RCTS show potential _________ benefit from ECMO.

2. when should ECMO be considered? (hint 5)

Answer 21

1. mortality (strong evidence)
2. severe PARDS when lung-protective strategies result in inadequate gas exchange, after serial evaluations demonstrate deteriorating trend, Disease process must be deemed reversible or lung transplant suitable treatment, and high OI (20s-30s)