Acute respiratory distress syndrome: Difference between revisions

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==Background==
==Background==
*Acronym: ARDS
*Non-cardiogenic [[pulmonary edema]] due to lung capillary endothelial injury (diffuse alveolar damage)
*Non-cardiogenic pulmonary edema due to lung capillary endothelial injury
**Proteinaceous material accumulate in alveoli in a heterogeneous manner (hyalinosis)
**Proteinaceous material accumulate in alveoli in a heterogeneous manner
*Symptom of an underlying disease
*Symptom of an underlying disease


==Clinical Features==
===Diagnostic criteria<ref>Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.</ref>===
#New onset respiratory symptoms
#Bilateral pulmonary opacities
#Symptoms not explained by cardiac etiology or volume overload
===Severity by Berlin definition<ref>Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.</ref>===
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''PaO2/FiO2'''
| align="center" style="background:#f0f0f0;"|'''Severity'''
| align="center" style="background:#f0f0f0;"|'''Mortality'''
|-
| 200-300||Mild||27%
|-
| 100-200||Mod||32%
|-
| <100||Severe||45%
|-
|}
===Presentation===
*Severe dyspnea
*Hypoxemia
*Diffuse crackles
===Imaging===
*Diffuse patchy pulmonary infiltrates
===Causes===
===Causes===
*[[Sepsis]]
*[[Sepsis]]
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*[[Toxicology (Main)|Overdose]]
*[[Toxicology (Main)|Overdose]]
*[[Massive transfusion]]
*[[Massive transfusion]]
*[[Transfusion-related acute lung injury]]
==Clinical Features==
*Severe [[dyspnea]]
*[[Hypoxemia]]
*Diffuse crackles


==Differential Diagnosis==
==Differential Diagnosis==
*[[Pneumonia]]
*[[Pneumonia]]
*[[PE]]
*[[PE]]
*Diffuse alveolar hemorrhage
*[[Diffuse alveolar hemorrhage]]
*[[DIC]]
*[[DIC]]
*[[CHF]]


{{Pulmonary edema types}}
{{Pulmonary edema types}}


==Diagnosis==
==Evaluation==
*CXR
[[File:ARDSSevere.png|thumb|Classic ARDS on [[CXR]].]]
[[File:ARDS.png|thumb|ARDS on CXR]]
===Workup===
*[[CXR]]
*CBC
*CBC
*Chem 10
*Chem 10
*UA
*[[Urinalysis]]
*LFT
*[[LFTs]]
*Lipase
*Lipase
*PT/PTT
*PT/PTT
*Influenza (seasonal)
*[[Influenza]] testing (seasonal)
*Blood cultures
*Blood cultures
*Lactate
*[[Lactate]]
*Consider bedside echo
*Consider bedside [[echocardiography|echo]]
*Consider ABG/VBG
*Consider [[ABG]]/[[VBG]]
*Consider BNP
*Consider [[BNP]]
 
===Diagnosis===
*[[CXR]] shows diffuse patchy pulmonary infiltrates
 
====Diagnostic Criteria<ref name="Ferguson">Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.</ref>====
#New onset [[SOB|respiratory symptoms]]
#Bilateral pulmonary opacities
#Symptoms not explained by cardiac etiology or volume overload


==Management==
==Management==
===General Care===
*Treat underlying cause
*Treat underlying cause
**Cover for sepsis
**Cover for [[sepsis]]
***Pneumonia in addition to other identified source
***[[Pneumonia]] in addition to other identified source
**Tamiflu 75mg BID oral or NGT if influenza season <ref>http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm</ref>
**[[Tamiflu]] 75mg BID oral or NGT if influenza season <ref>http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm</ref>
*Supplemental O2
 
