Question 1 of 10

    Acute Respiratory Distress Syndrome (Shock Lung Syndrome)

    AARDS X-ray cropped[1]

    Acute respiratory distress syndrome (ARDS) is a potentially life-threatening condition in which there is profound respiratory failure. It usually occurs in critically ill and is diagnosed clinically. 

    Presentation

    ARDS is mostly prevalent in critically ill hospitalized patients. The initial presentation of ARDS includes acute onset of dyspnea, tachypnea, hyperventilation, low oxygen saturation, cyanosis, and anxiety. A cough with frothy sputum may also be seen. The underlying cause will most likely exhibit signs and symptoms as well such as in the cases with pneumonia. Ominous signs are hypotension, tachycardia, confusion, and fatigue which are indicative of inadequate oxygen perfusion of organs. 

    Hospitalized patients with ARDS are susceptible to other medical conditions such as pneumonia. Ventilation is also a risk factor for pneumonia. In addition to infection, there are other complications. One of them is pneumothorax, in which ventilated air pressure enters the space around the lungs causing subsequent collapse in one or both. In addition, lung scarring inhibits its ability to expand. Another major and potentially fatal complication is clot formation. Thromboembolism can occur due to prolonged immobility and other pathological mechanisms.

    psychiatrical
    Agitation
    • […] starting trial Able to meet oxygen requirement with noninvasive methods Hemodynamically stable Minute ventilation 15 L Positive end-expiratory pressure 5 cm H 2 O Parameters for weaning off of ventilator* Airway can be protected Hemodynamically stable No agitation[aafp.org]
    • Hypoxemia usually leads to restlessness, confusion, agitation , and even combative behavior.[medical-dictionary.thefreedictionary.com]
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  • cardiovascular
    Cyanosis
    • The person experiences shortness of breath, usually with rapid, shallow breathing, the skin may become mottled or blue (cyanosis), and other organs such as the heart and brain may malfunction.[merckmanuals.com]
    • The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts.[orpha.net]
    • Patients initially present with acute onset cyanosis , dyspnea , and tachypnea .[amboss.com]
    • Following are some general symptoms seen with ARDS: Extreme efforts to breath Cough Discharge from nostrils Fever Cyanosis (blue discoloration of skin) Other signs related to underlying disease Causes Following are a few of the major causes of ARDS in[petmd.com]
    • Cyanosis (blue skin, lips, and nails caused by lack of oxygen to the tissues) is often seen.[mountsinai.org]
    Tachycardia
    • The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts.[orpha.net]
    • […] pulmonary edema [3] Impaired gas exchange ; , reduced compliance ; , hypertension ; and a right-to-left pulmonary shunt ; [3] [6] hypoxemia [3] compensation through hyperventilation respiratory alkalosis Clinical features Acute onset [7] Tachypnea ; and tachycardia[amboss.com]
    • , seizure Sepsis* Fever, tachypnea, tachycardia, elevated or depressed white blood cell count Table 2.[aafp.org]
    • Case study FM is a 39-year-old previously healthy man who was admitted to the emergency department (E.D.) with severe pain in his left calf and ankle, a fever to 103.1 degrees Fahrenheit, tachycardia with a heart rate of 130 beats per minute, and hypotension[dmm.biologists.org]
    • ARDS is characterized clinically by dyspnea , tachypnea , tachycardia , cyanosis , and hypoxemia .[medical-dictionary.thefreedictionary.com]
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  • respiratoric
    Dyspnea
    • Clinical signs include respiratory distress characterized by tachypnea and dyspnea, and affected cattle may be found dead if clinical signs are unobserved.[merckvetmanual.com]
    • Exudative phase initially hyaline membrane comprised of fibrin form Proliferative phase 3 days alveolar exudate resolves or organizes Fibrotic phase 3-4 weeks alveolar ducts and spaces undergo fibrosis Presentation Symptoms acute onset (12-48 hours) of dyspnea[orthobullets.com]
    • Patients initially present with acute onset cyanosis , dyspnea , and tachypnea .[amboss.com]
    • PATHOPHYSIOLOGY Acute lung injury and ARDS are severe disturbances in respiration that result in hypoxemia, tachypnea, dyspnea, and death in about 50% of affected people. 3 ARDS is the more severe form of acute lung injury; it has a specific and more[veterinarymedicine.dvm360.com]
    • […] damage to the capillary endothelium • Synonyms: Shock lung, non-cardiogenic pulmonary edema, post-traumatic pulmonary insufficiency, pump lung, stiff lung syndrome, respirator lung, hemorrhagic lung • Constellation of Signs and Symptoms • Tachypnea, dyspnea[learningradiology.com]
    Tachypnea
    • The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts.[orpha.net]
    • Clinical signs include respiratory distress characterized by tachypnea and dyspnea, and affected cattle may be found dead if clinical signs are unobserved.[merckvetmanual.com]
    • […] organizes Fibrotic phase 3-4 weeks alveolar ducts and spaces undergo fibrosis Presentation Symptoms acute onset (12-48 hours) of dyspnea fever mottled or cyanotic skin Physical exam resistant hypoxia intercostal retractions rales/crackles and ronchi tachypnea[orthobullets.com]
    • Patients initially present with acute onset cyanosis , dyspnea , and tachypnea .[amboss.com]
    • Acute respiratory distress syndrome manifests as rapidly progressive dyspnea, tachypnea, and hypoxemia.[aafp.org]
    Cough
    • […] venous distension, peripheral edema, third heart sound Pneumonia* Productive cough, fever, pleuritic chest pain Less common Acute eosinophilic pneumonia Fever, cough, diffuse infiltrates, increased eosinophils on bronchoalveolar lavage Hypersensitivity[aafp.org]
