Treatment of noncardiogenic edema

The treatment of non-cardiogenic edema has been reviewed recently (Hudson ! 995). Treatment modalities are typically considered as either supportive or directed against the injury. Supportive modalities

The use of positive end-expiratory pressure remains the most important therapeutic modality and is described elsewhere in this book. The aim is to achieve adequate oxygenation with the lowest possible FiO2 and the lowest possible mean airway pressures. A high FiO2 and high ventilatory pressures and volumes may result in further lung injury. However, in some cases, despite careful manipulation of the ventilator settings, it is impossible to achieve adequate oxygenation. If that is the case, options include paralysis (to minimize desaturation associated with patient efforts), accepting lower oxygen saturation and decreasing the frequency of endotracheal tube suctioning (acute desaturation), or increasing the hemoglobin to improve the oxygen-carrying capacity. Ultimately, one may have to accept ventilation with pure oxygen and try other available ventilatory approaches.

None of the alternative ventilatory modes has been proved to be superior. Therefore it is necessary to try them individually on each patient. The most commonly used modes are inverse ratio ventilation and high frequency ventilation. Inverse ratio ventilation requires sedation and often paralysis. The inspiratory time is gradually prolonged as long as it is hemodynamically possible. Presumably, longer inspiratory times may recruit air spaces and improve gas exchange. There is some anecdotal evidence that high frequency ventilation has beneficial results at frequencies in the range of 300 breaths/min.

There are anecdotal reports of the use of intracorporeal and extracorporeal gas exchange devices in highly specialized centers ( Hudson..1995). Liquid ventilation with perfluorocarbons which carry dissolved oxygen has been used. Very limited experience is available.

Pharmacological supportive therapies must still be considered experimental. They include vasoactive agents aimed at diverting blood flow away from edematous areas in an effort to minimize the intrapulmonary shunt (NO and almitrine). Surfactant replacement seems to be successful in children but has yet to be proved beneficial in the adult population (Hudson 1995).

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