Acute Respiratory

Distress Syndrome in
near drowning and
poisoning
F.C.SALATI
Msc
Acute Respiratory Distress Syndrome
(ARDS) is a sudden and progressive form of
acute respiratory failure in which the
alveolar capillary membrane becomes
damaged and become more permeable.
 Resulting in severe dyspnea, hypoxemia
and diffuse pulmonary infiltrates.

INTRODUCTION
Laboured and rapid breathing
Muscle fatigue and general weakness
Low blood pressure
Discoloured skin or nails
A dry, hacking cough
A fever
Headaches
A fast pulse rate
Mental confusion

SYMPTOMS
Direct Lung Injury
Aspiration of gastric contents or other
substances.
Viral/ bacterial pneumonia
Near-drowning
Inhalation of toxic substances
O2 Toxicity

Etiology and Risk Factors

Indirect Lung Injury
Sepsis
Severe traumatic injury
Acute pancreatitis
Narcotic drug overdose
Anaphylaxis
Multiple blood transfusions
Early ARDS is characterized by an increase
in the permeability of the alveolar-capillary
barrier, leading to an influx of fluid into the
alveoli. The alveolar-capillary barrier is
formed by the microvascular endothelium
and the epithelial lining of the alveoli.
Hence, a variety of insults resulting in
damage either to the vascular endothelium
or to the alveolar epithelium could result in
ARDS.

PATHOPYSIOLOGY
The main site of injury may be focused on
either the vascular endothelium
(eg, sepsis) or the alveolar epithelium
(eg, aspiration of gastric contents). Injury
to the endothelium results in increased
capillary permeability and the influx of
protein-rich fluid into the alveolar space.
Injury to the alveolar lining cells also
promotes pulmonary edema formation.
The acute phase of ARDS usually resolves
completely. Less commonly, residual
pulmonary fibrosis occurs, in which the
alveolar spaces are filled with
mesenchymal cells and new blood vessels.
This and the finding of fibrosis on biopsy
correlate with an increased mortality rate.
 Approximately 20% of patients with
ARDS have no identified risk factor. 
Causes of ARDS include the following:
Sepsis
Trauma to chest or head
Fractures, long bones
Burns
Severe Covid 19

ETIOLOGY
Massive transfusion
Pneumonia
Aspiration
Drug overdose
Near drowning
Postperfusion injury after cardiopulmonary
bypass
Pancreatitis
Fat embolism

ETIOLOGY CONTINUES
Most deaths in ARDS patients are
attributable to sepsis or multi-organ
failure rather than to a primary pulmonary
cause, although the recent success of
mechanical ventilation using smaller tidal
volumes may suggest a role of lung injury
as a direct cause of death.
Patients with ARDS are likely to have
prolonged hospital courses, and they
frequently develop ventilator-associated
pneumonia (VAP), significant weight loss,
muscle weakness, and functional
impairment which may persist for months
after hospital discharge. 
In a study of 109 survivors of ARDS, 12
patients died in the first year. In 83 evaluable
survivors, spirometry and lung volumes were
normal at 6 months, but diffusing capacity
remained mildly diminished (72%) at 1
year. ARDS survivors had abnormal 6-minute
walking distances at 1 year, and only 49%
had returned to work. Their health-related
quality of life was significantly below normal.
However, no patient remained oxygen
dependent at 12 months. Radiographic
abnormalities had also completely
resolved
PATHOPHYSIOLOGY OF ARDS IN
THE ALVEOLI
Drowning is death secondary to asphyxia
while immersed in a liquid, usually water,
or within 24 hours of submersion.
ARDS in near drowning is characterized by
Interstitial pulmonary oedema,
hypoxia,hypercapnia and acidosis.
Leading to direct alteration of the alveolar
membrane by aspirated water and
particulate matters and a volume
overloading by absorption.

Near Drowning
Pathophysiology
Predisposing illness: Epilepsy, seizures
Trauma: Diving and boating accidents,
falls
Mental impairment :drugs and alcohol
Exhaustion
Rapidly moving water
Hyperventilation

Predisposing factors
The common cause of mortality due to
poisoning is respiratory failure.
Poisons induce pathological changes in the
lung following absorption.
Causing direct damage to the respiratory
cells at the alveolar level or indirectly
through inflammation mediators in a
severely exposed patient.

POISIONING
Patients with ARDS are hospitalized in the
Intensive Care Unit.
Input from physiotherapy is often limited and
minimal due to the need of high
PEEP( Positive end expiratory pressure).
However treatment may include:
Positioning in prone lying and lateral rotation
using a Lateral Rotation therapy bed.
Minimal suctioning

Physiotherapy Management
Placing the ARDS patient into prone will result
in a significant increase in PaO2(partial
pressure of oxygen-oxygen pressure in
arterial blood)
By placing the patient in prone , there is an
improvement in the recruitment of the dorsal
aspect of the lung.
Resulting in a more evenly distributed
perfusion and improving V/Q (the amount of
air that reaches the alveoli)matching.

Prone positioning
If you have ARDS, you can develop other medical
problems while in the hospital. The most common
problems are:
Blood clots. Lying still in the hospital while on a
ventilator can increase your risk of developing
blood clots, in the deep veins in your legs. If a
clot forms in your leg, a portion of it can break off
and travel to one or both of your lungs
(pulmonary embolism) — where it blocks blood
flow.
COMPLICATIONS
Collapsed lung (pneumothorax). 
Infections due to ventilator
Scarring (pulmonary
fibrosis). Scarring and thickening of the
tissue between the air sacs can occur
within a few weeks of the onset of ARDS.
This stiffens your lungs, making it difficult
for oxygen to flow from the air sacs into
your bloodstream.
Breathing problems.
Depresion
Problems with memory
Tiredness and muscle weakness

LONG TERM EFFECTS

Oxygen levels
X ray
Ct scan
HEART TESTS
ECG
Electrocardiogram
Lab tests-arterial blood gas

DIAGNOSIS
Improve O2 levels
Supplemental oxygen. For milder
symptoms or as a temporary measure,
oxygen may be delivered through a mask
Mechanical ventilation. Most people
with ARDS will need mechanical
ventilator pushes air into your lungs and
forces some of the fluid out of the air
sacs.

TREATMENT

People with ARDS usually are given
medication to:
Prevent and treat infections
Relieve pain and discomfort
Prevent blood clots in the legs and lungs
Minimize gastric reflux
Sedate
Attend pulmonary rehabilitation. Many
medical centers now offer pulmonary
rehabilitation programs.
If you're recovering from ARDS, the following
suggestions can help protect your lungs:
Quit smoking. If you smoke, and avoid
secondhand smoke whenever possible.
Get vaccinated. The yearly flu (influenza)
shot, as well as the pneumonia vaccine every
five years, can reduce your risk of lung
infections.
tips:
.
1. Semple-Hess J, 2015.Drowning in the adult
population: emergency department
resuscitation and treatment. Emerg.Med.Pract .
17 (5) (2015)
2. S Hraiech, 2014.Acute respiratory distress
syndrome. J.Emerge.Med 46(6) (2014)
3. Ruggeri, P., Calcaterra, S., Bottari, a., Girbino,
G. & V Fodale, V. (2016). Successful
management of acute respiratory failure with
noninvasive mechanical ventilation after
drowning in an epileptic-patient. Respiratory
Medicine Case Reports 17(2016) 90-92

References