WEBVTT 1 00:00:10.400 --> 00:00:13.300 This is a very good platform for the young buddies or young 2 00:00:13.600 --> 00:00:18.800 physicians to learn about a few medical problems that 3 00:00:18.800 --> 00:00:22.000 you face to face on the routine practice. So one of those 4 00:00:22.000 --> 00:00:27.100 kind of routine syndrome or syndrome you can say 5 00:00:27.100 --> 00:00:31.500 that is acute respiratory distress syndrome. So to begin with I would 6 00:00:31.500 --> 00:00:36.600 like to outline our next one hour. So we'll be introducing 7 00:00:36.600 --> 00:00:42.200 with the definition, then the clinical history of the patients, pathophysiology behind 8 00:00:42.500 --> 00:00:47.000 ARDS, how to diagnose and how to manage. So to begin with, 9 00:00:47.300 --> 00:00:51.000 let's discuss a case. So let's say if you are working in 10 00:00:51.000 --> 00:00:56.100 your ICU or ER and you have this male patient 11 00:00:56.200 --> 00:01:00.500 who is 35 years old and he had met with an accident 12 00:01:01.000 --> 00:01:06.200 and was admitted with tachypnea, dyspnea within 24 hours of 13 00:01:06.200 --> 00:01:11.200 admission. So once you examine, then you have pulse of 110, 14 00:01:11.200 --> 00:01:15.600 BP higher on a higher lower side that is 80/50. Patient is 15 00:01:15.600 --> 00:01:21.100 pallor, cyanotic, but there is no JVP. Heart sounds are normal, 16 00:01:21.100 --> 00:01:26.100 chest on auscultation suggests bilateral rails in mid 17 00:01:26.100 --> 00:01:30.800 and lower areas. Abdomen is soft and there is no bowel sound 18 00:01:30.800 --> 00:01:35.800 or any heart sound. ABC we did because of tachypnea, dyspnea and 19 00:01:35.800 --> 00:01:41.400 hypertension and on 50% of FiO2. PaO2 was 40%, 20 00:01:41.400 --> 00:01:46.800 PaCO2 45% and pH was 7.3. So 21 00:01:47.000 --> 00:01:51.400 more or less it's a kind of dyspnea or breathlessness. We did 22 00:01:51.400 --> 00:01:55.400 X-ray and X-ray suggestive of this. So you can make out what 23 00:01:55.400 --> 00:02:00.800 X-ray has to say and after that we 24 00:02:00.800 --> 00:02:06.100 treated the patient. So on X-ray and on clinical examination 25 00:02:06.100 --> 00:02:10.000 we can find out the patient might be in ARDS, right? So 26 00:02:10.000 --> 00:02:14.500 now what is ARDS? That is acute respiratory distress syndrome. So it's 27 00:02:14.500 --> 00:02:18.400 a syndrome, it's a clinical syndrome. Uh it's not a particular disease, 28 00:02:18.400 --> 00:02:23.400 but uh it's one of the step behind after a few diseases. 29 00:02:23.800 --> 00:02:28.900 So it's a clinical syndrome of dyspnea of rapid onset, hypoxemia 30 00:02:29.000 --> 00:02:34.300 and diffuse pulmonary infiltrates leading to respiratory failure. So 31 00:02:34.300 --> 00:02:38.200 in this what happens actually that we'll discuss about pathophysiology, but in 32 00:02:38.200 --> 00:02:43.300 a nutshell you can say that inflammatory cells and the proteinaceous fluid 33 00:02:43.700 --> 00:02:49.300 accumulate in the alveolar spaces and it leads to the decreased 34 00:02:49.300 --> 00:02:55.400 diffusion capacity and because of that patient is having hypoxemia. So 35 00:02:55.400 --> 00:02:58.200 what is the difference between ALI that is acute lung injury and 36 00:02:58.200 --> 00:03:03.300 ARDS? So ALI term is used when your PaO2 FiO2 37 00:03:03.300 --> 00:03:07.700 ratio is less than 300. So that is called as significant hypoxia. 38 00:03:07.700 --> 00:03:12.900 So both whatsoever may be the condition if PaO2 39 00:03:13.100 --> 00:03:17.200 and FiO2 ratio that is PF ratio if it is less than 40 00:03:17.200 --> 00:03:21.400 300, then you can say that patient is having acute lung injury. 41 00:03:21.700 --> 00:03:26.900 It can be anything. So ARDS is a subset of ALI because 42 00:03:26.900 --> 00:03:31.400 in ARDS PF ratio is less than 200. So there are a 43 00:03:31.400 --> 00:03:34.800 few more conditions as well in which PF ratio is between 200 44 00:03:34.800 --> 00:03:39.200 to 300. Now that is not ARDS, but that is ALI. So 45 00:03:39.200 --> 00:03:44.500 ALI is a broad term and ARDS is one part of ALI 46 00:03:44.700 --> 00:03:49.400 and both can be differentiated by PF ratio. So any PF ratio 47 00:03:49.400 --> 00:03:55.300 between 200 to 300 is not ARDS, but definitely it is ALI. 48 00:03:56.000 --> 00:04:01.400 So this is the difference you can say that between ALI and 49 00:04:01.400 --> 00:04:06.500 ARDS. So both are acute as the A 50 00:04:06.500 --> 00:04:11.000 stands the first and foremost letters. So both are acute. Uh as 51 00:04:11.000 --> 00:04:14.100 I told you the PA difference of PF ratio, so if it 52 00:04:14.100 --> 00:04:17.100 is less than 300, then it is a broad ALI. If it 53 00:04:17.100 --> 00:04:22.100 is 200, then it is specific ARDS. Both are having bilateral interstitial 54 00:04:22.100 --> 00:04:27.400 or alveolar infiltrates and in both PCWP that is pulmonary capillary wedge 55 00:04:27.400 --> 00:04:32.300 pressure is less than 18. Now if both are same and if 56 00:04:32.300 --> 00:04:36.000 in both PCWP is less than 18, then what would be the 57 00:04:36.000 --> 00:04:40.100 condition in which PCW could be more than 18? So you think 58 00:04:40.100 --> 00:04:45.100 over it and during this session we'll discuss if PCWP is 59 00:04:45.100 --> 00:04:49.100 more than 18 and if PCW is less than 18, then what 60 00:04:49.100 --> 00:04:54.300 could be our management plan? So how to diagnose ARDS? 61 00:04:54.700 --> 00:05:00.000 So it should be acute. There has to be a predisposing condition. 