    • […] of ARDS include: Inhaling saltwater Inhaling smoke or fumes Pneumonia Lung Infection Shock Sedatives Narcotics Breathing vomit into the lungs Trauma Sepsis (infection of the blood) COPD and ARDS ARDS can be brought on by shortness of breath, chronic coughing[lunginstitute.com]
    • Cough and chest pain may also be present.[my.clevelandclinic.org]
    • Following are some general symptoms seen with ARDS: Extreme efforts to breath Cough Discharge from nostrils Fever Cyanosis (blue discoloration of skin) Other signs related to underlying disease Causes Following are a few of the major causes of ARDS in[petmd.com]
    • […] the capillary endothelium • Synonyms: Shock lung, non-cardiogenic pulmonary edema, post-traumatic pulmonary insufficiency, pump lung, stiff lung syndrome, respirator lung, hemorrhagic lung • Constellation of Signs and Symptoms • Tachypnea, dyspnea, cough[learningradiology.com]
    Rales
    • […] alveolar exudate resolves or organizes Fibrotic phase 3-4 weeks alveolar ducts and spaces undergo fibrosis Presentation Symptoms acute onset (12-48 hours) of dyspnea fever mottled or cyanotic skin Physical exam resistant hypoxia intercostal retractions rales[orthobullets.com]
    • […] resolves/organizes Fibrotic 3-4 weeks Alveolar ducts and spaces undergo fibrosis Presentation Symptoms can manifest within 1 week of known clinical insult dyspnea / shortness of breath fever Physical exam tachypnea / intercostal retractions bilateral rales[medbullets.com]
    • Rales are frequently heard on auscultation of the lungs.[amfs.com]
    • Factors That Distinguish ARDS, CHF, and Pneumonia Distinguishing factor ARDS CHF Pneumonia Symptoms Dyspnea Hypoxia Tachypnea Pleuritic chest pain /– – Sputum production /– – Signs Rales Fever /– – Edema – – Jugular venous distension – – Third heart sound[aafp.org]
    Nasal Flaring
    • The symptoms usually appear shortly after birth and may include tachypnea, tachycardia, chest wall retractions (recession), expiratory grunting, nasal flaring and cyanosis during breathing efforts.[orpha.net]
    • Assessment History The patient with ARDS appears in acute respiratory distress with a marked increase in the work of breathing that may lead to nasal flaring , the use of accessory muscles to breathe, and profound diaphoresis.[medical-dictionary.thefreedictionary.com]
    Labored Breathing
    • They include: [2] Severe shortness of breath Rapid, labored breathing Rapid heart rate Extreme sweating Diagnosing ARDS There is no test available to specifically diagnose ARDS.[inogen.com]
    • Physical examination is notable for labored breathing and crackles at both lung bases.[medbullets.com]
    Dyspnea at Rest
    • […] at rest Hypoxia; PaO 2 /FIO 2 300 mm Hg Often sepsis and MODS ( JAMA 2016;315:788 ) Respiratory dysfunction and physical disability may persist for months after remission of ARDS, with gradual improvement ( N Engl J Med 2003;348:683 ) Diagnosis Diagnosis[pathologyoutlines.com]
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  • neurologic
    Confusion
    • There may also be signs, such as confusion or low blood pressure, that the vital organs aren't getting enough oxygen.[columbiasurgery.org]
    • It can lead to infections and pneumonia , a collapsed lung, kidney failure, muscle weakness, and confusion.[medicalnewstoday.com]
    • Extreme fatigue and confusion.[northmemorial.com]
    • Symptoms of ARDS Symptoms of ARDS can include: severe shortness of breath rapid, shallow breathing tiredness, drowsiness or confusion feeling faint When to get urgent medical help Although most people develop ARDS when they're already in hospital, this[nhs.uk]
    • Medically Qualifying with ARDS The immediate symptoms of ARDS include severe breathing difficulties, low blood pressure, extreme fatigue, and confusion.[disability-benefits-help.org]
    Agitation
    • […] starting trial Able to meet oxygen requirement with noninvasive methods Hemodynamically stable Minute ventilation 15 L Positive end-expiratory pressure 5 cm H 2 O Parameters for weaning off of ventilator* Airway can be protected Hemodynamically stable No agitation[aafp.org]
    • Hypoxemia usually leads to restlessness, confusion, agitation , and even combative behavior.[medical-dictionary.thefreedictionary.com]
    Altered Mental Status
    • mental status; white blood cell count 12,000 per mm 3 (12 10 9 per L), 4,000 mm 3 (4 10 9 per L), or 10 percent immature forms; elevated C-reactive protein level; arterial hypotension; acute oliguria; hyperlactatemia Sepsis Less common History of institutionalization[aafp.org]
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  • Entire body system
    Multiple Organ Dysfunction Syndrome
    • organ dysfunction syndrome, causing multiple organ failure including pulmonary failure or acute lung injury and ARDS.[veterinarymedicine.dvm360.com]
    • organ dysfunction syndrome (MODS) DAD is the most common morphological pattern of ARDS; however the clinical syndrome of ARDS is not synonymous with the pathologic diagnosis of DAD DAD pattern is often characterized by hyaline membranes in acute phase[pathologyoutlines.com]
    • organ dysfunction syndrome follows paths analogous to the pathophysiology of sepsis.[en.wikipedia.org]
    Agitation
    • […] starting trial Able to meet oxygen requirement with noninvasive methods Hemodynamically stable Minute ventilation 15 L Positive end-expiratory pressure 5 cm H 2 O Parameters for weaning off of ventilator* Airway can be protected Hemodynamically stable No agitation[aafp.org]
    • Hypoxemia usually leads to restlessness, confusion, agitation , and even combative behavior.[medical-dictionary.thefreedictionary.com]
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  • Workup

