Acute respiratory distress syndrome
Acute respiratory distress syndrome | |
---|---|
Other names | Respiratory distress syndrome (RDS), adult respiratory distress syndrome, shock lung, wet lung |
ECMO[1] | |
Prognosis | 35 to 90 % risk of death[1] |
Frequency | 3 million per year[1] |
Acute respiratory distress syndrome (ARDS) is a type of
Causes may include
The primary treatment involves
Globally, ARDS affects more than 3 million people a year.[1] The condition was first described in 1967.[1] Although the terminology of "adult respiratory distress syndrome" has at times been used to differentiate ARDS from "infant respiratory distress syndrome" in newborns, the international consensus is that "acute respiratory distress syndrome" is the best term because ARDS can affect people of all ages.[6] There are separate diagnostic criteria for children and those in areas of the world with fewer resources.[4]
Signs and symptoms
The signs and symptoms of ARDS often begin within two hours of an inciting event, but have been known to take as long as 1–3 days; diagnostic criteria require a known insult to have happened within 7 days of the syndrome. Signs and symptoms may include
Complications
Complications may include the following:[10]
- Lungs: barotrauma (volutrauma), pulmonary embolism (PE), pulmonary fibrosis, ventilator-associated pneumonia (VAP)
- Gastrointestinal: bleeding (ulcer), dysmotility, pneumoperitoneum, bacterial translocation
- Neurological: hypoxic brain damage
- Cardiac: abnormal heart rhythms, myocardial dysfunction
- Kidney: acute kidney failure, positive fluid balance
- Mechanical: vascular injury, endotracheal tube)
- Nutritional: electrolyte abnormalities
Other complications that are typically associated with ARDS include:[9]
- Atelectasis: small air pockets within the lung collapse
- Complications that arise from treatment in a hospital: blood clots formed by lying down for long periods of time, weakness in muscles that are used for breathing, stress ulcers, and issues with mental health and depression.
- Failure of multiple organs
- Pulmonary hypertension or increase in blood pressure in the main artery from the heart to the lungs. This complication typically occurs due to the restriction of the blood vessel due to inflammation of the mechanical ventilation
Causes
There are direct and indirect causes of ARDS depending whether the lungs are initially affected. Direct causes include pneumonia (including bacterial and viral), aspiration, inhalational lung injury, lung contusion, chest trauma, and near-drowning. Indirect causes include sepsis, shock, pancreatitis, trauma (e.g. fat embolism), cardiopulmonary bypass, TRALI, burns, increased intracranial pressure.[11] Fewer cases of ARDS are linked to large volumes of fluid used during post-trauma resuscitation.[12]
Pathophysiology
ARDS is a form of
One research group has reported that broncho-alveolar lavage fluid in later-stage ARDS often contains trichomonads,[14] in an amoeboid form (i.e. lacking their characteristic flagellum) which makes them difficult to identify under the microscope.[15]
Diagnosis
Diagnostic criteria
Diagnostic criteria for ARDS have changed over time as understanding of the pathophysiology has evolved. The international consensus criteria for ARDS were most recently updated in 2012 and are known as the "Berlin definition".[16][17] In addition to generally broadening the diagnostic thresholds, other notable changes from the prior 1994 consensus criteria[6] include discouraging the term "acute lung injury", and defining grades of ARDS severity according to degree of decrease in the oxygen content of the blood.[citation needed]
According to the 2012 Berlin definition, adult ARDS is characterized by the following: [citation needed]
- lung injury of acute onset, within 1 week of an apparent clinical insult and with the progression of respiratory symptoms
- bilateral opacities on chest imaging (lung pathology (e.g. effusion, lobar/lung collapse, or nodules)
- respiratory failure not explained by heart failure or volume overload
- decreased PaO
2/FiO
2 ratio (a decreased PaO
2/FiO
2 ratio indicates reduced arterial oxygenation from the available inhaled gas):- mild ARDS: 201 – 300 mmHg (≤ 39.9 kPa)
- moderate ARDS: 101 – 200 mmHg (≤ 26.6 kPa)
- severe ARDS: ≤ 100 mmHg (≤ 13.3 kPa)
- The Berlin definition requires a minimum positive end expiratory pressure (PEEP) of 5 cmHto diagnose mild ARDS.