62 00:05:00.000 --> 00:05:05.500 It cannot occur by itself. It it is because of some diseases 63 00:05:05.900 --> 00:05:10.400 and which presents as respiratory distress. So that's what is we called 64 00:05:10.400 --> 00:05:15.300 as it's a clinical syndrome. In uh you have to have bilateral 65 00:05:15.300 --> 00:05:19.700 infiltrates. If infiltrates would be only one side, then maybe it is 66 00:05:19.700 --> 00:05:24.100 not ARDS. PF ratio must be less than 200. If it is 67 00:05:24.100 --> 00:05:27.100 less more than 200, then it is not ARDS, it could be 68 00:05:27.100 --> 00:05:31.400 ALI. And PCWP that is pulmonary capillary wedge pressure should be less 69 00:05:31.400 --> 00:05:35.400 than 18. If it is more than 18, then we'll consider it 70 00:05:35.400 --> 00:05:39.800 as a different pathophysiology. So make sure that if you have this 71 00:05:39.800 --> 00:05:44.500 findings available, all of these findings available, then you can stamp it 72 00:05:44.600 --> 00:05:49.400 as ARDS. Otherwise we have to think something else. So it has 73 00:05:49.400 --> 00:05:54.600 to be acute. You have to have a predisposing condition. Patient on 74 00:05:54.600 --> 00:05:59.700 X-ray or CT scan must have bilateral infiltrates. PF ratio should 75 00:05:59.700 --> 00:06:04.500 be less than 200 and pulmonary capillary wedge pressure should be less 76 00:06:04.500 --> 00:06:10.200 than 18. So this is must for ARDS. Now 77 00:06:10.200 --> 00:06:13.200 causes it could be direct lung injury, it could be indirect lung 78 00:06:13.300 --> 00:06:18.600 injury. So indirect lung injury, pneumonia first and foremost that we think 79 00:06:18.600 --> 00:06:23.900 of pulmonary contusion because of trauma, in patients with near drowning, 80 00:06:24.200 --> 00:06:29.800 inhalational injury in commercial places and aspiration of gastric 81 00:06:29.800 --> 00:06:34.800 contents can lead to ARDS. What 82 00:06:34.800 --> 00:06:40.400 are the indirect lung injuries? So sepsis, sepsis because of anything, severe 83 00:06:40.400 --> 00:06:46.300 trauma versus with shock of hyperperfusion, acute pancreatitis 84 00:06:46.800 --> 00:06:51.900 and transfusion of multiple blood products. So ultimately 85 00:06:52.100 --> 00:06:56.000 if I have to remember three or four most common causes of 86 00:06:56.000 --> 00:07:01.600 ARDS, then first would be sepsis, second trauma, third acute pancreatitis 87 00:07:02.200 --> 00:07:07.500 and fourth one is lung direct lung injury because 88 00:07:07.500 --> 00:07:12.900 of any of these. So pancreatitis, trauma, sepsis can 89 00:07:13.000 --> 00:07:18.100 lead to ARDS and once you are you are treating such 90 00:07:18.100 --> 00:07:23.100 patient, then you have to forecast that this patient can go into 91 00:07:23.100 --> 00:07:29.200 ARDS and steps must be taken to avoid ARDS. Once 92 00:07:29.200 --> 00:07:34.200 it is developed, then your treatment strategy would be different. So 93 00:07:35.200 --> 00:07:39.700 in my opinion, if we are having such patients, then ARDS is 94 00:07:39.800 --> 00:07:45.100 not the presenting complaint within 24 hours. It will develop gradually 95 00:07:45.600 --> 00:07:48.600 and once it is developed, then it is very difficult to treat. 96 00:07:48.900 --> 00:07:54.700 So make sure that your patients don't go into ARDS situation. 97 00:07:55.700 --> 00:08:02.000 So pathophysiology there will be a diffuse alveolar damage. After 98 00:08:02.000 --> 00:08:06.400 that, lung capillaries would also be damaged. Inflammatory cells would be gathered 99 00:08:06.400 --> 00:08:11.500 into alveolar alveolar space and creates alveolar edema 100 00:08:11.500 --> 00:08:16.700 that gives rise to severe hypoxemia, decreased lung compliance and lastly pulmonary 101 00:08:16.700 --> 00:08:21.600 hypertension. Let's discuss one by one. So this is a normal alveoli 102 00:08:21.700 --> 00:08:25.100 on the left side. So in which you have type one cells, 103 00:08:25.400 --> 00:08:30.400 type two cells and surfactant layer and there are a few macrophages 104 00:08:30.400 --> 00:08:34.700 in the alveolar space. Outside alveoli you have interstitium and then blood 105 00:08:34.700 --> 00:08:39.800 vessels. In blood vessels also you have epithelial cell, endothelial cells 106 00:08:39.800 --> 00:08:43.800 and between these endothelial cells and epithelial cells of the alveoli there 107 00:08:43.800 --> 00:08:48.600 is a blood or gas exchange and there are very few microblasts 108 00:08:48.700 --> 00:08:53.800 or fibroblasts within the interstitial space. So interstitial space is very 109 00:08:53.800 --> 00:08:58.800 much looking transparent and easy gas exchange between normal alveolar space 110 00:08:59.300 --> 00:09:04.500 and the blood vessels. Now what happens if 111 00:09:05.000 --> 00:09:10.100 alveolus is injured during acute phase, then inflammatory reaction 112 00:09:10.200 --> 00:09:16.600 would come into place and because of that inflammatory reactions cytokine 113 00:09:16.600 --> 00:09:21.600 release IL-1, 2, 1, 6, 8, 10, TNF alpha, 114 00:09:21.600 --> 00:09:26.700 MIF would come into place and they don't activate the macrophages. Now 115 00:09:26.700 --> 00:09:32.300 this activated macrophages what they will do it will secrete leukotrienes, oxidants, 116 00:09:32.300 --> 00:09:37.600 PAF and proteases. Now these proteases would damage and apoptize 117 00:09:37.900 --> 00:09:42.600 or the type one and type two cells. And because of that 118 00:09:42.600 --> 00:09:47.400 there is a membrane disruption and because of that disruption there is 119 00:09:47.400 --> 00:09:52.600 an alveolar edema. The proteinaceous fluid will come into the alveoli. In 120 00:09:52.600 --> 00:09:57.400 interstitium there would be an edema. So widened edematous interstitium would be 121 00:09:57.400 --> 00:10:02.400 there. Neutrophils would be migrated from inside to outside and from another 122 00:10:02.400 --> 00:10:06.200 place to that place that secretes proteases and this proteases would further 123 00:10:06.200 --> 00:10:11.300 damage the alveolar cells as well as the endothelial cells. And 124 00:10:11.300 --> 00:10:16.800 now these endothelial cells again would decrease the transfusion of 125 00:10:16.800 --> 00:10:21.900 gases. So and there would be much of the fibroblast and procollagen 126 00:10:21.900 --> 00:10:27.000 within the interstitial space and that would create an inelastic 127 00:10:27.300 --> 00:10:34.000 or impermeable interstitial membrane. And because of this the 128 00:10:34.000 --> 00:10:39.300 transfusion of gases O2 and CO2 between alveoli to the blood vessels 129 00:10:39.300 --> 00:10:44.300 would be hampered and alveoli would be filled with 130 00:10:44.400 --> 00:10:49.400 proteinaceous fluid. There will be lack of surfactant layer and because 131 00:10:49.400 --> 00:10:54.600 of lack of surfactant