    The diagnosis of ARDS is clinical and should be considered in ill patients presenting with acute respiratory failure. The Berlin definition guides the clinician in terms of timing of the onset, chest X-ray findings (opacities not consistent with effusion, atelectasis, or nodules) and oxygenation criteria per the Berlin definition [2].

    In addition to the above, a full history and physical is key. The clinician should investigate and ascertain any underlying conditions. One should be highly suspicious for sepsis, which is associated with the highest rate of mortality. Examination of patient involves lung exam and determination of basilar or diffuse rales [11]. Also another critical finding is the requirement of high oxygenation and/or PEEP to maintain saturation greater than 90%. Workup is comprised of the following tests:

    1. Arterial blood gas analysis provides values to calculate the PaO2/FIO2 ratio per the Berlin definition.
    2. Chest X-ray will show any opacities indicative of pulmonary edema.
    3. Brain natriuretic protein (BNP) can determine the etiology of pulmonary edema. BNP<100 picograms/mL suggest non cardiac causes while BNP> 500 picograms/mL are suggestive of cardiac etiology.
    4. Echocardiogram is performed to assess cardiac function if BNP and other findings are inconclusive.
    5. Pulmonary artery catheterization measures estimation of left ventricular end diastolic pressure. This is used to differentiate cardiogenic versus noncardiogenic etiology of pulmonary edema if BNP levels, echocardiogram and findings from history and physical are inconclusive. This is not a routine procedure. 
    6. Other significant laboratory tests include cultures of blood, urine, and sputum to assess for infection. Lipase and liver functions tests are helpful to detect pancreatitis
    7. Bronchoalveolar lavage (BAL) or endotracheal aspiration provides samples for culture and Gram stain are done to confirm suspected pneumonia [12]. There is a high mortality risk associated with these procedures. Therefore, the risks and benefits have to be weighed.
    8. CT of chest is more sensitive than a chest X-ray and is useful in diagnosing pneumonia and underlying lung processes [13].

    Laboratory

    Serum
    Hypercapnia
    • Mechanical Ventilation Because ARDS patients experience hypoxemia and a high work of breathing, many of them experience ventilatory failure with hypercapnia and respiratory acidosis [6] .[physio-pedia.com]
    • (I:E ratio 1) - increased mean airway pressure haemodynamic instability regional hyperinflation oxygenation target: SpO2 90%, PaO2 60mmHg carbon dioxide target: ARDSnet aimed for a normal CO2 - but lung is exposed to repeated tidal stretch, ideally hypercapnia[lifeinthefastlane.com]
    • With this type of ventilation, higher levels of CO 2 can be tolerated ( permissive hypercapnia ).[amboss.com]
    • A landmark trial conducted in the late 1990s by the ARDS Network compared conventional Vt of 12 ml/kg with low Vt of 6 ml/kg and permissive hypercapnia.[pmj.bmj.com]
    • Note that in non-neurosurgical patients, permissive hypercapnia may be an acceptable consequence of low tidal volumes – in fact, data suggest that pCO2 of 60-70 mm Hg and pH levels of 7.2 – 7.25 are safe in most non-neurosurgical patients [Crit Care Med[openanesthesia.org]
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  • Imaging

