ARDS Guidelines

Dr. George John,

Critical Care,
Christian Medical College,
Vellore

Causative Factors in ARDS

PRIMARY
INJURY

HOST
RESPONSE

CONSEQUENCES
OF THERAPY

SPECTRUM OF LUNG INJURY

Cardiogenic
pulmonary
oedema

Altered
Starlings
Forces

ALI

P/F RATIO 200 - 300

ARDS

P/F RATIO < 200

Pulmonary Changes
Alveolar Flooding
Interstitial inflammation

Atelectasis

Early Exudative Phase < 1 week

Late Fibro Proliferative Phase > 1 week

Guidelines

Oxygenation
Ventilation
Position
Fluid management
Miscellaneous

Oxygenation
Lowest FiO2
- to keep PaO2 55 80mm Hg
Increase Alveolar Recruitment = degree of penetration
of gas into poorly / nonaerated lung regions
- PEEP
- recruitment manoeuver
- inverse ratio ventilation
Prone positioning ( proning )
NO (Nitric Oxide)

The Pressure Profile

Peak Pressure

Plateau Pressure
Mean Pressure
PEEP

Ventilation
VENTILATION
Volume Control mode; I:E ratio 1:1 1:3
- Tidal Volume 6ml / kg
- Plateau Pressure < 30cm H2O
- High rate if CO2 high up to 35 / minute
Measures to decrease CO2 production (sedation, decrease
temperature)
Permissive hypercapnoea
If pH < 7.30 use HCO3 infusion
Other techniques:
?Tracheal gas insufflation (TGI) / Expiratory washout (EWO)
(use humidified gas only)
? Pressure Control Mode with pressure = 30
- many with less pressure needed for ventilation in the
study

Position
PRONING
Ventilation in the prone position improves
oxygenation but most clinical studies have not shown
that prone ventilation improves outcome. In a study of
paediatric patients (2 weeks to 18 years of age) with
acute lung injury, prone positioning did not
significantly reduce ventilator-free days or improve
clinical outcome.
However, in a study published in 2006, prolonged
prone positioning (at least 20 hours a day) in patients
greater than 18 years of age showed that it was safe
and may reduce mortality.

Fluid Management
Liberal versus Conservative
Conservative strategy:
maintain a low target filling pressure (CVP of less than 4mm Hg or PAOP
of less than 8 mm Hg)
versus
Liberal strategy: maintain higher filling pressure CVP 10 14mm Hg or
PAOP 14-18mm Hg. This was achieved by a combination of bolus fluid
administration, use of frusemide or dobutamine, depending on the
perfusion, urine output , measured filling pressures and cardiac output (if
available).
Result:
There was no significant difference in mortality (25.5% in the conservative group vs.
28.4% in the liberal group). However, the conservative strategy improved the
oxygenation index, lung injury score, increased the number of ventilator free days
and days not spent in ICU. The conservative strategy did not increase the
incidence or prevalence of shock during the study. In addition, the conservative
strategy did not increase the use of dialysis during the first 60 days.

Monitoring
In a landmark study published in 2006, the
use of PA catheter guided therapy did not
improve organ function or survival as
compared to CVC guided therapy. The PA
catheter was associated with more
complications (twice as many catheter
related complications, predominantly
arrhythmias) than CVC guided therapy.

Cardiovascular
Haemoglobin 8 10 g%

Maintain Cardiac Output

Judicious fluids
Use inotropes as needed

Other Modalities

Steroids
Earlier study:
Evidence that use of steroids after the first week of ARDS improves
prognosis significantly.
In 2006:
No benefit in the use of methylprednisolone after the first week of
ARDS. Use of sterods after 14 days of ARDS was associated with
increased mortality at 60 days. This was in spite of the steroid therapy
and improving ventilator free shock free days during the first 28 days.
Methyprednisolone did not increase infectious complications but was
associated with a higher rate of neuromuscular weakness.
Nitric Oxide
No benefit
Beta agonists:
The beta agonist lung injury trial (BALTI) has shown that treatment with
intravenous albutamol (15ug / kg / hr) reduces extravascular lung water (EVLW)
in patients with ALI / ARDS with a reduction in plateau pressures at Day 7.
The effect on EVLW started at 48 hours. Patients receiving intravenous
salbutamol had a higher incidence ofsupraventricular arrhythmias these were not
sustained as the dose of salbutamol was modified in these patients. There was
no improvement in mortality with the use of salbutamol however the study was
not Powered to detect a difference in mortality.