*[[Noninvasive Ventilation|Noninvasive ventilation]]
===Pulse Dose [[Steroids]]===
**Limited data to support use
*Consider in early, established, severe ARDS in ICU setting<ref>Khilnani GC and Hadda V. Corticosteroids and ARDS: A review of treatment and prevention evidence. Lung India. 2011 Apr-Jun; 28(2): 114–119.</ref>
*Consider pulse dose steroids in early, established, severe ARDS in ICU setting<ref>Khilnani GC and Hadda V. Corticosteroids and ARDS: A review of treatment and prevention evidence. Lung India. 2011 Apr-Jun; 28(2): 114–119.</ref>
**'''NOT''' for prevention of ARDS (will increase risk for ARDS and worsening sepsis if not in ARDS already)
**'''NOT''' for prevention of ARDS (will increase risk for ARDS and worsening sepsis if not in ARDS already)
**In theory, may reduce fibro-proliferative inflammatory changes during exudative phase (< 1 wk)
**In theory, may reduce fibro-proliferative inflammatory changes during exudative phase (< 1 wk)
**No benefit to starting in late ARDS (> 2 wks)
**No benefit to starting in late ARDS (> 2 wks)
**Meduri protocol (21 vs. 43% mortality)<ref>Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest. 2007;131:954–63.</ref>
*Meduri protocol (21 vs. 43% mortality)<ref>Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest. 2007;131:954–63.</ref>
***1 mg/kg loading dose methyprednisolone
**1mg/kg loading dose [[methylprednisolone]]
***Followed by infusion of 1 mg/kg/day from day 1-14
**Followed by infusion of 1mg/kg/day from day 1-14
***Then 0.5 mg/kg/day from day 15-21
**Then 0.5mg/kg/day from day 15-21
***Then 0.25 mg/kg/day from day 22-25
**Then 0.25mg/kg/day from day 22-25
***Finally 0.125 mg/kg/day from day 26-28
**Finally 0.125mg/kg/day from day 26-28
*[[Ventilation (Main)|Ventilator Settings]]
 
**Permissive hypercapnia
{{Lung Protective Ventilator Settings}}
**Tidal volume 6-8cc/kg of [http://www.mdcalc.com/ideal-body-weight/ ideal body weight]<ref>Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.</ref>
{{Lung Protective FiO2 and PEEP Scale}}
***Limit barotrauma to healthy area of lung
***Increase PEEP to improve oxygenation
****High FiO2 can cause absorptive atelectasis<ref>O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.</ref>
****Ardsnet PEEP/FiO2 [http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf protocol card]<ref>Kallet RH, et al. "Respiratory controversies in the critical care setting. Do the NIH ARDS Clinical Trials Network PEEP/FIO2 tables provide the best evidence-based guide to balancing PEEP and FIO2 settings in adults?" Respiratory Care. 2007. 52(4):461-75.</ref>
**Maintain plateau pressures < 30 <ref>Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14</ref>
**Ensure adequate sedation
***Better synchrony with vent
***Decreased oxygen consumption
***Less [[delirium]]
***Increased patient comfort
**Prone ventilation <ref>Guerin, C. (2014) ‘Prone ventilation in acute respiratory distress syndrome’, European Respiratory Review, 23(132), pp. 249–257.</ref>
***Increases survival for severe ARDS
***Consider for refractory hypoxemia
***Many consider this a type of [[recruitment maneuver]]
**[[APRV]] ([[BiVent]]) to recruit alveoli, if minimal to no respiratory acidosis<ref>CritCareMed. 2005;33:S228 Other Approaches to Open-Lung Ventilation–Airway Pressure Release Ventilation.</ref><ref>CleveClinJMed 2011;78:101 Airway Pressure Release Ventilation–Alternative Mode of Mechanical Ventilation in Acute Respiratory Distress Syndrome.</ref>
***Start PHigh at PPlat at 28, try not to go beyond 35 cmH2O
***PPlateau = desired Pmean + 3 cmH2O
***PLow at 0 cmH2O for maximal expiration
***THigh at 4.5-6 seconds (inspiratory time)
***Tlow at 0.5-0.8 seconds (expiratory time), with TV 4-6 cc/kg
***[[Automatic tube compensation]] ON if pt spontaneously breathing<ref>Guttmann J et al. Automatic tube compensation (ATC). Minerva Anestesiol. 2002 May;68(5):369-77.</ref>
**[[Pressure control ventilation]] ([[PCV]]) if acidosis with APRV
***Attempt to maintain same rate
***Maintain same Pmean
**[[Recruitment maneuver]]
***Varying methods and protocols
***Controversial in risks and benefits