    X-ray
    Pulmonary Infiltrate
    • Abstract The acute respiratory distress syndrome (ARDS) is a heterogeneous group of illnesses affecting the pulmonary parenchyma with acute onset bilateral inflammatory pulmonary infiltrates with associated hypoxemia.[vumc.org]
    • infiltrates normal sized heart makes CHF less likely Respiratory compliance ( Positive end-expiratory pressure ( 10cm H20) Corrected expired volume per minute ( 10L/min) Differential Cardiogenic pulmonary edema (i.e.[orthobullets.com]
    • This pulmonary infiltrate and can lead to respiratory failure or, in approximately 20-30% of ARDS cases, death [2] .[physio-pedia.com]
    • Acute respiratory distress syndrome (ARDS) was first described in 1967 by Ashbaugh, who described a syndrome of severe respiratory failure associated with pulmonary infiltrates, similar to infant hyaline membrane disease.[amfs.com]
    • [Clin Chest Med 6: 459, 1985] Treatment/Management of ARDS Low Tidal Volumes and ARDS Patients with ARDS (PaO2/FiO2 300, bilateral pulmonary infiltrates on a CXR, no clinical evidence of left atrial hypertension or if measured a wedge 18 mm Hg, excluding[openanesthesia.org]
    Bilateral Pulmonary Infiltrate
    • pulmonary infiltrates normal sized heart makes CHF less likely Respiratory compliance ( Positive end-expiratory pressure ( 10cm H20) Corrected expired volume per minute ( 10L/min) Differential Cardiogenic pulmonary edema (i.e.[orthobullets.com]
    • [Clin Chest Med 6: 459, 1985] Treatment/Management of ARDS Low Tidal Volumes and ARDS Patients with ARDS (PaO2/FiO2 300, bilateral pulmonary infiltrates on a CXR, no clinical evidence of left atrial hypertension or if measured a wedge 18 mm Hg, excluding[openanesthesia.org]
    • The AECC defined ARDS as an acute condition characterized by bilateral pulmonary infiltrates and severe hypoxemia in the absence of evidence for cardiogenic pulmonary edema.[emedicine.medscape.com]
    • Diagnostic criteria include acute onset, profound hypoxemia, bilateral pulmonary infiltrates, and the absence of left atrial hypertension.[aafp.org]
    Air Bronchogram
    • bronchograms 20% 20% 70% Adult Respiratory Distress Syndrome.[learningradiology.com]
    • Imaging : chest x-ray [1] Diffuse bilateral infiltrates (perihilar bat wing or butterfly distribution of infiltrates) [10] Air bronchogram Atelectasis Pleural effusions ARDS is a likely diagnosis in the presence of both typical causes and therapy-resistant[amboss.com]
    • […] description General Heterogeneous bilateral shadows due to pulmonary edema Must rule out atelectasis, pleural effusion and mass Takes 12 - 24 hours from onset to be apparent Chest radiograph Exudative phase: ground glass opacity and consolidation with air[pathologyoutlines.com]
    Kerley A Lines
    • B lines/ peribronchial cuffing 30% 30% None Pleural effusions 40% 30% 10% Air bronchograms 20% 20% 70% Adult Respiratory Distress Syndrome.[learningradiology.com]
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  • ECG

    Rhythm
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  • Axis
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  • Test Results

    Pulmonary Function Test
    Decreased Lung Compliance
    • Introduction Acute Respiratory Distress Syndrome (ARDS) results from acute lung injury that leads to non-cardiogenic pulmonary edema respiratory distress refractory hypoxemia decreased lung compliance Etiology acute endot helial damage resulting from[orthobullets.com]
    • Pulmonary edema causes poor oxygen exchange in the lungs, decreased lung compliance, and increased ventilation-perfusion (V/Q) mismatch; in acute lung injury and ARDS, this edema is considered noncardiogenic. 3,6,7 Phases of acute lung injury and ARDS[veterinarymedicine.dvm360.com]
    • As ARDS progresses, patients exhibit decreased lung volumes and markedly decreased lung compliance.[medical-dictionary.thefreedictionary.com]
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  • Cardiac Catheterization
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  • Treatment

    These patients are admitted to ICU. Treatment is divided into 3 categories: Respiratory support, cardiovascular resuscitation, and other therapies.

    Respiratory support: Most patients require ventilation when: PaO2 <8.3kPa (60mm HG) despite using FIO2 60% and PaCO2 >6kPa (45mm HG). Clinicians should be aware that increased tidal volumes coupled with poor lung compliance can further increase lung damage. Lower tidal volumes have been shown to improve survival [10].

    Cardiovascular support: Clinicians should remain vigilant while monitoring the cardiovascular status in these ill patients. It is critical to maintain cardiac output and oxygenation. In many cases, drugs such as dobutamine and other vasodilators are beneficial. Fluid resuscitation is carefully monitored as well. Blood transfusions may be warranted. Clinician may consider Swan-Ganz catheter placement for invasive monitoring of cardiac output and pulmonary capillary wedge pressure.

    Further therapy depends on underlying diseases. It is critical to treat sepsis and the source if the organism(s) is/are known. In certain cases where organisms are not found on culture, broad spectrum renal safe antibiotics are used.  

