Acute Respiratory Distress Syndrom

7/25/2019 Acute Respiratory Distress Syndrom

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Acute Respiratory

Distress Syndrome

Alice Gray, MD

Duke University Medical Center

March 21, 200


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!"#ectives

De$ine ARDS and descri"e thepatholo%ical process

&no' causes o$ ARDS, and di$$erentialdia%nosis Understand speci$ic challen%es in

mechanical ventilation o$ patients 'ith

ARDS Understand treatment strate%ies and

evidence "ehind them


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ARDS

(irst descri"ed 1)* "y Ash"au%h and collea%ues Severe lun% in#ury characteri+ed "y non

cardio%enic pulmonary edema, decreased lun%

compliance, re$ractory hypo-emia 1)). Consensus De$inition

Acute onset /2 'eeksilateral in$iltrates on chest -ray

3C43 516mm7% or lack o$ evidence o$ le$t atrialhypertensionAcute lun% in#ury i$ 3a!28(i!2 5900ARDS i$ 3a!28(i!2 5200


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:pidemiolo%y

;ncidence o$ acute lun% in#ury /A)

6>) cases per 100,000 personyears

;ncidence o$ acute respiratory distresssyndrome /ARDS= 19>??6> cases per

100,000 personyears

Appro- )@ o$ ;CU "eds in US

:n%l B Med> 200?9?9=1*6?)9> Am B Respir Crit Care Med> 1)))1?)=16.)*1>


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Most common causes ARDS

3neumonia /9.@

Sepsis /2@

Aspiration /1?@ rauma /11@

3ulmonary contusion

Multiple $ractures

ARDSnet :BM 2000=9.2=19016>


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Causes o$ ARDS

:BM 20009.2,16=199.19.)


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Risk $actors $or ARDS

3ree-istin% lun% disease

Chronic alcohol use


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Di$$erential dia%nosis

3ulmonary edema $rom le$theart $ailure

Di$$use alveolar hemorrha%e

Acute eosinophilicpneumonia


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:-cludin% other dia%noses

:cho

Central venous catheter

ronchoscopy 'ith "ronchoalveolarlava%e /to eval $or hemorrha%e, A:3,

etc

Chest C


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Acute /:-udative 3hase

Rapid onset respiratory $ailure in patient

at risk $or ARDS

7ypo-emia re$ractory to o-y%en Chest -ray resem"les cardio%enic

pulmonary edema

ilateral in$iltrates 'orse in dependentlun% +ones, e$$usions

;n$iltrates may "e asymmetric


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Acute 3hase Radio%raphs

:BM 20009.2,16=199.19.)


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3atholo%ical $indin%s

Di$$use alveolar dama%e

eutrophils, macropha%es, erythrocytes

7yaline mem"ranes 3roteinrich edema in alveolar spaces


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Acute /:-udative 3hase

Expansion ofinterstitium withmacrophages andinammation

HyalineMembranes

AlveolarFilling


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(i"roproli$erative 3hase

3ersistent hypo-emia

(i"rosin% alveolitis

;ncreased alveolar dead space Decreased pulmonary compliance

3ulmonary hypertension

(rom o"literation o$ capillary "ed

May cause ri%ht heart $ailure


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(i"roproli$erative phase

Chest -ray sho's linear opacities consistent 'ithevolvin% $i"rosis

3neumothora- in 1019@ o$ patients C= di$$use interstitial opacities and "ullae 7istolo%ically, $i"rosis, mesenchymal cells,

vascular proli$eration, colla%en and $i"ronectinaccumulation

Can start ? days a$ter symptom onset ot present in every patient 'ith ARDS, "ut does

portend poorer pro%nosis


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(i"roproli$erative phase

:BM 20009.2,16=199.19.)


