Professional Documents
Culture Documents
Acute Respiratory Distress Syndrome
Acute Respiratory Distress Syndrome
ARDS
Objectives
Updated definition of ARDS
Briefly review Pathophysiology and Pathogenesis
Etiology/Risk factors
Clinical Presentation
Diagnosis, Differential Diagnosis
Management
ARDS
Case #1
A 70-year-old man was admitted to the ICU
acute hypoxemic respiratory failure
48 hours earlier
He underwent a surgical resection of the left lower lobe for stage
IIIB adenocarcinoma of the lung.
Intra-operative course
He received a total fluid infusion of 5.5 L (including 3 units of
packed red blood cells)
The cumulative fluid infusion given during the peri-operative
period was 8.0 L with a net negative 0.7L
ARDS
Case#1
Post Operative course
Extubated and transferred to the ward
36 hours later
dyspnea and hypoxemia were noted
re-intubated
ARDS
Case#1
Past Medical History
Adenocarcinoma of the lung, stage IIIb, diagnosed 3
months before surgery, treated with preoperative
neo-adjuvant chemotherapy and radiotherapy
History of moderate COPD
Social History
80-pack-years of cigarette smoking
chronic alcohol consumption of approximately 30g of
ethanol per day.
ARDS
Case #1
Pre-operative evaluation
Complete blood count and blood chemistry were
normal
Pre-operative evaluation for chronic heart
disease was negative
Forced Expiratory Volume in 1s (FEV1) was 1.79
L; 58% of the predicted value; calculated postoperative FEV1 was 49% of the predicted value
ICU Admission
Physical examination
Vital signs,
BP 100/70 mmHg, Pulse 120/min, Respirations 33/min, SpO2 of 85% on
100% Non rebreather, Temperature 37.0 C
Cardiovascular
S1, S2 normal
Respiratory
Decreased breath sounds over the left lower lung field, diffuse end-inspiratory
crackles over the remaining lobes .
Laboratory Data
Normal complete blood count and chemistry
Blood and bronchoalveolar lavage (BAL) specimens were collected and sent
for microbiologic analysis.
Blood cultures, done
Arterial blood gases: (on FiO2 0.6), PaO2 70mmHg,, PaCO2 45mmHg,
HCO3 24, PaO2/ FiO2 117
CXR
ARDS
Case #1
What is your next diagnostic study?
CT chest/PE Protocol
Transthoracic Echocardiogram
Right Cardiac Catheterization
Repeat Bronchoscopy
CT chest
ARDS
Case #1
Transthoracic echocardiography:
Ejection fraction 60 %, normal left ventricular systolic
function. Mild right ventricular dilation
ARDS
Case #1
Which of the following statements is true:
The Development of acute respiratory
failure in this patient is due to:
A. Pulmonary edema due to fluid overload
B. Cardiogenic pulmonary edema due to left-sided heart
failure
C. Acute respiratory distress syndrome (ARDS)
D. Pneumonia
E. Massive pulmonary embolism
AECC Criticism
Cardiac output
A-V O2 Difference
Distribution of blood flow to different V/Q regions
Low V/Q
Shunt
Oxygen consumption
Hemoglobin concentration
ARDS
New Definition
JAMA. 2012;307(23):2526-2533.
doi:10.1001/jama.2012.5669
ARDS
The Berlin Definition
JAMA. 2012;307(23):2526-2533.
doi:10.1001/jama.2012.5669
ARDS
The Berlin Definition
No change in the underlying conceptual understanding of
ARDS
acute diffuse, inflammatory lung injury, leading to increased
pulmonary vascular permeability, increased lung weight, and loss
of aerated lung tissue[with] hypoxemia and bilateral radiographic
opacities, associated with increased venous admixture, increased
physiological dead space, and decreased lung compliance.
ARDS
Pathophysiology
ARDS
Pathological Stages
Initial "exudative" stage-diffuse alveolar damage
within the first week
Proliferative" stage-resolution of pulmonary
edema, proliferation of type II alveolar cells,
squamous metaplasia, interstitial infiltration by
myofibroblasts, and early deposition of collagen.
Some patients progress to a third "fibrotic" stage,
characterized by obliteration of normal lung
architecture, diffuse fibrosis, and cyst formation
ARDS
Pathophysiology
Risk Factors
Sepsis
Severe trauma
Surface burns
Multiple blood
transfusions
Drug overdose
Following bone marrow
transplantation
Multiple fractures
Aspiration
Pneumonia
Pulmonary contusion
Pulmonary embolism
Inhalational injury
Near drowning
ARDS
Clinical Presentation
Dyspnea, Tachypnea
Persistent hypoxemia, despite the
administration of high concentrations of
inspired oxygen
Increase in the shunt fraction
Decrease in pulmonary compliance
Increase in the dead space ventilation
Management of ARDS
ARDS
FACTT
Patients were treated with the specific fluid
management strategy (to which they were
randomized) for 7 days or until unassisted
ventilation, whichever occurs first.
The study enrolled 1000 patients and
showed no benefit with PAC guided fluid
therapy over the less invasive CVC guided
therapy.