    Other supportive therapies include prophylactic drugs such as low molecular weight heparin for venous thromboembolism prophylaxis and antacids for gastric ulcer prophylactics. Also nutrition has to be maintained. 

    While steroids were commonly used in ARDS patients, their use is no longer recommended. Steroids have been linked to many cases of septicemia and hyperglycemia. Results from the Late Steroid Rescue Study report the increase in the mortality rate with methylprednisolone therapy.

    Prognosis

    The mortality rate in patients with ARDS is 30 to 50% and increases with severity [2]. Fatality is usually secondary to multiorgan failure [5]. Furthermore, younger age is associated with better prognosis [6]. Residual lung damage may be seen in survivors [7] [8]. Post ARDS residual effects can include neuropathies, joint disorders, chronic pain, and muscle weakness [9].

    Mechanical ventilation can cause lung damage and increased mortality. Furthermore, the 2000 ARDS Network Trial shows that lower tidal volumes decrease mortality from 40 to 31% [2]. This research study further demonstrates that tidal volumes at 4-6 mL/kg are protective [10].

    Complications

    Acidosis
    • Disease Respiratory acidosis Respiratory acidosis is a condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces.[scripps.org]
    • Mechanical Ventilation Because ARDS patients experience hypoxemia and a high work of breathing, many of them experience ventilatory failure with hypercapnia and respiratory acidosis [6] .[physio-pedia.com]
    • Respiratory alkalosis may be present early in the course of the disease; hypercarbia and respiratory acidosis develop as the disease progresses.[amfs.com]
    • This leads to the impaired oxygenation, which is the central problem of ARDS, as well as to respiratory acidosis .[en.wikipedia.org]
    • The hypoxemia causes metabolic acidosis from increased production of lactic acid and respiratory acidosis due to the hypercapnia.[medical-dictionary.thefreedictionary.com]
    Acute Respiratory Failure
    Hypercapnia
    • Mechanical Ventilation Because ARDS patients experience hypoxemia and a high work of breathing, many of them experience ventilatory failure with hypercapnia and respiratory acidosis [6] .[physio-pedia.com]
    • (I:E ratio 1) - increased mean airway pressure haemodynamic instability regional hyperinflation oxygenation target: SpO2 90%, PaO2 60mmHg carbon dioxide target: ARDSnet aimed for a normal CO2 - but lung is exposed to repeated tidal stretch, ideally hypercapnia[lifeinthefastlane.com]
    • With this type of ventilation, higher levels of CO 2 can be tolerated ( permissive hypercapnia ).[amboss.com]
    • A landmark trial conducted in the late 1990s by the ARDS Network compared conventional Vt of 12 ml/kg with low Vt of 6 ml/kg and permissive hypercapnia.[pmj.bmj.com]
    • Note that in non-neurosurgical patients, permissive hypercapnia may be an acceptable consequence of low tidal volumes – in fact, data suggest that pCO2 of 60-70 mm Hg and pH levels of 7.2 – 7.25 are safe in most non-neurosurgical patients [Crit Care Med[openanesthesia.org]
    Respiratory Acidosis
    • Disease Respiratory acidosis Respiratory acidosis is a condition that occurs when the lungs cannot remove all of the carbon dioxide the body produces.[scripps.org]
    • Mechanical Ventilation Because ARDS patients experience hypoxemia and a high work of breathing, many of them experience ventilatory failure with hypercapnia and respiratory acidosis [6] .[physio-pedia.com]
    • Respiratory alkalosis may be present early in the course of the disease; hypercarbia and respiratory acidosis develop as the disease progresses.[amfs.com]
    • This leads to the impaired oxygenation, which is the central problem of ARDS, as well as to respiratory acidosis .[en.wikipedia.org]
    • The hypoxemia causes metabolic acidosis from increased production of lactic acid and respiratory acidosis due to the hypercapnia.[medical-dictionary.thefreedictionary.com]
    Pulmonary Hypertension
    • hypertension (vasoconstriction, microvascular thrombi, fibrosis, PEEP) MANAGEMENT General diagnosis and appropriate treatment to minimise physiological impact of cause (drain collection, antibiotics, resuscitate, splint fractures) feed standard ICU prophylaxis[lifeinthefastlane.com]
    • Hypertension Pulmonary Edema Other Pulmonary Conditions Cystic Fibrosis Atelectasis Hepatopulmonary Syndrome Carbon Monoxide Poisoning Primary Ciliary Dyskinesia PHARMACOLOGY General Inhaled Beta-Agonists Inhaled Steroids Inhaled Muscarinic-Antagonists[medbullets.com]
    • After severe head injury, ARDS is thought to result from a sudden discharge of the sympathetic nervous system, leading to acute pulmonary hypertension and injury to the pulmonary capillary bed.[amfs.com]
    • ARDS is uniformly associated with pulmonary hypertension.[emedicine.medscape.com]
    • However, it can improve oxygenation and reduce pulmonary arterial pressure and may be beneficial in patients with severe hypoxemia or concurrent pulmonary hypertension.[omicsonline.org]