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(i"rosin% alveolitis

:BM 20009.2,16=199.19.)>


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Recovery phase

Gradual resolution o$ hypo-emia

7ypo-emia improves as edema resolves via active

transport a8Cl, aEuaporins

3rotein removal via endocytosis

Reepitheliali+ation o$ denuded alveolar space 'ith

type ;; pneumocytes that di$$erentiate into type ; cells

;mproved lun% compliance Chest -ray and C $indin%s resolve

3(s improve, o$ten normali+e


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Mana%ement o$ ARDS

reat underlyin% illness

Sepsis, etc

utrition Supportive care

DF prophyla-is

G; prophyla-is Medications


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Complications in Mana%in%

ARDS patients

Mechanical ventilation causes=!verdistention o$ lun%s /volutrauma

(urther dama%in% epithelium

;ncreased $luid leak, indistin%uisha"le $rom ARDS dama%earotrauma

Rupture alveolar mem"ranes 3neuomothora-, pneumomediastinum

Sheer stress

!penin%8closin% alveoli ;n$lammatory reaction, cytokine release

!-y%en to-icity(ree radical $ormation


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ARDS et'ork

;7$unded consortium o$ 10 centers,2. hospitals, ? intensive care units

Goal to desi%n lar%e RCs todetermine e$$ective treatments &ey ARDSnet studies=Fentilator volumesSteroids3::3Folume mana%ement83A catheter


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3ulmonary artery catheters

!$ten used to help evaluate $or cardio%enicpulmonary edema

SU33!R trial /retrospective study $irstraised dou"ts a"out utility 'o multicenter RCs con$irmed lack o$

mortality "ene$it o$ 3A catheters in ARDS

/ARDSnet (AC Monitorin% CF3 eEually e$$ective, so 3AC not

recommended in routine mana%ement

BAMA> 1))*2*=66))> :n%l B Med> 200*=9?.=22192.


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Fentilator mana%ement H

ARDSnet protocol

6*1 patients randomi+ed to Ft 1012 m%8k% ideal"ody 'ei%ht and plateau pressure 5?0cm72! vsFt *6 m%8k% ;4 and plateau pressure 590cm

72! &:IS


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ARDSnet idal Folume

Study

:BM 20009.2=19016>


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3ositive :nd:-piratory

3ressure /3::3 itrate 3::3 to decrease (i!2

Goal sat 66@ 'ith (i!2 *0@ Minimi+e o-y%en to-icity

3::3 can improve lun% recruitment and decrease

ende-piratory alveolar collapse /and there$oreri%httole$t shuntCan also decrease venous return, cause

hemodynamic compromise, 'orsen pulmonaryedema

ARDSnet 3::3 trial o$ ?.) patients sho' nodi$$erence in mortality or days on ventilator 'ithhi%h vs lo' 3::3

:BM 200.=9?1/.=9299*


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!ther ;deas in Fentilator

Mana%ement

3rone positionin%

May "e "ene$icial in certain su"%roup, "ut

complications includin% pressure sores

RC o$ 90. patients sho'ed no mortality "ene$it

7i%h$reEuency oscillatory ventilation

;n RC, improved o-y%enation initially, "ut results not

sustained a$ter 2. hours, no mortality "ene$it

:CM!

RC o$ .0 adults sho'ed no "ene$it

BAMA 1))2.2=21)9*> Am B Respir Crit Care Med> 20021**=6016


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Dru% therapy

A%ents studied=

Corticosteroids

&etocona+ole;nhaled nitric o-ide

Sur$actant

o "ene$it demonstrated


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Steroids in ARDS

:arlier studies sho'ed no "ene$it to early use steroids,

"ut small study in 1))0s sho'ed improved

o-y%enation and possi"le mortality "ene$it in late sta%e

ARDSnet trial /


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Steroids in ARDS

:n%l B Med 200*9?.=1*16.


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!ther dru%s in ARDS

&etocona+oleARDSnet study o$ 29. patients, ketocona+ole did !

decrease mortality, duration o$ mechanical ventilation orimprove lun% $unction

Sur$actantMulticenter trial, 2? patients 'ith sepsisinduced

ARDS, sur$actant had no e$$ect on 90day survival, ;CU

$unction ;nhaled itric o-ide

1 patients RC, improved o-y%enation, "ut no e$$ecton mortality o$ duration o$ mechanical ventilation