layer and on fluids accumulation in the alveoli 132 00:10:54.600 --> 00:10:58.700 there would be collapse of alveoli. And because of that there would 133 00:10:58.700 --> 00:11:03.300 be increased dead space. So oxygenation would be decreased and because of 134 00:11:03.300 --> 00:11:09.400 lack of oxygenation patient would feel hypoxia. And whatever amount of FiO2 135 00:11:09.400 --> 00:11:14.100 you increase PaO2 will not be increased. And if PaO2 is not 136 00:11:14.100 --> 00:11:19.200 increasing in spite of FiO2, your PF ratio would go less than 137 00:11:19.200 --> 00:11:22.300 200. And if it is less than 200, then it fits into 138 00:11:22.300 --> 00:11:27.400 the definition of ARDS. So ARDS is nothing but the alveolar 139 00:11:27.400 --> 00:11:33.000 damage and because of the damage the whole cascade of inflammatory 140 00:11:33.000 --> 00:11:37.400 reaction come into place and because of that there will be collapse 141 00:11:37.400 --> 00:11:42.700 of alveoli. Proteinaceous fluid would be accumulated in the alveoli and 142 00:11:42.800 --> 00:11:48.000 decreased gas exchange between alveoli and blood vessels. And that 143 00:11:48.000 --> 00:11:54.000 would create this kind of picture in which fibronectin, myofibroblast, 144 00:11:54.100 --> 00:11:59.700 collagen cells and this the whole cascade would damage ultimately 145 00:11:59.700 --> 00:12:05.300 the alveoli and gas exchange. So this is the pathophysiology behind the 146 00:12:05.400 --> 00:12:09.800 ARDS. So if you see in the histopathology, then if a normal 147 00:12:09.800 --> 00:12:13.800 lung you can see in the lower picture. So the large alveolar 148 00:12:13.800 --> 00:12:19.300 volumes, septal spaces very thin, septa are very thin and 149 00:12:19.300 --> 00:12:24.400 no cellular congestion. And in comparison to the upper picture, there is 150 00:12:24.400 --> 00:12:29.800 a hyaline protein air in the spaces, cellular congestion, thickened interstitial 151 00:12:30.200 --> 00:12:35.200 walls. So this is typical uh histological findings in ARDS. So 152 00:12:35.500 --> 00:12:40.900 there would be alveolar inflammation, thickened septal from protein leak 153 00:12:41.000 --> 00:12:45.800 so that is the pink color and congestion and decreased alveolar volume. 154 00:12:45.800 --> 00:12:50.600 And because of this decreased volume decreased exchange and patient would be 155 00:12:50.700 --> 00:12:56.000 into hypoxia. So as we discussed, if you come into 156 00:12:56.000 --> 00:13:00.800 the clinical history part, then it's an acute condition. Okay, there is 157 00:13:00.800 --> 00:13:04.800 no chronicity. It's an acute condition. Patient would be critically ill because 158 00:13:05.900 --> 00:13:10.600 patient is into hypoxia. And because of this inflammation patient may be 159 00:13:10.600 --> 00:13:15.700 into the sepsis, septic shock. So multiple infusions, multiple transfusions, patient 160 00:13:15.700 --> 00:13:20.300 would be in the on the mechanical ventilation. So patient is ultimately 161 00:13:20.300 --> 00:13:25.300 falling into critically ill situation. Rapid breathing, 162 00:13:25.300 --> 00:13:29.800 rapid pulse and hypoxia. So that is trademark. So patient would have 163 00:13:29.800 --> 00:13:35.000 tachypnea, tachycardia, dyspnea, hypertension, maybe hypoxia 164 00:13:35.000 --> 00:13:40.100 as well. And it occurs basically within 12 to 24 165 00:13:40.100 --> 00:13:43.700 to 8 hours of precipitating events. After trauma within two days you 166 00:13:43.700 --> 00:13:47.400 can expect that patient may go into ARDS. So you have to 167 00:13:47.400 --> 00:13:53.400 be very careful while treating the patients with pancreatitis and trauma. Initially 168 00:13:53.400 --> 00:13:58.800 respiratory alkalosis would be there because uh you know there is increased 169 00:13:59.200 --> 00:14:02.900 work of breathing. So CO2 wash out will be there and because 170 00:14:02.900 --> 00:14:08.200 of that patient would be into respiratory alkalosis because of tachypnea. But 171 00:14:08.200 --> 00:14:13.500 later on, later on patient would go into respiratory 172 00:14:13.600 --> 00:14:17.900 failure. So there would be hypoxia. So type one respiratory failure you 173 00:14:17.900 --> 00:14:23.000 will come across after due course of time. So to 174 00:14:23.000 --> 00:14:27.100 know whether patient is going into hypoxia or not or hypercapnia or 175 00:14:27.100 --> 00:14:31.700 not ultimately ABG is the investigation of choice for us. So to 176 00:14:31.700 --> 00:14:36.200 begin with ABG because uh patient would be admitted because of trauma 177 00:14:36.400 --> 00:14:40.900 or pancreatitis or sepsis, septic shock or any of the lung pathology 178 00:14:41.100 --> 00:14:44.400 patient would be indoors. So you will be having a routine blood 179 00:14:44.400 --> 00:14:49.900 counts or RFT, CT if required, BNP, 2D cobalt, 180 00:14:49.900 --> 00:14:54.800 PCWP. So ultimately one of the most important investigation that I would 181 00:14:54.800 --> 00:14:57.800 like to send in this patient is ABG because I want to 182 00:14:57.800 --> 00:15:02.900 know what is the PO2 level, PCO2 level and pH level. If 183 00:15:03.600 --> 00:15:07.300 patient is not having any of the chest pathology, then now this 184 00:15:07.300 --> 00:15:09.600 is the time to get chest X-ray done. If it is chest 185 00:15:09.600 --> 00:15:13.600 X-ray is not good, then ultimately CTS or CT chest is required 186 00:15:13.600 --> 00:15:18.600 diagnose what actually it is going on inside. BNP is 187 00:15:18.600 --> 00:15:22.700 required to rule out heart failure. Now it's a time to discuss 188 00:15:22.800 --> 00:15:28.400 about uh cardiogenic and non-cardiogenic shock. So 189 00:15:28.400 --> 00:15:33.000 chest X-ray is required because in chest X-ray why we have the 190 00:15:33.000 --> 00:15:37.600 uh criteria to diagnose the infiltrates. So infiltrates would be on the 191 00:15:37.600 --> 00:15:42.700 both sides. And both sides infiltrates can be seen in cardiogenic as 192 00:15:42.700 --> 00:15:47.900 well as non-cardiogenic pulmonary edema. Now ARDS is non-cardiogenic pulmonary 193 00:15:47.900 --> 00:15:52.100 edema. So we need to rule out the cardiogenic pulmonary