2O for consideration of the PaO
2/FiO
2 ratio. This degree of PEEP may be delivered noninvasively with CPAP
The 2012 "Berlin criteria" are a modification of the prior 1994 consensus conference definitions (see history).[10]
Medical imaging
Radiologic imaging has long been a criterion for diagnosis of ARDS. Original definitions of ARDS specified that correlative
- Anterior subpleural consolidations
- Absence or reduction of lung sliding
- "Spared areas" of normal parenchyma
- Pleuralline abnormalities (irregular thickened fragmented pleural line)
- Nonhomogeneous distribution of B-lines (a characteristic ultrasound finding suggestive of fluid accumulation in the lungs)[19]
Treatment
Acute respiratory distress syndrome is usually treated with
Mechanical ventilation
The overall goal of mechanical ventilation is to maintain acceptable gas exchange to meet the body's metabolic demands and to minimize adverse effects in its application. The parameters PEEP (positive end-expiratory pressure, to keep alveoli open), mean airway pressure (to promote recruitment (opening) of easily collapsible alveoli and predictor of hemodynamic effects), and plateau pressure (best predictor of alveolar overdistention) are used.[20]
Previously, mechanical ventilation aimed to achieve tidal volumes (Vt) of 12–15 ml/kg (where the weight is
Low tidal volume ventilation was the primary independent variable associated with reduced mortality in the NIH-sponsored ARDSNet trial of tidal volume in ARDS. Plateau pressure less than 30 cm H
2O was a secondary goal, and subsequent analyses of the data from the ARDSNet trial and other experimental data demonstrate that there appears to be no safe upper limit to plateau pressure; regardless of plateau pressure, individuals with ARDS fare better with low tidal volumes.[21]
Airway pressure release ventilation
No particular ventilator mode is known to improve mortality in acute respiratory distress syndrome (ARDS).[22]
Some practitioners favor airway pressure release ventilation when treating ARDS. Well documented advantages to APRV ventilation[23] include decreased airway pressures, decreased minute ventilation, decreased dead-space ventilation, promotion of spontaneous breathing, almost 24-hour-a-day alveolar recruitment, decreased use of sedation, near elimination of neuromuscular blockade, optimized arterial blood gas results, mechanical restoration of FRC (functional residual capacity), a positive effect on cardiac output[24] (due to the negative inflection from the elevated baseline with each spontaneous breath), increased organ and tissue perfusion and potential for increased urine output secondary to increased kidney perfusion.[citation needed]
A patient with ARDS, on average, spends between 8 and 11 days on a mechanical ventilator; APRV may reduce this time significantly and thus may conserve valuable resources.[25]
Positive end-expiratory pressure
Positive end-expiratory pressure (PEEP) is used in mechanically ventilated people with ARDS to improve oxygenation. In ARDS, three populations of alveoli can be distinguished. There are normal alveoli that are always inflated and engaging in gas exchange, flooded alveoli which can never, under any ventilatory regime, be used for gas exchange, and atelectatic or partially flooded alveoli that can be "recruited" to participate in gas exchange under certain ventilatory regimens. The recruitable alveoli represent a continuous population, some of which can be recruited with minimal PEEP, and others can only be recruited with high levels of PEEP. An additional complication is that some alveoli can only be opened with higher airway pressures than are needed to keep them open, hence the justification for maneuvers where PEEP is increased to very high levels for seconds to minutes before dropping the PEEP to a lower level. PEEP can be harmful; high PEEP necessarily increases mean airway pressure and alveolar pressure, which can damage normal alveoli by overdistension resulting in DAD. A compromise between the beneficial and adverse effects of PEEP is inevitable.[citation needed]
The 'best PEEP' used to be defined as 'some' cmH
2O above the lower inflection point (LIP) in the sigmoidal pressure-volume relationship curve of the lung. Recent research has shown that the LIP-point pressure is no better than any pressure above it, as recruitment of collapsed alveoli—and, more importantly, the overdistension of aerated units—occur throughout the whole inflation. Despite the awkwardness of most procedures used to trace the pressure-volume curve, it is still used by some[who?] to define the minimum PEEP to be applied to their patients. Some new ventilators can automatically plot a pressure-volume curve.[citation needed]