==Adjuncts==
===Additional [[Ventilation (Main)|Ventilation]] Considerations===
*Permissive hypercapnia
*Maintain plateau pressures < 30 <ref>Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14</ref>
*Ensure adequate [[sedation]]
**Better synchrony with vent
**Decreased oxygen consumption
**Less [[delirium]]
**Increased patient comfort
*Prone ventilation <ref>Guerin, C. (2014) ‘Prone ventilation in acute respiratory distress syndrome’, European Respiratory Review, 23(132), pp. 249–257.</ref>
**Increases survival for severe ARDS
**Consider for refractory hypoxemia
**Many consider this a type of [[recruitment maneuver]]
*Consider [[Airway pressure release ventilation]] (APRV)
*[[Pressure control ventilation]] ([[PCV]]) if acidosis with APRV
**Attempt to maintain same rate
**Maintain same Pmean
*[[PRVC]] or [[Volume control ventilation]] with paralysis to prevent barotrauma in breath stacking and vent dyssynchrony<ref>Gainnier M, Roch A, Forel JM, et al. Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2004;32:113-119.</ref><ref>Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107-1116.</ref>
**[[Cisatricurium]] loading dose 0.15 mg/kg, followed by 1-3 mcg/kg/min
**Titrated to less than 2 twitches in train of four
**Cisatricurium preferred to pancuronium in renal impairment
**Cannot use paralysis with APRV
*[[Recruitment maneuver]]
**Varying methods and protocols
**Controversial in risks and benefits
 
===Adjuncts===
*Evidence of [[pulmonary hypertension]]
*Evidence of [[pulmonary hypertension]]
**[[Inhaled nitric oxide]] ([[iNO]])
**[[Inhaled nitric oxide]] ([[iNO]])
**[[Prostacyclins]], [[epoprostenol]] ([[Flolan]])
**[[Epoprostenol (prostacyclin)]]
*[[ECMO]]
*[[ECMO]]
*[[Oscillation ventilation]], [[High frequency oscillation ventilation]] ([[HFOV]])
*[[Oscillation ventilation]], [[High frequency oscillation ventilation]] ([[HFOV]])


==Disposition==
==Disposition==
* Admit to ICU
*Admit to ICU
 
==Prognosis==
===Severity (Berlin Definition)<ref name="Ferguson" />===
{| class="wikitable"
| align="center" style="background:#f0f0f0;"|'''PaO2/FiO2'''
| align="center" style="background:#f0f0f0;"|'''Severity'''
| align="center" style="background:#f0f0f0;"|'''Mortality'''
|-
| 200-300||Mild||27%
|-
| 100-200||Mod||32%
|-
| <100||Severe||45%
|-
|}


==See Also==
==See Also==
*[[EBQ:ARDSnet Trial]]
*[[Pulmonary edema]]
*[[Pulmonary edema]]
*[[CHF]]
 
*[[EBQ:ARDSnet Trial]]
{{Mechanical ventilation pages}}


==External Links==
==External Links==
[http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf ARDSnet Ventilator Settings]
*[http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf ARDSnet Ventilator Settings]
*[https://resusreview.com/2013/aprv-ventilation-mode-introduction-basic-use-management-and-advanced-tips/ APRV / BiVent]


==References==
==References==

Revision as of 20:56, 2 July 2020

Background

  • Non-cardiogenic pulmonary edema due to lung capillary endothelial injury (diffuse alveolar damage)
    • Proteinaceous material accumulate in alveoli in a heterogeneous manner (hyalinosis)
  • Symptom of an underlying disease

Causes

Clinical Features

Differential Diagnosis

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[1]

Evaluation

Classic ARDS on CXR.
ARDS on CXR

Workup

Diagnosis

  • CXR shows diffuse patchy pulmonary infiltrates

Diagnostic Criteria[2]

  1. New onset respiratory symptoms
  2. Bilateral pulmonary opacities
  3. Symptoms not explained by cardiac etiology or volume overload