edema. Now 194 00:15:52.100 --> 00:15:55.600 how to rule out? First thing is BNP. If BNP is normal, 195 00:15:55.600 --> 00:15:58.400 then you can say this is not patient is in not into 196 00:15:58.400 --> 00:16:02.200 cardiogenic pulmonary edema and 2D echo to see what is the ejection 197 00:16:02.200 --> 00:16:08.500 fraction. Ejection fraction is normal if there is no uh IVC 198 00:16:08.600 --> 00:16:13.800 dilatation and if there is no any signs of left ventricular dysfunction, 199 00:16:13.800 --> 00:16:17.000 then you can say this is not a cardiogenic pulmonary edema. It 200 00:16:17.000 --> 00:16:21.300 must be because of non-cardiogenic pulmonary edema because you may see have 201 00:16:21.300 --> 00:16:25.000 patient with HFrEF or HFpEF. So what is HFpEF? That is a 202 00:16:25.000 --> 00:16:30.000 heart failure with preserved ejection fraction. And now this preserved ejection fraction 203 00:16:30.000 --> 00:16:35.800 with heart failure can be seen in non-cardiac pathologies like CKD, 204 00:16:35.900 --> 00:16:40.900 like MR, like uh hyperproteinemia. So there are 205 00:16:40.900 --> 00:16:44.400 different different pathologies in which you have HFpEF. So we need to 206 00:16:44.400 --> 00:16:49.000 rule out whether patient is having HFpEF or ARDS. So cardiogenic pulmonary 207 00:16:49.000 --> 00:16:49.600 edema is in the bilateral side. Even non-cardiogenic it is also bilateral, 208 00:16:54.100 --> 00:16:59.100 but in cardiogenic you have tendency of infiltrates on 209 00:16:59.100 --> 00:17:04.700 the lower side. But in non-cardiogenic you have diffuse. Uh in 210 00:17:04.700 --> 00:17:10.400 cardiogenic you have curly B lines and cardiomegaly whereas in non-cardiogenic 211 00:17:10.400 --> 00:17:15.200 you have homogeneously distributed throughout the lung and there is no curly 212 00:17:15.200 --> 00:17:20.400 B lines. So this is a very important point to rule 213 00:17:20.400 --> 00:17:25.000 out in chest X-ray whether patient is having cardiogenic pulmonary edema or 214 00:17:25.100 --> 00:17:30.400 non-cardiogenic pulmonary edema. So patch infiltrates in bases 215 00:17:30.400 --> 00:17:35.100 that is as seen in cardiogenic pulmonary edema and homogeneous fluffy opacities 216 00:17:35.500 --> 00:17:40.700 in non-cardiogenic pulmonary edema. In cardiogenic you have pleural effusion. In cardiogenic 217 00:17:40.700 --> 00:17:45.700 non-cardiogenic pleural effusion is generally not there. In cardiogenic you have curly 218 00:17:45.700 --> 00:17:49.300 B lines, whereas in ARDS there is no curly B lines. In 219 00:17:49.300 --> 00:17:53.000 cardiogenic you have cardiomegaly. In non-cardiogenic you don't have any kind of 220 00:17:53.000 --> 00:17:58.000 cardiomegaly. In cardiogenic you have pulmonary vascular redistribution that is bat wing 221 00:17:58.000 --> 00:18:03.000 appearance, but here it there is no pulmonary vascular redistribution. So in 222 00:18:03.000 --> 00:18:07.400 cardiogenic you have excess fluid in the alveoli, clear fluid. Whereas in 223 00:18:07.400 --> 00:18:12.500 non-cardiogenic you have proteinaceous inflammatory cells and fluid in 224 00:18:12.500 --> 00:18:19.100 the alveoli. So that is more dangerous than cardiogenic pulmonary edema. So 225 00:18:19.100 --> 00:18:22.300 early signs you can see these are maybe the lower side, but 226 00:18:22.300 --> 00:18:27.500 in late signs you have almost diffuse cardiogenic pulmonary edema 227 00:18:27.600 --> 00:18:31.500 so uh in ARDS. So these are the very clear-cut signs on 228 00:18:31.500 --> 00:18:36.000 chest CT scan. So there is a septal thickening and more severing 229 00:18:36.000 --> 00:18:40.400 lung bases, whereas here there is no patchy septal uh thickening. There 230 00:18:40.400 --> 00:18:45.900 is a diffuse alveolar infiltrates, atelectasis of the dependent lobes usually 231 00:18:45.900 --> 00:18:51.400 seen in ARDS. So very typical, very clear-cut 232 00:18:51.400 --> 00:18:57.500 differentiation between cardiogenic pulmonary edema and non-cardiogenic pulmonary edema. So 233 00:18:57.500 --> 00:19:00.500 you should know when you treat your patient with hypoxia and you 234 00:19:00.500 --> 00:19:05.200 have chest X-ray with bilateral infiltrates, then as the primary consultant you 235 00:19:05.200 --> 00:19:10.200 should be able to differentiate between cardiogenic and non-cardiogenic. And lastly, once 236 00:19:10.200 --> 00:19:15.700 you have a confirmed diagnosis of ARDS, then there are therapies 237 00:19:16.000 --> 00:19:21.100 that should be implemented. So first and foremost treatment 238 00:19:21.100 --> 00:19:25.000 of underlying cause. So we have direct lung injury as well as 239 00:19:25.000 --> 00:19:30.000 the causes which cause or the diseases which cause indirect lung 240 00:19:30.000 --> 00:19:35.200 injury like trauma, sepsis, pancreatitis or multiple blood transfusions. 241 00:19:35.600 --> 00:19:40.900 And in direct lung injury like pneumonia or what 242 00:19:41.000 --> 00:19:45.900 you can say the contusions. So these will give rise to the 243 00:19:46.400 --> 00:19:49.800 direct lung injury in ARDS. So treat the underlying cause as soon 244 00:19:49.800 --> 00:19:54.800 as possible to reduce the chances of ARDS. Then second comes the 245 00:19:54.800 --> 00:20:00.400 cardiogenic support if patient is having hypoxia or hypertension or tachycardia, 246 00:20:00.400 --> 00:20:05.900 then it is required to support the cardiac and pulmonary status. 247 00:20:06.700 --> 00:20:10.700 There are few specific therapies that can be targeted to the lung 248 00:20:10.800 --> 00:20:15.200 injury in ARDS. And then the rest of the supportive therapy that 249 00:20:15.200 --> 00:20:19.800 you generally give in ICU setting. So underlying cause we'll not discuss 250 00:20:19.800 --> 00:20:23.700 much because we know that you know how to treat pancreatitis or 251 00:20:23.700 --> 00:20:27.000 how to treat trauma or how to treat multiple lung multiple blood 252 00:20:27.000 --> 00:20:32.900 transfusions. Just we'll focus mainly on cardiogenic support and ARDS. 253 00:20:34.200 --> 00:20:38.700 So if patient is spontaneously breathing, so in early stages ARDS the 254 00:20:38.700 --> 00:20:44.200 hypoxia may be corrected by 40 to 60% of inspired oxygen. So 255 00:20:44.200 --> 00:20:48.500 if you feel that patient is having hypoxia and hypoxia and tachypnea, 256 00:20:48.500 --> 00:20:53.700 then you can start the full 100% FiO2 oxygen through NRBM. And 257 00:20:53.700 --> 00:20:58.800 then see how it goes and how patient improves. So the first 258 00:20:58.800 --> 00:21:03.400 and foremost thing is to give oxygen through mask that is NRBM 259 00:21:03.600 --> 00:21:07.600 and check what the SpO2 level, what is the level of tachypnea. 