Imitators
Acute Interstitial Pneumonia (AIP)
Acute Eosinophilic Pneumonia
Acute BOOP

DAH
Acute HP

Suspecting Imitators
Common features: fever, cough,
myalgia, raised WBC, CRP, LDH

Distinguishing features: BAL, Lung

Biopsy, Response to steroids and
prognosis (in some)

Possible Approach

Early BAL infectious agents, differential WBC count

Serological tests for autoimmune disease, CK (polymyositis)
Haematocrit serial
Ferritin (increased in adult Stills)
Renal function
Urine microscopy
Lung biopsy if BAL is inconclusive, after considering risk vs.
benefit. Specially important in DAH (vasculitis induced) ;
necessary for immunofluorecent staing for ABMA.
The suggestion to start all these patients initially on steroids for
3 days till the BAL results / other tests are available is
controversial and needs to be evaluated in a RCT.

References - 1
1.
2.
3.
4.
5.
6.
7.
8.

9.

10.
11.
12.
13.

Bernard GR et al. The American European Consensus Conference on ARDS. Am J Respir Crit
Care Med 1994; 149: 818 824
Meduri et al. Corticosteroid rescue treatment of progressive fibroproliferation in late ARDS.
Patterns of response and predictors of outcome. Chest 1994; 105: 1516 1527
Meduri GU et al. Effect of prolonged methylprednisoloine therapy in unresolving acute respiratory
distress syndrome. A randomized controlled trial. JAMA 1998; 280: 159 165
Brun-Buisson C and Brochard L. Corticosteroid therapy in acute respiratory distress syndrome.
Better late than never? JAMA 1998; 280: 182 183
Cook D et al. A comparison of Sucralfate and Ranitidine for the prevention of upper gastrointestinal
bleeding in patients requiring mechanical ventilation. N Engl J Med 1998; 338: 791 - 79
Amato MBP et al. Effect of protective ventilation strategy on mortality in the acute respiratory
distress syndrome. N Engl J Med 1998; 338: 347 - 354
Stewart TE et al. Evaluation of a ventilation strategy to prevent barotrauma in patients at high risk
for acute respiratory distress syndrome. N Engl J Med 1998: 338: 355 361
Richecoeur J et al. Respiratory washout versus optimisation of mechanical ventilation during
permissive hypercapnoea in patients with severe acute respiratory distress syndrome. Am J Respir
Crit Care Med. 1999; 160: 77 - 85
The Acute Respiratory Distress Syndrome Network. Ventilation with lower tidal volumes as
compared with traditional tidal volumes for Acute Lung Injury and the Acute Respiratory Distress
Syndrome. N Engl J Med 2000; 342: 1301 1308
Gattinoni L et al. Effect of prone positioning on the survival of patients with acute respiratory failure.
N Engl J Med 2001; 345: 568 573
Nuckton T et al. Pulmonary dead space fraction as a risk factor for death in the acute respiratory
distress syndrome. N Engl J Med 2002; 346: 1281 1286
New Management strategies in ARDS. Editor Levy MM. Critical Care Clinics, January 2002
Jindal SK et al. Adult respiratory distress syndrome in the tropics. Clin Chest Med 2002; 23: 445
455

References - 2
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.

Kopp R et al. Evidence based medicine in the therapy of the acute respiratory distress
syndrome. Intensive Care Medicine 2002; 28: 244 245
The ARDS Clinical Trials Network. Effects of recruitment manoeuvers in patients with
acute lung injury and acute respiratory distress syndrome ventilated with high positive
end expiratory pressure. Crit. Care Med. 2003; 31: 2592 2597
Marini JJ. Are recruiting maneuvers needed when ventilating acute respiratory distress
syndrome? Crit. Care Med. 2003; 31: 2701 2702
Barbas CSV. Lung recruitment menoeuvers in acute respiratory distress syndrome and
facilitating resolution. Crit. Care Med. 2003; 31 (Suppl): S265 S271
Marini J & Gattinoni L. Ventilatory management of acute respiratory distress syndrome: a
consensus of two Crit. Care Med 2004; 32: 250 255
The Margaux IV Conference on Critical Illness: Acute Lung Injury Understanding the
mechanisms of injury and repair. Crit. Care Med. 2003; 31 (Suppl): S183 S342
Schwarz MI et al. Imitators of the ARDS. Implications for diagnosis and treatment.
Chest 2004; 125: 1530- 1535
Mancebo J et al. A multicenter trial of prolonged prone ventilation in severe acute
respiratory distress syndrome. Am J Respir Crit Care Med. 2006; 173: 1233 1239
Barrett NA & Kam PCA. Transfusion-related lung injury: a literature review. Anaesthesia
2006; 61: 777 785
ARDS Clinical Trials Network. Pulmonary Artery versus Central Venous Catheter to
guide treatment of Acute Lung Injury. The New Engl. J Med. 2006; 354: 2213 - 2224
ARDS CLINICAL Trials Network. Comparison of two fluid management strategies in
Acute Lung Injury. The New Engl J Med. 2006; 354: 2564 2575
Rivers EP. Fluid Management Strategies in Acute Lung Injury Liberal or Conservative
or both? The New Engl J Med. 2006; 354: 2598 2600