    Hypoxia
    • The alveoli are then filled with fluid and are unable to perform the normal oxygenation of the blood and the patient suffers from hypoxia.[faron.com]
    • […] form Proliferative phase 3 days alveolar exudate resolves or organizes Fibrotic phase 3-4 weeks alveolar ducts and spaces undergo fibrosis Presentation Symptoms acute onset (12-48 hours) of dyspnea fever mottled or cyanotic skin Physical exam resistant hypoxia[orthobullets.com]
    • Pages 19-24 Molecular biology of lung Na absorption Barbry, Pascal Pages 25-34 Regulation of Alveolar Sodium Transport by Hypoxia Planès, Carole (et al.)[springer.com]
    • Lab and Imaging Studies ABG (arterial blood gas) usually reveals hypoxia.[amfs.com]
    • […] and endothelial cells, pulmonary edema, hyaline membrane formation and later by proliferative changes involving alveolar and bronchiolar lining cells and interstitial cells ( Am J Pathol 1976;85:209 ) Essential features Acute and rapidly progressive hypoxia[pathologyoutlines.com]
    Respiratory Alkalosis
    • Some develop pulmonary fibrosis with prolonged resolution of symptoms and extended ventilator dependence. [8] Diagnostics Laboratory studies [1] Arterial blood gas Initially, hypoxemic respiratory failure ; with PaO 2 and respiratory alkalosis ; PaO 2[amboss.com]
    • Respiratory alkalosis may be present early in the course of the disease; hypercarbia and respiratory acidosis develop as the disease progresses.[amfs.com]
    Alkalosis
    • Some develop pulmonary fibrosis with prolonged resolution of symptoms and extended ventilator dependence. [8] Diagnostics Laboratory studies [1] Arterial blood gas Initially, hypoxemic respiratory failure ; with PaO 2 and respiratory alkalosis ; PaO 2[amboss.com]
    • Respiratory alkalosis may be present early in the course of the disease; hypercarbia and respiratory acidosis develop as the disease progresses.[amfs.com]
    Pulmonary Edema
    • edema (see below) Cardiogenic Renal ARDS Distribution of Pulmonary edema 90% even 70% central 45% Peripheral 35% Even Kerley B lines/ peribronchial cuffing 30% 30% None Pleural effusions 40% 30% 10% Air bronchograms 20% 20% 70% Adult Respiratory Distress[learningradiology.com]
    • edema ( Chest 2007;131:964 ) BNP 200 pg/ml is suggestive for ARDS (sensitivity: 40%, specificity: 91%) BNP 1200 pg/ml is suggestive for cardiogenic pulmonary edema (sensitivity: 52%, specificity: 92%) Radiology description General Heterogeneous bilateral[pathologyoutlines.com]
    • ARDS presents with progressive hypoxemia not responsive to supplemental oxygen and other signs and symptoms similar to cardiogenic pulmonary edema.[medbullets.com]
    • Patients with ARDS are characterized as having high-permeability pulmonary edema (HPPE) in contrast to cardiogenic pulmonary edema.[medical-dictionary.thefreedictionary.com]
    Viral Pneumonia
    • […] their toxins, in the blood or tissues) Severe traumatic injury (especially multiple fractures), severe head injury , and injury to the chest Fracture of the long bones Transfusion of multiple units of blood Acute pancreatitis Drug overdose Aspiration Viral[emedicinehealth.com]
    • […] gram negative • Burns • Massive aspiration of gastric contents (Mendelssohn’s Syndrome) • Acute pancreatitis • Heroin/methadone/crack cocaine overdose • Disseminated intravascular coagulation • Smoke, chlorine gas, nitrogen dioxide inhalation • Massive viral[learningradiology.com]
    • The syndrome is associated with a high mortality rate between 20 and 50% and currently therapy includes diagnosis and treatment of the underying cause (e.g. bacterial or viral pneumonia) as well as organ support until recovery e.g.[imperial.ac.uk]
    Tension Pneumothorax
    • Pulmonary ANATOMY & PHYSIOLOGY PFTs and Procedures High-Yield Topics Arterial Blood Gases Pulmonary Function Tests Mechanical Ventilation CLINICAL CONDITIONS Trauma Tension Pneumothorax Open Pneumothorax Pneumothorax Flail Chest Massive Hemothorax Drowning[medbullets.com]
    Respiratory Failure
    • Non-Specific Code Type 1 Excludes acute respiratory distress syndrome ( J80 ) respiratory arrest ( R09.2 ) respiratory arrest of newborn ( P28.81 ) respiratory distress syndrome of newborn ( P22.- ) respiratory failure ( J96.- ) respiratory failure of[icd10data.com]
    • : respiratory failure of sudden onset in adults or children that follows injury to the endothelium of the lung (as in sepsis , chest trauma, massive blood transfusion, aspiration of the gastric contents, or pneumonia) and results in the accumulation of[merriam-webster.com]
    • A PCWP 18 mmHg would provide additional clinical evidence that the respiratory failure was secondary to ARDS and not hydrostatic edema.[medbullets.com]
    • The chief finding in ARDS is hypoxemic respiratory failure with decreased arterial oxygen pressure, which usually progresses to hypercapnic respiratory failure .[amboss.com]
    • Diagnosis involves excluding other causes of acute respiratory failure.[medical-dictionary.thefreedictionary.com]