ARDS
FACTT
The Use of Conservative fluid management
strategy was associated with
Significant improvement in oxygenation
index
Significant improvement in Lung Injury
score
increase in the number of ventilator- free
days
ARDS
Mechanical Ventilation
Ventilator associated lung injury
Volutrauma
Atelectotrauma
Biotrauma
Barotrauma
Air embolism/translocation
Mechanical
Ventilation
[2.3 *(height in inches
- 60) + 45.5 for women or + 50 for men].
Respiratory rate up to 35 breaths/min
ARDS
Mechanical Ventilation
ARDS
Mechanical Ventilation
Plateau pressure (measured during an inspiratory hold of
0.5 sec) less than 30 cm H2O,
High plateau pressures vastly elevate the risk for harmful alveolar
distension ( volutrauma).
ARDS
High versus Low PEEP
Higher PEEP along with low tidal volume
ventilation should be considered for
patients receiving mechanical ventilation for
ARDS. This suggestion is based on a
2010 meta-analysis of 3 randomized trials
(n=2,229) testing higher vs. lower PEEP in
patients with acute lung injury or ARDS, in which
ARDS patients receiving higher PEEP had a
strong trend toward improved survival.
ARDS
High versus Low PEEP
However, patients with milder acute lung injury
(paO2/FiO2 ratio > 200) receiving higher PEEP had
a strong trend toward harm in that same metaanalysis.
Higher PEEP can conceivably cause ventilatorinduced lung injury by increasing plateau pressures,
or cause pneumothorax or decreased cardiac
output. These adverse effects were not noted in the
largest ARDSNet trial (2004) testing high vs. low
PEEP.
ARDS
Mechanical Ventilation
ARDS
Mechanical Ventilation
ARDS
Mechanical Ventilation
CASE #1
On admission to the ICU, the patient was sedated and
placed on volume control mechanical ventilation with the
follow settings: FiO2: 0.6, VT: 450 ml, RR:18, PEEP:10 cm
H2O, V:8 L/min.
Additional supportive therapy included initial, empiric, broadspectrum antibiotics and restrictive fluid management.
On Day 3, due to further impairment of oxygenation (SaO2
<80%) that did not improve with increases in both PEEP and
FiO2, the patient was placed on high frequency oscillatory
ventilation.
Although he had an initial improvement in oxygenation, his
overall condition continued to decline and he died on Day 5
due to multiple organ failure.
ARDS
Inhaled NO
Steroids
Prone Position
High Frequency Oscillatory
Ventilation
ECMO
ARDS
Steroid
A protocol for steroids in late ARDS, based on the Meduri
paper*
The patient must have no demonstrable infection
broncho-alveolar lavage may be necessary to confirm this. This
includes undrained abscesses, disseminated fungal infection and
septic shock
ARDS
Steroids
The patient should have evidence of ARDS and
require an FiO2 >/= 50%
The steroid regimen:
Loading dose 2mg/kg
Then 2mg/kg/day from day 1 to 14
Then 1mg/kg/day from day 15 to 21
Then 0.5mg/kg/day from day 22 to 28
Then 0.25mg/kg/day on days 29 and 30
Finally 0.125mg/kg on days 31 and 32.
Prone Positioning
Relieves the cardiac and abdominal
compression exerted on the lower lobes
Makes regional Ventilation/Perfusion ratios
and chest elastance more uniform
Facilitates drainage of secretions
Potentiates the beneficial effect of
recruitment maneuvers
Study Overview
Placing patients who require mechanical ventilation in the prone rather
than the supine position improves oxygenation.
In this trial, the investigators found a benefit with respect to all-cause
mortality with this change in body position in patients with severe
ARDS.
Conclusions
In patients with severe ARDS, early application of prolonged pronepositioning sessions significantly decreased 28-day and 90-day
mortality.
FIO2
Simplest maneuver to quickly increase PaO2
Long-term toxicity at >60%
Free radical damage
PEEP
Increases FRC
Prevents progressive atelectasis and
intrapulmonary shunting
Prevents repetitive opening/closing
(injury)
Recruits collapsed alveoli and
improves V/Q matching
Resolves intrapulmonary shunting
Improves compliance
Enables maintenance of adequate
PaO2 at a safe FiO2 level
Disadvantages
Increases intrathoracic pressure (may
require pulmonary a. catheter)
May lead to ARDS
TV
Goal of 10 ml/kg
Risk of volutrauma
Permissive hypercapnea
Preferable to dangerously high RR and TV, as long as
pH > 7.15
Respiratory rate
Max RR at 35 breaths/min
Efficiency of ventilation
decreases with increasing RR
Decreased time for alveolar
emptying
TV
Goal of 10 ml/kg
Risk of volutrauma
PIP
Elevated PIP suggests need
for switch from volumecycled to pressure-cycled
mode
Plateau pressures
Pressure measured at the
end of inspiratory phase
Maintained at <30-35cm
H2O to minimize barotrauma
Negative-pressure
ventilators (iron lungs)
Non-invasive ventilation first
used in Boston Childrens
Hospital in 1928
Used extensively during
polio outbreaks in 1940s
1950s
Positive-pressure
ventilators