ACUTE RESPIRATORY

DISTRESS SYNDROME
Lyonel Carre PGY2
SICU conf
10/02/06
 ARDS
Definition
• Severe, acute lung injury involving diffuse
alveolar damage, increased microvascular
permeability and non cardiogenic
pulmonary edema
• Acute refractory hypoxemia
• Annual incidence 75/100,000 in the US
• High mortality- 40%-60%
• First described in 1967
 ARDS
Criteria
• Acute onset of respiratory failure
• Bilateral infiltrate on CXR(some cases do
present unilaterally or with pleural effusion
• PCWP <18 or absence of left atrial htn,
• PaO2/FiO2 < 200
 ARDS
•
 ARDS
mechanism of lung injury
• Activation of inflammatory mediators and cellular
components resulting in damage to capillary
endothelial and alveolar epithelial cells
• Increased permeability of alveolar capillary
membrane
• Influx of protein rich edema fluid and
inflammatory cells into air spaces
• Dysfunction of surfactant
 ARDS causes
• Direct Lung Injury:
a) PNA and aspiration of gastric contents
or other causes of chemical pneumonitis
b) pulmonary contusion, penetrating lung injury
c) fat emboli
d) near drowning
e) inhalation injury
f) reperfusion pulm edema after lung transplant
 ARDS causes
• Indirect lung injury
a) sepsis
b) severe trauma w/ shock hypoperfusion
c) drug over dose
d) cardiopulmonary bypass
e) acute pancreatitis
f) transfusion of multp blood products
 Stages of ARDS

• 1. Exudative (acute) phase - 0- 4 days

• 2. Proliferative phase - 4- 8 days
• 3. Fibrotic phase - >8 days
• 4. Recovery
ARDS exudative and fibrotic
phases
 Predictors of outcome
• Factors whose presence can be used to predict the
risk of death at the time of diagnosis of acute lung
injury and the acute respiratory distress syndrome
include
a)chronic liver disease
b)non-pulmonary organ dysfunction,
c)sepsis,
d)advanced age.
 ARDS network study

• patients with ALI/ARDS at 10 centers, 861

patients
• Patients randomized to tidal volumes of 12 mL
/kg or 6 ml/kg(volume control, assist control, plat
Press = 30 cm H2O)
• 22% reduction in mortality in patients receiving
smaller tidal volume
• Number-needed to treat: 12 patients
 ARDS Network Study
 

6ml/kg 12m/kg
PaCO2 43 ± 12 36 ±9
Respiratory rate 30 ± 7 17 ± 7
PaO2/F /FIO2 160 ± 68 177 ± 81
Plateau pressure 26 ± 7 34 ± 9
PEEP 9.2 ± 3.6 8.6 ± 4.2
 ARDSnet protocol
• Calculated predicted body weight(pbw)
male: 50+2.3[height(inches)-60]
female: 45.5+2.3[height(inches)-60]
Mode: Volume assist-control
Change rate to adjust minute ventilation(not>35/min)
PH goal 7.30-7.45
Plateau press<30cmh20
PaO2 goal: 55-80mmhg or SpO2 88-95%
FiO2/PEEP combination to achieve oxygenation goal.
 ARDSnet
How to select PEEP
• PEEP/FiO2 relationship to maintain adequate
PaO2/SpO2
• PaO2 goal: 55-80mmHg or SpO2 88-95% use
FiO2/PEEP combination to achieve oxygenation goal

0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
FIO2
5 5 8 8 10 10 10 12 14 14 14 16 18 20-
PEEP 24
 ARDSNet
Ventilator protocol
 ARDS
Ventilator setting
• Greatest Lung strain PC IRV(I:E 2:1), least w/ PC
(I:E 1:2) and intermediate w/ VC (I:E 1:2)
• No difference in gas exchanged, hemodynamics,
and plateau pressure
• No difference in outcome w/ ARDS pts
randomized to pressure control vs volume cycled
PC(n=37), VC(n=42).
Edibam et al Am J Resp Crit Care Med 2003
Esteban et al , Chest 2000
 Permissive Hypercapnia

• Low Vt (6ml/kg) to prevent over-distention

• increase respiratory rate to avoid very high level
of hypercapnia
• PaCO2 allowed to rise
• Usually well tolerated
• May be beneficial
• Potential Problems: tissue acidosis, autonomic
dysregulation, CNS effect, and circulatory effects
HISTORY OF ALTERNATIVE VENTILATORY
STRATEGIES FOR ACUTE LUNG INJURY
AND THE ACUTE RESPIRATORY DISTRESS
SYNDROME.
 ARDS
Treatment
• Ventilator-induced lung injury: it was previously thought that oxygen
toxicity was one of the most important factors in the progression of
ARDS and resultant mortality. Recently, it was found that high
volume(volutrauma) and high press(barotrauma) are equally if not more
detrimental to these pts
• Treatment strategy is one of low volume and high frequency
ventilation(ARDSNet protocol)
• Search for and treat the underlying cause
• Treat abdominal infx promptly w/ abx and surgery
• Ensure adequate nutrition and place on GI/DVT prophylaxis
• Prevent and treat nosocomial infx
• Consider short course of high dose steroids in pts w/ severe dz that is not
resolving.
 When all else fails..
• Recruitment maneuvers
• Prone
• Inhaled nitric oxide
• High frequency oscillation
 ARDSnet and Long-term
outcome
120pts randomized to low Vt or high Vt
a) 25%mortality w/ low tidal volume
b) 45% mortality w/ high tidal volume
20% had restricitve defect and 20% had obstructive defect 1 yr
after recovery
About 80% had DLCO reduction 1 yr after recovery
Standardized tested showed health-related quality of life lower
than normal
No difference in long-term outcomes between tidal volume
group
Orme Am J respir Crit Care Med 2003