    Etiology

    The etiology of ARDS is extensive. Underlying diseases serve as risk factors. Sepsis is the most common cause and can be attributed to pulmonary and nonpulmonary etiologies [4]. Direct pulmonary insults such as pneumonia, aspiration of gastric contents, inhalation injury, pulmonary contusion, transfusion-related lung injury, and cardiopulmonary bypass are risk factors for ARDS. Nondirect pulmonary insults such as acute pancreatitis, fat embolism, noncardiogenic shock, disseminated intravascular coagulation, drug overdose, and trauma also place patients at risk for this debilitating pulmonary failure [1]. Other risk factors may include previous lung disease, smoking, obesity, and alcohol abuse.

    Causes

    Hypoxia
    • The alveoli are then filled with fluid and are unable to perform the normal oxygenation of the blood and the patient suffers from hypoxia.[faron.com]
    • […] form Proliferative phase 3 days alveolar exudate resolves or organizes Fibrotic phase 3-4 weeks alveolar ducts and spaces undergo fibrosis Presentation Symptoms acute onset (12-48 hours) of dyspnea fever mottled or cyanotic skin Physical exam resistant hypoxia[orthobullets.com]
    • Pages 19-24 Molecular biology of lung Na absorption Barbry, Pascal Pages 25-34 Regulation of Alveolar Sodium Transport by Hypoxia Planès, Carole (et al.)[springer.com]
    • Lab and Imaging Studies ABG (arterial blood gas) usually reveals hypoxia.[amfs.com]
    • […] and endothelial cells, pulmonary edema, hyaline membrane formation and later by proliferative changes involving alveolar and bronchiolar lining cells and interstitial cells ( Am J Pathol 1976;85:209 ) Essential features Acute and rapidly progressive hypoxia[pathologyoutlines.com]
    Alkalosis
    • Some develop pulmonary fibrosis with prolonged resolution of symptoms and extended ventilator dependence. [8] Diagnostics Laboratory studies [1] Arterial blood gas Initially, hypoxemic respiratory failure ; with PaO 2 and respiratory alkalosis ; PaO 2[amboss.com]
    • Respiratory alkalosis may be present early in the course of the disease; hypercarbia and respiratory acidosis develop as the disease progresses.[amfs.com]

    Epidemiology

    Due to the usage of varied definitions of ARDS in older research studies, there is an inaccurate estimate regarding the actual incidence of ARDS. However, research emerging from the United States and international regions provide some insight on the incidence.

    About 4 decades ago, the National Institute of Health (NIH) estimated that the incidence is 75 cases per 100,000 population. However, the ARDS Study Network suggests that the incidence is actually greater than that. The 2005 study in King County, Washington, using the outdated definition from the 1994 AECC, reports the incidence of ALI as 86.2 per 100,000 population [4]. A further statistical analysis of the data yields an estimate of 190,600 annual cases in the United States of which 74,500 result in death. Furthermore it is estimated that ALI is associated with an annual 3.5 million hospital days [4].

    The same study also shows that age is directly proportional to the incidence of ALI. In the 15-19 year old range, the incidence was 16 per 100,000 while it was 306 in the age range of 75 to 84 [4]. As for gender, the incidences are similar with the exception of trauma patients in which females have a higher incidence of ARDS.

    Sex distribution
    Age distribution

    Pathophysiology

    The complex pathophysiology of ARDS is not completely clear. The early stages consist of diffuse alveolar damage and increased permeability across the alveolar capillary membrane. Capillary endothelial cells and alveolar pneumocytes (Type I and Type II) undergo necrosis and apoptosis marking an exudative inflammatory process. This involves flooding of alveolar air spaces with edema, neutrophils and activated alveolar macrophages, in addition to mediators such as cytokines and oxidants [1]. The acute onset of alveolar flooding may result in recovery due to active clearance of pulmonary edema or may progress to disease [1].

    Type II cell injury and exudative flooding contribute to surfactant dysfunction. This consequently increases alveolar-arterial oxygen gradient and leads to acute hypoxemic respiratory failure. The main features of this phase include respiratory failure, high minute ventilation and low compliant lungs [1].

    Severe epithelial injury can cause progression of the inflammatory phase to a fibroproliferative phase. Necrotic type I cells denude the basement membrane thereby allowing fibrin deposition. Histologically, hyaline membranes are observed. This irreversible devastating phase consists of extensive formation or fibrous and collagen deposition [1] [4].

    Prevention

    ARDS cannot necessarily be prevented but cessation of smoking and alcohol may help. It is also important for all individuals, especially those as risk, to comply with appropriate immunization recommendations such as flu (annual) and pneumococcal (per guidelines) vaccines. 