PEEP may also be set empirically. Some authors[who?] suggest performing a 'recruiting maneuver'—a short time at a very high continuous positive airway pressure, such as 50 cmH
2O (4.9 kPa)—to recruit or open collapsed units with a high distending pressure before restoring previous ventilation. The final PEEP level should be the one just before the drop in PaO
2 or peripheral blood oxygen saturation during a step-down trial. A large randomized controlled trial of patients with ARDS found that lung recruitment maneuvers and PEEP titration was associated with high rates of barotrauma and pneumothorax and increased mortality.[26]
Intrinsic PEEP (iPEEP) or auto-PEEP—first described by John Marini of St. Paul Regions Hospital—is a potentially unrecognized contributor to PEEP in intubated individuals. When ventilating at high frequencies, its contribution can be substantial, particularly in people with obstructive lung disease such as asthma or chronic obstructive pulmonary disease (COPD). iPEEP has been measured in very few formal studies on ventilation in ARDS, and its contribution is largely unknown. Its measurement is recommended in the treatment of people who have ARDS, especially when using high-frequency (oscillatory/jet) ventilation.[citation needed]
Prone position
The position of lung infiltrates in acute respiratory distress syndrome is non-uniform. Repositioning into the prone position (face down) might improve oxygenation by relieving
Fluid management
Several studies have shown that pulmonary function and outcome are better in people with ARDS who lost weight or whose pulmonary wedge pressure was lowered by diuresis or fluid restriction.[10]
Medications
As of 2019, it is uncertain whether or not treatment with corticosteroids improves overall survival. Corticosteroids may increase the number of ventilator-free days during the first 28 days of hospitalization.[29] One study found that dexamethasone may help.[30] The combination of hydrocortisone, ascorbic acid, and thiamine also requires further study as of 2018.[31]
Inhaled nitric oxide (NO) selectively widens the lung's arteries which allows for more blood flow to open alveoli for gas exchange. Despite evidence of increased oxygenation status, there is no evidence that inhaled nitric oxide decreases morbidity and mortality in people with ARDS.[32] Furthermore, nitric oxide may cause kidney damage and is not recommended as therapy for ARDS regardless of severity.[33]
Alvelestat (AZD 9668) had been quoted according to one review article.[34]
Extracorporeal membrane oxygenation
Extracorporeal membrane oxygenation (ECMO) is mechanically applied prolonged cardiopulmonary support. There are two types of ECMO: Venovenous which provides respiratory support and venoarterial which provides respiratory and hemodynamic support. People with ARDS who do not require cardiac support typically undergo venovenous ECMO. Multiple studies have shown the effectiveness of ECMO in acute respiratory failure.[35][36][37] Specifically, the CESAR (Conventional ventilatory support versus Extracorporeal membrane oxygenation for Severe Acute Respiratory failure) trial[38] demonstrated that a group referred to an ECMO center demonstrated significantly increased survival compared to conventional management (63% to 47%).[39]
Ineffective treatments
As of 2019, there is no evidence showing that treatments with exogenous surfactants, statins, beta-blockers or n-acetylcysteine decreases early mortality, late all-cause mortality, duration of mechanical ventilation, or number of ventilator-free days.[29]
Prognosis
The overall prognosis of ARDS is poor, with mortality rates of approximately 40%.[29] Exercise limitation, physical and psychological sequelae, decreased physical quality of life, and increased costs and use of health care services are important sequelae of ARDS.[citation needed]
Epidemiology
The annual rate of ARDS is generally 13–23 people per 100,000 in the general population.[40] It is more common in people who are mechanically ventilated with acute lung injury (ALI) occurring in 16% of ventilated people. Rates increased in 2020 due to COVID-19, with some cases also appearing similar to HAPE.[41][42]
Worldwide, severe sepsis is the most common trigger causing ARDS.