260 00:21:07.800 --> 00:21:11.400 If patient is improving, then continue with that. But if patient is 261 00:21:11.400 --> 00:21:15.400 deteriorating, then you need to go one step higher. So if the 262 00:21:15.400 --> 00:21:20.400 patient is well oxygenated on less than 60% of expired oxygen 263 00:21:20.400 --> 00:21:25.400 and apparently stable without CO2 retention, so we need we do ABG 264 00:21:25.600 --> 00:21:30.500 and see what is the PaO2 and PaCO2 level. Then monitoring would 265 00:21:30.500 --> 00:21:35.800 be feasible and continuous oximetry and regular blood gases 266 00:21:35.800 --> 00:21:40.800 are required to check whether this therapy is 267 00:21:40.800 --> 00:21:46.000 effective or not. Now what are the indication for mechanical 268 00:21:46.000 --> 00:21:51.300 ventilation? So inadequate oxygenation with P so that is PaO2 269 00:21:51.300 --> 00:21:56.700 less than 60 with FiO2 more than 60% rising or elevated PaCO2 270 00:21:56.700 --> 00:22:01.300 level that is more than 50 mmHg and if you feel that 271 00:22:01.700 --> 00:22:06.900 patient is going into respiratory failure, patient is going into fatigue and 272 00:22:06.900 --> 00:22:12.000 other signs of mechanical ventilation like GCS is worsening, like 273 00:22:12.000 --> 00:22:17.100 hypotension is there and patient needs to be ventilated, then yes mechanical 274 00:22:17.100 --> 00:22:20.700 ventilation is a good choice to implement. So you have to be 275 00:22:20.700 --> 00:22:24.600 very careful while treating the patient on NRBM because at any moment 276 00:22:24.600 --> 00:22:29.900 patient may require mechanical ventilation. So it is very very 277 00:22:29.900 --> 00:22:34.200 important to understand the severity of the patient on NRBM than the 278 00:22:34.200 --> 00:22:38.600 mechanical ventilation because on mechanical ventilation you are safe because airway is 279 00:22:38.600 --> 00:22:43.900 protected and machine is delivering whatever we want. But in NRBM 280 00:22:44.300 --> 00:22:49.400 patient's airway is not protected and patient is breathing on his own. 281 00:22:49.500 --> 00:22:54.900 So you have to be very watchful on patients with NRBM. Don't 282 00:22:54.900 --> 00:22:57.600 take it lightly as patient is only on NRBM, that's okay. Patient 283 00:22:57.600 --> 00:23:02.700 is not critical. Even on NRBM we have to think that patient 284 00:23:02.700 --> 00:23:07.700 is critical and we have to give utmost care to 285 00:23:07.700 --> 00:23:13.000 the patient on NRBM. So in mechanical ventilation 286 00:23:13.000 --> 00:23:18.000 the aim is to increase PO2 while minimizing the risk of 287 00:23:18.100 --> 00:23:24.000 further lung injury. So this ventilator induced lung injury. So 288 00:23:24.000 --> 00:23:29.200 mechanical ventilation doesn't only come with benefits, it has disadvantages, it has 289 00:23:29.200 --> 00:23:34.200 complications and it is causing lung injury. So 290 00:23:34.200 --> 00:23:39.600 you have to be very watchful while doing mechanical ventilation. So ideal 291 00:23:39.800 --> 00:23:44.800 ARDS net protocol. So patient should be on ventilator uh volume 292 00:23:44.800 --> 00:23:49.800 assisted control mode, back mode, tidal volume of around 6 ml 293 00:23:49.800 --> 00:23:54.600 per kg. So if patient is uh 60 kg, then you can 294 00:23:54.600 --> 00:23:59.000 put it as a 350 to 400 ml. Plateau pressure of it 295 00:23:59.000 --> 00:24:03.700 should be less than 30 cm of water. Rates 6 to 35 296 00:24:03.700 --> 00:24:07.800 whatever you are feeling convenient. IE ratio should be 1 is to 297 00:24:07.800 --> 00:24:12.000 1 to 1 is to 3. So expiratory is more than inspiratory. 298 00:24:13.200 --> 00:24:19.200 Our target of PaO2 is 7.3 to 10.7 kPa and SpO2 299 00:24:19.200 --> 00:24:24.200 of around 90 to 95. So peep and FiO2 set 300 00:24:24.200 --> 00:24:28.400 according to the predetermined combination that is peep should be between 5 301 00:24:28.400 --> 00:24:32.400 to 24. Peep should not be less than five. So it should 302 00:24:32.400 --> 00:24:40.000 be low volume or low tidal volume ventilation to avoid any further 303 00:24:40.000 --> 00:24:45.000 lung injury. So how to wean? Once patient 304 00:24:45.000 --> 00:24:48.800 is put on ventilator, so patient is improved, then we have to 305 00:24:48.800 --> 00:24:54.500 wean. Now before weaning we have to follow these protocols like 306 00:24:54.600 --> 00:24:57.900 spontaneous breathing trial should be given on daily basis. And you are 307 00:24:57.900 --> 00:25:02.400 satisfied with the spontaneous breathing, then you can think of weaning. Systolic 308 00:25:02.400 --> 00:25:06.000 blood pressure should be more than 90 mmHg without any kind of 309 00:25:06.000 --> 00:25:10.700 vasopressors. There should not be any neuromuscular blockade. So patient should be 310 00:25:10.700 --> 00:25:15.300 fully conscious and oriented. Two hour trial with TPs and one to 311 00:25:15.400 --> 00:25:20.200 with 1 to 5 cm water of CPAP should be given. Continuous 312 00:25:20.200 --> 00:25:25.500 ABG respiratory with monitoring is required. And if patient is tolerating 313 00:25:25.500 --> 00:25:30.800 for 30 minutes, then you can consider for extubation. 314 00:25:31.300 --> 00:25:36.500 So extubation is very tricky. And after extubation 315 00:25:36.500 --> 00:25:39.400 if you have to reintubate the patient, then it is very traumatic 316 00:25:40.000 --> 00:25:45.300 for you, for patient and for relatives. So you 317 00:25:45.300 --> 00:25:48.700 cannot just go ahead and extubate the patient. You have to follow 318 00:25:48.700 --> 00:25:54.200 certain criteria to wean and then consider extubation. 