Management

General Care

  • Treat underlying cause

Pulse Dose Steroids

  • Consider in early, established, severe ARDS in ICU setting[4]
    • NOT for prevention of ARDS (will increase risk for ARDS and worsening sepsis if not in ARDS already)
    • In theory, may reduce fibro-proliferative inflammatory changes during exudative phase (< 1 wk)
    • No benefit to starting in late ARDS (> 2 wks)
  • Meduri protocol (21 vs. 43% mortality)[5]
    • 1mg/kg loading dose methylprednisolone
    • Followed by infusion of 1mg/kg/day from day 1-14
    • Then 0.5mg/kg/day from day 15-21
    • Then 0.25mg/kg/day from day 22-25
    • Finally 0.125mg/kg/day from day 26-28

Lung Protective Mechanical Ventilation

Lung Protective Ventilator Settings[6] should be the default for all intubated patients, unless contraindicated. It has demonstrated mortality benefit for ARDS-like pulmonary conditions; limits barotrauma and decreases complications of high FiO2[7][8]

  1. Mode
    • Volume-assist control
  2. Tidal Volume
    • Start 6-8cc/kg predicted body weight[9]
      • Predicted/"ideal" body weight is used because a person's lung parenchyma does not increase in size as the person gains more weight.
    • Titrate down if plateau pressure >30 mmHg
  3. Inspiratory Flow Rate (comfort)
    • More comfortable if higher rather than lower
    • Start at 60-80 LPM
  4. Respiratory Rate (titrate for ventilation)
    • Average patient on ventilator requires 120mL/kg/min for eucapnia
    • Start 16-18 breaths/min
    • Maintain pH = 7.30-7.45
  5. FiO2/PEEP (titrate for oxygenation)
    • Move in tandem to achieve:
    • SpO2 BETWEEN 88-95%
    • PaO2 BETWEEN 55-80mmHg

Lung Protective FiO2 and PEEP Scale[10][11][12]

FiO2 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 1.0 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 20 22 24

Additional Ventilation Considerations

Adjuncts

Disposition

  • Admit to ICU

Prognosis

Severity (Berlin Definition)[2]

PaO2/FiO2 Severity Mortality
200-300 Mild 27%
100-200 Mod 32%
<100 Severe 45%

See Also

Mechanical Ventilation Pages

External Links

References

  1. ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
  2. ↑ 2.0 2.1 Ferguson ND et. al. The Berlin definition of ARDS: an expanded rationale, justification, and supplementary material. Intensive Care Med. 2012 Oct;38(10):1573-82.
  3. ↑ http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm
  4. ↑ Khilnani GC and Hadda V. Corticosteroids and ARDS: A review of treatment and prevention evidence. Lung India. 2011 Apr-Jun; 28(2): 114–119.
  5. ↑ Meduri GU, Golden E, Freire AX, Taylor E, Zaman M, Carson SJ, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest. 2007;131:954–63.
  6. ↑ 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. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  7. ↑ ARDSnet
  8. ↑ O'Brien J. Absorption Atelectasis: Incidence and Clinical Implications. AANA Journal. June 2013. Vol. 81, No. 3.
  9. ↑ Brower RG, et al. "Ventilation With Lower Tidal Volumes As Compared With Traditional Tidal Volumes For Acute Lung Injury And The Acute Respiratory Distress Syndrome". The New England Journal of Medicine. 2000. 342(18):1301-1308.
  10. ↑ 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. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-1308.
  11. ↑ Kallet RH, et al. "Respiratory controversies in the critical care setting. Do the NIH ARDS Clinical Trials Network PEEP/FIO2 tables provide the best evidence-based guide to balancing PEEP and FIO2 settings in adults?" Respiratory Care. 2007. 52(4):461-75.
  12. ↑ ARDSnet protocol card
  13. ↑ Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14
  14. ↑ Guerin, C. (2014) ‘Prone ventilation in acute respiratory distress syndrome’, European Respiratory Review, 23(132), pp. 249–257.
  15. ↑ Gainnier M, Roch A, Forel JM, et al. Effect of neuromuscular blocking agents on gas exchange in patients presenting with acute respiratory distress syndrome. Crit Care Med. 2004;32:113-119.
  16. ↑ Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl J Med. 2010;363:1107-1116.
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