Pneumonia and sepsis are the most common triggers, and pneumonia is present in up to 60% of patients and may be either causes or complications of ARDS. Alcohol excess appears to increase the risk of ARDS.[45] Diabetes was originally thought to decrease the risk of ARDS, but this has shown to be due to an increase in the risk of pulmonary edema.[46][47] Elevated abdominal pressure of any cause is also probably a risk factor for the development of ARDS, particularly during mechanical ventilation.[citation needed]
History
Acute respiratory distress syndrome was first described in 1967 by Ashbaugh et al.[10][48] Initially there was no clearly established definition, which resulted in controversy regarding the incidence and death of ARDS.
In 1988, an expanded definition was proposed, which quantified physiologic respiratory impairment.
1994 American-European Consensus Conference
In 1994, a new definition was recommended by the American-European Consensus Conference Committee [6][10] which recognized the variability in severity of pulmonary injury.[49]
The definition required the following criteria to be met:
- acute onset, persistent dyspnea
- bilateral infiltrates on chest radiograph consistent with pulmonary edema
- hypoxemia, defined as PaO
2:FiO
2 < 200 mmHg (26.7 kPa) - absence of left atrial (LA) hypertension
- pulmonary artery wedge pressure < 18 mmHg (obtained by pulmonary artery catheterization)
- if no measured LA pressure available, there must be no other clinical evidence to suggest elevated left heart pressure.
If PaO
2:FiO
2 < 300 mmHg (40 kPa), then the definitions recommended a classification as "acute lung injury" (ALI). Note that according to these criteria,
2 thresholds without systematic data.[50]
2012 Berlin definition
In 2012, the Berlin Definition of ARDS was devised by the European Society of Intensive Care Medicine, and was endorsed by the American Thoracic Society and the Society of Critical Care Medicine. These recommendations were an effort to both update classification criteria in order to improve clinical usefulness and to clarify terminology. Notably, the Berlin guidelines discourage the use of the term "acute lung injury" or ALI, as the term was commonly being misused to characterize a less severe degree of lung injury. Instead, the committee proposes a classification of ARDS severity as mild, moderate, or severe according to arterial oxygen saturation.[16] The Berlin definitions represent the current international consensus guidelines for both clinical and research classification of ARDS.[citation needed]
Terminology
ARDS is the severe form of acute lung injury (ALI), and of transfusion-related acute lung injury (TRALI), though there are other causes. The Berlin definition included ALI as a mild form of ARDS.[51] However, the criteria for the diagnosis of ARDS in the Berlin definition excludes many children, and a new definition for children was termed pediatric acute respiratory distress syndrome (PARDS); this is known as the PALICC definition (2015).[52][53]
Research directions
There is ongoing research on the treatment of ARDS by
Aspirin has been studied in those who are at high risk and was not found to be useful.[1]
An intravenous
See also
- Respiratory monitoring
References
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Further reading
- Marino, Paul (2006). The ICU Book. Baltimore: Williams & Wilkins. ISBN 978-0781748025.
- Martin GS, Moss M, Wheeler AP, Mealer M, Morris JA, Bernard GR (1 August 2005). "A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury". Crit. Care Med. 33 (8): 1681–7. S2CID 38941988.
- Jackson WL, Shorr AF (1 June 2005). "Blood transfusion and the development of acute respiratory distress syndrome: more evidence that blood transfusion in the intensive care unit may not be benign". Crit. Care Med. 33 (6): 1420–1. PMID 15942365.
- Mortelliti MP, Manning HL (May 2002). "Acute respiratory distress syndrome". Am Fam Physician. 65 (9): 1823–30. PMID 12018805. Archived from the originalon 2008-09-06. Retrieved 2005-08-28.
- Metnitz, P. G. H.; Bartens, C.; Fischer, M.; Fridrich, P.; Steltzer, H.; Druml, W. (17 February 1999). "Antioxidant status in patients with acute respiratory distress syndrome". Intensive Care Medicine. 25 (2): 180–185. S2CID 11377820.
External links
- ARDSNet—the NIH / NHLBI ARDS Network
- ARDS Support Center—information for patients with ARDS