319 00:25:56.000 --> 00:26:00.500 So there are a few recommendations. Uh evidence-based recommendation for ARDS therapy. 320 00:26:00.500 --> 00:26:04.400 So low tidal volume is the level A recommendation. So you have 321 00:26:04.400 --> 00:26:09.500 to follow uh low tidal volume principle in treating the patient with 322 00:26:09.500 --> 00:26:14.500 ARDS. High PEEP and minimize LFP. Okay, B 323 00:26:14.500 --> 00:26:19.500 recommendation. High PEEP C, type C recommendation. Prone position. Yes, it is 324 00:26:19.500 --> 00:26:25.000 type C recommendation. Recruitment maneuvers. Again time C. High frequency 325 00:26:25.000 --> 00:26:29.200 ventilation. Type D. So not of much value along with corticosteroids, surfactant 326 00:26:29.200 --> 00:26:34.000 replacement and inhaled NO or others. These are of type D recommendation. 327 00:26:34.000 --> 00:26:37.000 So we'll not go into detail of this much, but low tidal 328 00:26:37.000 --> 00:26:43.900 volume is that you should think of with minimizing LFP. So 329 00:26:43.900 --> 00:26:48.400 in this one thing uh we have to discuss is uh I 330 00:26:48.400 --> 00:26:53.500 forgot to discuss about PCWP that is pulmonary capillary wedge 331 00:26:53.600 --> 00:26:58.800 pressure. Now this pulmonary capillary wedge pressure in cardiogenic and non-cardiogenic pulmonary 332 00:26:58.800 --> 00:27:04.100 edema it should it is normal in non-cardiogenic pulmonary edema 333 00:27:04.100 --> 00:27:08.800 as while it would be increased in cardiogenic pulmonary edema. So nowadays 334 00:27:08.800 --> 00:27:13.200 we don't generally measure PCWP, but theoretically you should remember that if 335 00:27:13.200 --> 00:27:17.700 PCWP is increased, then it is cardiogenic pulmonary edema. If PCWP is 336 00:27:17.700 --> 00:27:22.800 normal, then it is non-cardiogenic pulmonary edema. So 337 00:27:22.800 --> 00:27:28.000 these are few differentiating point between cardiogenic pulmonary edema and non-cardiogenic 338 00:27:28.000 --> 00:27:33.400 pulmonary edema. So now you should be able to differentiate between 339 00:27:33.400 --> 00:27:38.300 cardiogenic pulmonary edema and non-cardiogenic on clinical examination, on investigations and on 340 00:27:38.400 --> 00:27:42.700 X-ray. And depending upon that you can go ahead and treat the 341 00:27:42.900 --> 00:27:48.200 patient. So low tidal volume ventilation that is very very important 342 00:27:48.200 --> 00:27:53.400 in reducing alveolar associated lung injury. So in ARDS 343 00:27:54.100 --> 00:27:58.900 there is a large amount of poorly compliant or non-ventilating lung and 344 00:27:58.900 --> 00:28:02.600 a small amount of healthy and compliant lung tissue as most of 345 00:28:02.600 --> 00:28:07.700 the lungs are collapsed. Now if you give large 346 00:28:07.700 --> 00:28:12.800 volume, then it can lead to overinflation of healthy lungs and resulting 347 00:28:12.800 --> 00:28:18.100 in ventilator-induced lung injury of that healthy tissue. So we are ventilating 348 00:28:18.100 --> 00:28:23.100 only few percentage of lungs, not the whole lung. 349 00:28:23.300 --> 00:28:27.500 And that's why uh the tidal volume from 10 ml per kg 350 00:28:27.500 --> 00:28:31.300 should be reduced to 6 ml per kg because we don't want 351 00:28:31.300 --> 00:28:36.300 the healthy tissue to get damaged. And peep would support us to 352 00:28:36.300 --> 00:28:41.200 prevent further lung injury due to shear forces by keeping airways patent 353 00:28:41.200 --> 00:28:46.500 and during expiration. So it peep will prevent the 354 00:28:46.500 --> 00:28:53.100 collapse of the lung and gradually it will increase the uh recruitment 355 00:28:53.500 --> 00:28:58.100 of lungs. And then you can increase the tidal volume. So the 356 00:28:58.100 --> 00:29:03.100 initial therapy should be with low tidal volume mechanical 357 00:29:03.300 --> 00:29:08.800 ventilation. So uh there were studies or trials 358 00:29:08.800 --> 00:29:12.300 done and you can see that high tidal volume versus low tidal 359 00:29:12.300 --> 00:29:17.400 volume uh the model rate was higher in tidal volume than low 360 00:29:17.400 --> 00:29:22.900 tidal volume. And in high peep versus low peep 13 versus 8 361 00:29:23.000 --> 00:29:27.000 there is no difference. So peep should be read uh I mean 362 00:29:27.000 --> 00:29:32.100 kept between 5 to 8 not more than that. And 363 00:29:33.800 --> 00:29:37.800 what one study suggested that optimal peep was 15 cm of water 364 00:29:37.900 --> 00:29:40.700 H2O, but in my opinion peep should be 5 to 8 not 365 00:29:40.700 --> 00:29:45.000 more than that with low tidal volume that would prevent further lung 366 00:29:45.000 --> 00:29:49.800 injuries and slowly and gradually as lungs would be drying up, there 367 00:29:49.800 --> 00:29:54.400 would be more and more accumulation or recruitment of alveoli into the 368 00:29:54.400 --> 00:30:00.000 ventilatory system. A study was done on inverse ratio relationship. So 369 00:30:00.000 --> 00:30:05.100 it reduced the peak airway pressure. So IE ratio if we keep 370 00:30:05.300 --> 00:30:10.800 4 is to 1, then it is required in severe hypoxic 371 00:30:10.800 --> 00:30:15.000 respiratory failure. So in which there should be the ratio of IE 372 00:30:15.000 --> 00:30:20.000 should be reversed to 4 is to 1. Hypercapnia 373 00:30:20.100 --> 00:30:25.100 we can keep up to 55. So pH up to 7.25 374 00:30:25.100 --> 00:30:30.300 is okay. pH should not go down. pH should be between 7.25 375 00:30:30.300 --> 00:30:35.600 nearly 7.25 and PCO2 nearly 55. And a controlled hypoventilation 376 00:30:35.600 --> 00:30:40.700 can be given a chance along with proning. So proning is required 377 00:30:40.700 --> 00:30:44.900 because in supine condition if we sleep, then our heart that is 378 00:30:44.900 --> 00:30:49.300 on the anterior side would compress the lungs from ventilation. So it 379 00:30:49.300 --> 00:30:51.900 will give its weight on the lungs. So lungs would have a 380 00:30:51.900 --> 00:30:57.100 difficulty in expansion. And secondly, if you lie down supine, 381 00:30:57.100 --> 00:31:02.100 then the abdominal content would gradually push the diaphragm 382 00:31:02.100 --> 00:31:06.800 up. And then again there are less space required for the lung 383 00:31:06.800 --> 00:31:13.400 to expand. So to cover up both the factors proning 384 00:31:13.400 --> 00:31:18.600 is recommended so that the ventilation is easier and 385 00:31:18.600 --> 00:31:22.900 without much troubles. So proning would help in this two situation, but 386 00:31:22.900 --> 00:31:26.300 again as we saw that it is level C or D recommendation. 