    Summary

    Acute respiratory distress syndrome (ARDS) is characterized by rapidly progressive respiratory failure. Individuals with ARDS can develop multiorgan damage and are usually at high risk for mortality [1].

    The European Society of Intensive Care Medicine, the American Thoracic Society and the Society of Critical Care Medicine formulated the new criteria for ARDS in 2011. The new updated guidelines, referred to as the Berlin definition, are as follows: [2]

    Timing of ARDS: Occurs within one week of clinical risk factor/insult or within one week of new or worsening respiratory condition.
    Chest imaging: Bilateral opacities that are not explained by effusions, atelectasis, or nodules.
    Etiology of edema: Respiratory failure not due to cardiac etiology or fluid overload.
    Oxygenation: Degree of oxygenation determines the severity. 

    • Mild: PaO2/FIO2 ≤300 mmHg and >200 mmHg  with PEEP or CPAP ≥5 cmH2O
    • Moderate: PaO2/FIO2 ≤200 mmHg and >100mm Hg with PEEP ≥5 cmH2O
    • Severe: PaO2/FIO2 ≤100 mmHg with PEEP ≥5 cmH2O

    The Berlin definition replaces the previous American -European Consensus Committee (AECC) definition which differentiated ARDS from other varied or lesser forms such as acute lung injury (ALI), noncardiac pulmonary edema, and increased permeability pulmonary edema [2] [3]. This AECC definition presented diagnostic limitations and therefore was updated for accuracy.

    Patient Information

    Acute respiratory distress Syndrome (ARDS) is a condition in which respiratory failure occurs. The most common cause is sepsis, which is an overwhelming response of the body to an infection. Other causes are acute pancreatitis, fat embolism, aspiration, inhalation injury, acute pancreatitis, disseminated intravascular coagulation, drug overdose, and trauma.

    In ARDS, fluid accumulates in the lungs and makes it very difficult to expand and facilitate oxygen exchange. Therefore, there are low oxygen blood levels in the body which can lead to damage of organs. The main common signs and symptoms are shortness of breath, difficulty breathing, fast and shallow breathing, blue colored skin, and other signs showing brain (confusion, lethargy) and heart dysfunction.

    In patients with suspected ARDS, a chest X-ray is done to evaluate for any fluid in the lungs. Also, a blood test is done to determine the levels of oxygen. Other laboratory tests may be important to determine the exact cause. Also an ultrasound of the heart may be done to look for any cardiac problems. Individuals with ARDS are likely very ill from other diseases as well. Patients with ARDS are admitted to the intensive care unit for special care. Since the lungs are not working properly and oxygen is low in the body, most patients require mechanical ventilation to help deliver oxygen to the organs. These patients are monitored closely to make sure their heart, lungs, kidneys, and other organs are receiving adequate oxygen. Other treatments are for prevention of blood clots, stomach ulcers and nutritional care.

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    References

    1. Ware LB, Matthay MA. The acute respiratory distress syndrome. New England Journal of Medicine. 2000;342(18):1334-1349.
    2. Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition. Journal of American Medical Association. 2012;307(23):2526-2533. doi:10.1001/jama.2012.5669.
    3. Tsushima K, King LS, Aggarwal NR, De Gorordo A, D’Alessio FR, Kubo K. Acute Lung Injury Review. Internal Medicine. 2009;48(9):621-630. 
    4. Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. New England Journal of Medicine. 2005;353(16):1685-1693.
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    6. Ely EW, Wheeler AP, Thompson BT, Ancukiewicz M, Steinberg KP, Bernard GR. Recovery rate and prognosis in older persons who develop acute lung injury and the acute respiratory distress syndrome. Annals of Internal Medicine. 2002;136(1):25-36.
    7. Neff TA, Stocker R, Frey HR, Stein S, Russi EW. Long-term assessment of lung function in survivors of severe ARDS. Chest. 2003;123(3):845-853. doi:10.1378/chest.123.3.845.
    8. Orme J, Romney JS, Hopkins RO, et al. Pulmonary function and health-related quality of life in survivors of acute respiratory distress syndrome. American Journal of Respiratory Critical Care Medicine. 2003;167(5):690-694.
    9. Herridge MS, Cheung AM, Tansey CM, et al. One-year outcomes in survivors of the Acute Respiratory Distress Syndrome. New England Journal of Medicine New England Journal of Medicine. 2003;348(8):683–693.
    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. New England Journal of Medicine. 2000;342(18):1301–1308.
    11. Leaver SK ET. Acute Respiratory Distress Syndrome. The British Medical Journal. 2007;335(7616):389-394.
    12. Schwarz MI AR. “Imitators” of the ARDS: implications for diagnosis and treatment. Chest. 2004;125(4):1530-1535.
    13. Gattinoni L, Caironi P, Pelosi P, Goodman LR. What has computed tomography taught us about the acute respiratory distress syndrome? American Journal of Respiratory Critical Care Medicine. 2001;164(9):1701-1711. 

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    1. AARDS X-ray cropped, CC BY-SA 3.0

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