:n%l B Med> 1))*99.=1.121> Crit Care Med> 1))62*=1?29>


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(luid mana%ement

JDry lun%s are happy lun%sK

ARDSnet RC o$ 1000 patients /(AC,

Conservative vs li"eral $luid strate%y usin% CF3 or

3A!3 monitorin% to %uide, primary outcome=

death> Conservative $luids

;mproved o-y%enation

More ventilator$ree daysMore days outside ;CU

o increase in shock or dialysis

o mortality e$$ects


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ARDSnet (luid Mana%ement

:BM 200*9?.=2?*.?>


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&eys to mana%ement

reat underlyin% illness Supportive care


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Survival and ?@ 'ith evidence o$ 3SD


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1 year a$ter ARDS survival


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Re$erences

Ru"en$eld GD, et al> ;ncidence and outcomes o$ acute lun% in#ury :n%l B Med>200?9?9=1*6?)9>

;ncidence and mortality a$ter acute respiratory $ailure and acute respiratorydistress syndrome in S'eden, Denmark, and ;celand> he AR( study %roup> Am B RespirCrit Care Med> 1)))1?)=16.)0*1,

ersten AD et al> Australian and e' Pealand ;ntensive Care Society Clinical rials Group>;ncidence and mortality o$ acute lun% in#ury and the acute respiratory distress syndrome

in three Australian states> Am B Respir Crit Care Med> 20021*?=..96>Connors A( Br, et al> he e$$ectiveness o$ ri%ht heart catheteri+ation in the initial care o$

critically ill patients> SU33!R investi%ators> BAMA> 1))*2*=66))>

Richard C, et al> :arly use o$ the pulmonary artery catheter and outcomes in patients 'ithshock and acute respiratory distress syndrome= a randomi+ed controlled trial> BAMA>20092)0=21920>

4heeler A3, et al> 3ulmonaryartery versus central venous catheter to %uide treatment o$acute lun% in#ury> :n%l B Med> 200*=9?.=22192.>

Fentilation 'ith lo'er tidal volumes as compared 'ith traditional tidal volumes $or acute lun%

in#ury and the acute respiratory distress syndrome> he Acute Respiratory DistressSyndrome et'ork> :n%l B Med> 20009.2=19016>

ational 7eart, :nl% BMed> 200*9?.=2?*.?>

&olle$, M7, Schuster D3> he acute respiratory distress syndrome> :n%l B Medicine1))?992/1=29>


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Re$erences

&etocona+ole $or early treatment o$ acute lun% in#ury and acute respiratory distress syndrome=a randomi+ed controlled trial> BAMA> 2000269=1))?2002>

An+ueto A, et al> Aerosoli+ed sur$actant in adults 'ith sepsisinduced acute respiratorydistress syndrome> :-osur$ Acute Respiratory Distress Syndrome Sepsis Study Group> :n%l B Med> 1))*99.=1.121>

Dellin%er R3 et al> :$$ects o$ inhaled nitric o-ide in patients 'ith acute respiratory distresssyndrome= results o$ randomi+ed phase ;; trial> ;nhaled itric !-ide in ARDS Study

Group> Crit Care Med> 1))62*=1?29>Papol 4M, et al> :-tracorporeal mem"rane o-y%enation in severe acute respiratory $ailure> A

randomi+ed prospective study> BAMA 1))2.2=21)9*>

Derdak S, et al> 7i%h$reEuency oscillatory ventilation $or adult respiratory distress syndrome=a randomi+ed controlled trial> Am B Respir Crit Care Med> 20021**=6016>

ernard GR, et al> 7i%hdose steroids in patients 'ith the adult respiratory distress syndrome> :n%l B Med> 1)691=1?*?0>

Stein"er% &3, et al> :$$icacy and sa$ety o$ corticosteroids $or persistent acute respiratorydistress syndrome> :n%l B Med> 200*=9?.=1*16.>

4are he acute respiratory distress syndrome> :n%l B Med20009.2=199..)>

Meduri GU et al> :$$ect o$ prolon%ed methylprednisolone therapy in unresolvin% acuterespiratory distress syndrome= a randomi+ed controlled trial> BAMA 1))6260=1?)*?>

ational 7eart,

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Acute Respiratory Distress Syndrom