387 00:31:26.900 --> 00:31:30.600 And you can try, you don't try, that's up to you if 388 00:31:30.600 --> 00:31:35.700 depending upon your comfort zone. So other methods, high flow 389 00:31:35.700 --> 00:31:41.000 ventilation, so nasal cannula, ECMO. ECMO is a 390 00:31:41.000 --> 00:31:44.700 recent and advanced therapy that is being given in the patients of 391 00:31:44.700 --> 00:31:49.800 ARDS. We have seen many ARDS patient during COVID. And we had 392 00:31:49.800 --> 00:31:53.100 put a lot of patients onto ECMO and it has given wonderful 393 00:31:53.100 --> 00:31:58.100 results. So ECMO is nothing but the artificial lung. So lungs would 394 00:31:58.100 --> 00:32:02.600 be at a rest and slowly they would improve, they would heal. 395 00:32:02.800 --> 00:32:06.100 And then once they are properly healed, then we remove the ECMO 396 00:32:06.100 --> 00:32:10.000 and put the patient in a normal ventilation. And there's last thing 397 00:32:10.000 --> 00:32:14.500 is partial fluid ventilation that even I don't think much of use. 398 00:32:15.000 --> 00:32:20.900 So ultimately ECMO is the last resort for us to prevent patients 399 00:32:20.900 --> 00:32:26.100 from dying and give time to for to learn to heal. 400 00:32:27.500 --> 00:32:33.400 So this is routine ECMO system that is bypassing lung and 401 00:32:34.400 --> 00:32:39.800 gives proper oxygenation patients. Uh few 402 00:32:39.900 --> 00:32:45.100 supportive therapies like fluids to be conservative. Uh you can 403 00:32:45.100 --> 00:32:49.600 choose a normal or low fluid therapy. And it will reduce the 404 00:32:49.600 --> 00:32:54.000 ICU stay and duration of ventilation, steroids in the initial days or 405 00:32:54.000 --> 00:32:59.000 initial time. Steroids may be useful before the proper 406 00:32:59.000 --> 00:33:04.000 inflammation is set in. After the proper inflammation is set in, then 407 00:33:04.000 --> 00:33:07.300 there is no much use of steroids. So what you can do 408 00:33:07.300 --> 00:33:10.800 is give his entire prednisolone 2 mg per kg and then taper 409 00:33:11.300 --> 00:33:14.400 1 mg per kg in one to two weeks. But it should 410 00:33:14.400 --> 00:33:19.400 be started in early stages of inflammation. And then 411 00:33:19.400 --> 00:33:21.400 sepsis, antibiotics. Yes, uh empirical antibiotics. And if you have culture, then 412 00:16:44.600 --> 00:16:44.600 culture oriented or targeted antibiotics you can give. Avoid nephrotoxic 413 00:16:49.600 --> 00:16:54.100 drugs 414 00:33:29.900 --> 00:33:35.500 because patient is going to stay long in your ICU. And 415 00:33:35.500 --> 00:33:39.700 a few more for the complications are expected like DVT and bed 416 00:33:39.700 --> 00:33:43.700 sore and web. So please make sure that you don't give any 417 00:33:43.700 --> 00:33:48.200 medicine that would further hamper kidney function and enteral feeding to support 418 00:33:48.200 --> 00:33:52.900 the nutrition. It is again very important. Other modality is that you 419 00:33:52.900 --> 00:33:59.000 can think of that is nitrous oxide, uh ketoconazole, pentacifyline, 420 00:33:59.000 --> 00:34:04.000 NSAIDs and acetylcysteine. These are all treatments that you can give, you 421 00:34:04.000 --> 00:34:08.800 don't give, but there are few very few studies that can give 422 00:34:08.900 --> 00:34:14.000 a concrete opinion on using this. So prognosis in such patients 423 00:34:14.600 --> 00:34:19.100 mortality ranges from 26 to 44%. So it is very high. So 424 00:34:19.100 --> 00:34:23.600 ARDS model prognosis is very high and uh what we feel as 425 00:34:23.600 --> 00:34:28.000 an uh doctor, as a doctor that we don't when we are 426 00:34:28.000 --> 00:34:31.900 very helpless when such situations set in. So we try as much 427 00:34:31.900 --> 00:34:35.900 as possible, but ultimately 44% that is one out of two patients 428 00:34:35.900 --> 00:34:39.500 is dying, then even we feel helpless at this end of the 429 00:34:39.500 --> 00:34:43.700 day that we could not do much. Even though we have given 430 00:34:43.700 --> 00:34:48.500 best of us. But that is very discouraging. So make sure that 431 00:34:48.700 --> 00:34:51.900 ARDS should be prevented and once it is set in, then from 432 00:34:51.900 --> 00:34:54.500 day one you have to be very very aggressive. You don't just 433 00:34:54.500 --> 00:34:58.200 wait to patient go into certain kind of other complications. So risk 434 00:34:58.200 --> 00:35:02.500 factors as I told you that chronic uh advanced age, chronic kidney 435 00:35:02.500 --> 00:35:06.900 disease, chronic liver disease, these are very prone to develop ARDS because 436 00:35:06.900 --> 00:35:12.300 of you know uh multi-organ dysfunction ultimately, chronic alcohol abuse 437 00:35:12.500 --> 00:35:16.700 and chronic immunosuppression. So that would also trigger sepsis, septic shock and 438 00:35:16.700 --> 00:35:21.800 ultimately ARDS. So uh and if ARDS is because of direct lung 439 00:35:21.800 --> 00:35:26.600 injury, then it is having a double mortality rate. So it is 440 00:35:26.600 --> 00:35:31.600 very very important. So ARDS is very common uh manageable, 441 00:35:31.800 --> 00:35:36.100 but again as I told you that it is disappointing. Once patient 442 00:35:36.100 --> 00:35:40.000 you dies in front of you after so many efforts you have 443 00:35:40.000 --> 00:35:43.400 put in. So these are my references that you can go ahead. 