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Management of ARDS
Management of ARDS
Syndrome
Dr Renu Sinha
Additional Professor
Dept. Of Anaesthesiology, Critical Care & pain Medicine
AIIMS
ARDS, or Acute Respiratory Distress Syndrome
• Inflammatory lung condition involving both lungs
• Inflammation leads to injury of lung tissue and
leakage of blood and plasma into the airspaces
resulting in low oxygen levels in the blood.
• Mechanical ventilation is required both to deliver
higher concentrations of oxygen and to provide
ventilation to remove carbon dioxide from the body.
• Inflammation in the lung may lead to inflammation
elsewhere causing shock and injury or dysfunction in
the kidneys, heart, and muscles.
First described 1967 by Ashbaugh and colleagues
Synonyms
– Shock lung
– Traumatic wet lung
• Incidence:
– Acute lung injury (ALI): 17.9-78.9 cases per 100,000 person-years
– Acute respiratory distress syndrome (ARDS): 13.5-58.7 cases per 100,000
person-years
Bernard et al. AJRCCM 1994; 149:818
Rice et al. Chest 2007: 132: 410
June 20, 2012, Vol 307, No. 23
I. Mild,
II. Moderate
III. Severe
1. Direct or indirect
injury to the alveolus
causes alveolar
macrophages to
release pro-
inflammatory cytokines
2. Cytokines attract
neutrophils into the
alveolus and
interstitium, where
they damage the
alveolar-capillary
membrane (ACM).
3. ACM integrity is
lost, interstitial and
alveolus fills with
proteinaceous fluid,
surfactant can no
longer support
alveolus
vs
• Unassisted breathing
– T-piece, trach collar
– Assess for 30minutes-2 hours
Weaning
• Tolerating Breathing Trial?
– SpO2 ≥90
– Spontaneous Vt ≥4ml/kg PBW
– RR ≤35
– pH ≥7.3
– Pass Spontaneous Awakening Trial (SAT)
– No Respiratory Distress ( 2 or more)
• HR > 120% baseline
• Accessory muscle use
• Abdominal Paradox
• Diaphoresis
• Marked Dyspnea
– If tolerated, consider extubation
Putting it all together
1) Calculate patient’s predicted body weight:
• Men (kg) = 50 + 2.3(height in inches – 60)
• Females (kg) = 45.5 + 2.3(height in inches – 60)
2) Set Vt = predicted body weight x 6cc
3) Set initial rate to approximate baseline minute ventilation
(RR x Vt)
4) Set FiO2 and PEEP to obtain SaO2 goal of >=88%
5) Diuresis after resolution of shock
6) Refer to ARDSnet guidelines
Common Problems
Refractory Hypoxia
• Mechanical Trouble (tubing, ventilator, ptx, plugging)
• Neuromuscular blockade
• Recruitment maneuvers – positioning, “good lung down”
optimizes V/Q mismatch
• Increase PEEP
• Inhaled epoprostenol sodium (Flolan)
– When inhaled, the vasodilator reaches the normal lung, is
concentrated in normal lung segments and recruits blood flow to
functional alveoli where it is oxygenated. This decreases shunting and
hypoxemia
• High frequency ventilation
-Neuromuscular blocking agents may increase oxygenation
and decrease ventilator associated lung injury in severe
ARDS patients
-Multicenter double blind trial with 340 patients; received
48hrs of cisatracurium (Nimbex) or placebo
-Found that early administration of NBA improved 90 day
survival and increased time off ventilator without increase
in muscle weakness
Papazian, L, et al. NEJM 2010; 363: 1107-1116.
Supportive Therapies
• Treat underlying infection
• DVT prophylaxis / stress ulcer prevention
• HOB 30°
• Hand washing
• Use full barriers with chlorhexidine
• Sedation / analgesia
• Feeding protocol
• Avoid contrast nephropathy
• Pressure ulcer prevention, turning Q2h
• Avoid steroid use
Treatment
• Tt underlying disease that caused ARDS: early and effective
antibiotics for pneumonia or sepsis.
• Small breaths and low pressures from the ventilator (so called
low tidal volume and pressure ventialtion).
• conservative use of intravenous fluids combined with
removal of excess fluids with diuetics lessens the need for
mechanical ventilation.
• Death: 40 percent% cases of severe form (multiple organ
failure).
Conclusion
• Recovery dependent on health prior to onset
Levy BD, & Choi AM, Harrison’s Principles of Internal Medicine, 2012
Summary
• ARDS is a clinical syndrome characterized by severe, acute
lung injury, inflammation and scarring
• Significant cause of ICU admissions, mortality and
morbidity
• Caused by either direct or indirect lung injury
• Mechanical ventilation with low tidal volumes and
plateau pressures improves outcomes
• So far, no pharmacologic therapies have demonstrated
mortality benefit
• Ongoing large, multi-center randomized controlled trials
are helping us better understand optimal management