444 00:35:44.000 --> 00:35:48.000 So thank you very much for patient listening. Sir uh when should 445 00:35:48.000 --> 00:35:53.900 you consider advanced airway management in acute respiratory distress? So 446 00:35:54.700 --> 00:35:58.100 as I told you that acute respiratory distress you begin with uh 447 00:35:58.100 --> 00:36:02.000 NRBM. So once patient is fully conscious surrounded, but as you feel 448 00:36:02.000 --> 00:36:07.100 that patient is going into certain kind of poor GCS or worsening 449 00:36:07.100 --> 00:36:12.600 in altered sensorium and other parameters like blood pressure is falling, then 450 00:36:12.700 --> 00:36:17.900 uh early intubation would help uh because you know that would prevent 451 00:36:17.900 --> 00:36:21.200 the lungs to go into further damage because if patient is breathing 452 00:36:21.200 --> 00:36:23.700 at the rate of 25 40 and patient is breathing at the 453 00:36:23.700 --> 00:36:28.500 rate of 12 15, then definitely the chances of lung injury much 454 00:36:28.500 --> 00:36:31.400 higher if we are breathing is at 35 to 40 rates. So 455 00:36:31.400 --> 00:36:34.300 we don't want patients to go into further trouble and we need 456 00:36:34.300 --> 00:36:39.200 to give proper rest. So if you consider yourself you're in viral 457 00:36:39.200 --> 00:36:42.900 fever, so you cannot run marathon in viral fever. You need rest 458 00:36:43.200 --> 00:36:46.900 for proper healing. It is same kind of principles you can apply 459 00:36:46.900 --> 00:36:50.400 that if lungs are at risk, lungs are damaged, then they need 460 00:36:50.400 --> 00:36:54.700 rest. And if patient is in altered sensorium, then you cannot put 461 00:36:54.700 --> 00:36:59.000 BiPAP, you cannot put NRBM. Ultimately it is the decision to intubate 462 00:36:59.000 --> 00:37:04.300 the patient put in on mechanical ventilation. All right, sir. Sir moving 463 00:37:04.300 --> 00:37:08.000 on to the next question that is and this is I think 464 00:37:08.000 --> 00:37:13.100 very important because I also hear it many times from different 465 00:37:14.000 --> 00:37:18.000 uh physicians. So how frequently should you reassess a patient with acute 466 00:37:18.000 --> 00:37:23.500 respiratory distress after initial stabilization? So after initial stabilization 467 00:37:23.500 --> 00:37:28.400 ABG uh see patient would be on monitor. So SpO2 pulse blood 468 00:37:28.400 --> 00:37:32.800 pressure should be almost measured every 5 10 minutes. And ABG you 469 00:37:32.800 --> 00:37:36.200 can consider checking every 6 hours so that you know can come 470 00:37:36.200 --> 00:37:39.900 to know what is the PO2 FiO2 ratio. So patient would be 471 00:37:40.000 --> 00:37:43.100 initially you know ALI so PaO2 PF ratio should be less than 472 00:37:43.100 --> 00:37:46.700 300, but at one moment you feel that PF ratio is less 473 00:37:46.700 --> 00:37:50.400 than 200. PF ratio is more less than 100. So if patient 474 00:37:50.400 --> 00:37:52.400 PF ratio is less than 100, then you can say it is 475 00:37:52.400 --> 00:37:56.300 severe respiratory distress syndrome. If PF pressure is between 100 to 200, 476 00:37:56.300 --> 00:37:58.800 then you can say it is moderate. And if it between 300 477 00:37:58.800 --> 00:38:02.400 to 200, then you can say it is mild. So depending upon 478 00:38:02.400 --> 00:38:06.800 the PF ratio you can differentiate between mild, moderate and severe. And 479 00:38:07.000 --> 00:38:09.800 mild, moderate and severe what you have to do is that it 480 00:38:09.900 --> 00:38:13.900 has to be predefined. So once you are studying and reading the 481 00:38:13.900 --> 00:38:17.300 textbook, then you should have your notes or you know uh in 482 00:38:17.300 --> 00:38:21.500 pharmacology we were studying P drugs. Yeah. So it is our personal 483 00:38:21.500 --> 00:38:25.300 drugs that we want to give to certain conditions. So in ARDS 484 00:38:25.300 --> 00:38:30.100 also you have to have your personal protocols for mild ARDS, moderate 485 00:38:30.100 --> 00:38:34.600 ARDS and severe ARDS. So whenever you come across any of the 486 00:38:34.600 --> 00:38:37.900 ARDS, it has to be on your tip of tongue what to 487 00:38:37.900 --> 00:38:42.400 do in this patients. All right, sir. Sir moving on to the 488 00:38:42.400 --> 00:38:46.400 last question for today's session that is sir what are the potential 489 00:38:46.400 --> 00:38:52.000 complications of endotracheal intubation in emergency department settings? So 490 00:38:52.000 --> 00:38:57.100 in emergency uh endotracheal intubation it's an invasive procedure. So an invasive 491 00:38:57.100 --> 00:39:01.700 procedure would have a few complications. So if we define complications then 492 00:39:02.200 --> 00:39:06.000 of the procedure, then you can have bleeding and damage to the 493 00:39:06.000 --> 00:39:10.500 oral cavity and trachea. While putting the endotracheal tube we have seen 494 00:39:10.500 --> 00:39:14.800 or the patients coming from outside the tracheal tear is there. Uh 495 00:39:16.000 --> 00:39:20.300 while intubation we give RSI drugs. So the drugs would have their 496 00:39:20.300 --> 00:39:25.300 own complications. Uh tube dislodgement while shifting the patient from one place 497 00:39:25.300 --> 00:39:30.400 to another. Tube blockage is another complication. During intubation tongue 498 00:39:30.700 --> 00:39:35.400 uh I mean tongue injury or tooth injury or pharyngeal injury that 499 00:39:35.600 --> 00:39:40.700 gives bleeding and ultimately if patient is on the antiplatelets and anticoagulants, 500 00:39:40.700 --> 00:39:44.300 then it will bleed a lot and it will cause another kind 501 00:39:44.300 --> 00:39:48.300 of you know pneumonitis. So these are the complications that you can 502 00:39:48.300 --> 00:39:52.800 uh think of while intubating the patient. So technique first and foremost 503 00:39:52.800 --> 00:39:56.900 is technique is very important. Visualization of trachea and larynx is very 504 00:39:56.900 --> 00:40:02.500 important. And avoid any uh procedure related 505 00:40:02.500 --> 00:40:07.100 injuries. All right, sir. Sir with this I would like to conclude 506 00:40:07.100 --> 00:40:09.800 today's session. Thank you so much for your time. And like I 507 00:40:09.800 --> 00:40:12.600 said the session was very very insightful. I'm sure our viewers will 508 00:40:12.600 --> 00:40:15.700 get to extract a lot of information from here. I'm really looking 509 00:40:15.700 --> 00:40:18.100 forward to hosting you again on our platform. Thank you so much. 510 00:40:18.100 --> 00:40:19.200 Thank you. Thank you.