Acute respiratory distress syndrome: Difference between revisions
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***Attempt to maintain same rate
***Attempt to maintain same rate
***Maintain same Pmean
***Maintain same Pmean
**[[Recruitment maneuver]]
***Varying methods and protocols
***Controversial in risks and benefits


==Disposition==
==Disposition==

Revision as of 05:18, 13 April 2016

Background

  • Acronym: ARDS
  • Non-cardiogenic pulmonary edema due to lung capillary endothelial injury
    • Proteinaceous material accumulate in alveoli in a heterogeneous manner
  • Symptom of an underlying disease

Clinical Features

  • Diagnostic criteria[1]
  1. New onset respiratory symptoms
  2. Bilateral pulmonary opacities
  3. Symptoms not explained by cardiac etiology or volume overload
  • Severity by Berlin definition[2]
PaO2/FiO2 Severity Mortality
200-300 Mild 27%
100-200 Mod 32%
<100 Severe 45%

Differential Diagnosis

Pulmonary Edema Types

Pulmonary capillary wedge pressure <18 mmHg differentiates noncardiogenic from cardiogenic pulmonary edema[3]

Diagnosis

  • CXR
  • CBC
  • Chem 10
  • UA
  • LFT
  • Lipase
  • PT/PTT
  • Influenza (seasonal)
  • Blood cultures
  • Lactate
  • Consider bedside echo
  • Consider ABG/VBG
  • Consider BNP

Management

  • Treat underlying cause
    • Cover for sepsis
      • Pneumonia in addition to other identified source
    • Tamiflu 75mg BID oral or NGT if influenza season [4]
  • Supplemental O2
  • Noninvasive ventilation
    • Limited data to support use
  • Ventilator Settings
    • Permissive hypercapnia
    • Tidal volume 6-8cc/kg of ideal body weight[5]
      • Limit barotrauma to healthy area of lung
      • Increase PEEP to improve oxygenation
    • Maintain plateau pressures < 30 [7]
    • Ensure adequate sedation
      • Better synchrony with vent
      • Decreased oxygen consumption
      • Less delirium
      • Increased patient comfort
    • Prone ventilation [8]
      • Increases survival for severe ARDS
      • Consider for refractory hypoxemia
    • APRV (BiVent) to recruit alveoli, if minimal to no respiratory acidosis[9][10]
      • 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[11]
    • 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

Disposition

  • Admit to ICU

See Also

External Links

ARDSnet Ventilator Settings

References

  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.
  2. ↑ 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. ↑ Clark SB, Soos MP. Noncardiogenic Pulmonary Edema. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 1, 2020.
  4. ↑ http://www.cdc.gov/flu/professionals/antivirals/summary-clinicians.htm
  5. ↑ 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.
  6. ↑ 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.
  7. ↑ Hansen-Flaschen et al. Acute respiratory distress syndrome: Clinical features and diagnosis.UpToDate accessed 3/26/14
  8. ↑ Guerin, C. (2014) ‘Prone ventilation in acute respiratory distress syndrome’, European Respiratory Review, 23(132), pp. 249–257.
  9. ↑ CritCareMed. 2005;33:S228 Other Approaches to Open-Lung Ventilation–Airway Pressure Release Ventilation.
  10. ↑ CleveClinJMed 2011;78:101 Airway Pressure Release Ventilation–Alternative Mode of Mechanical Ventilation in Acute Respiratory Distress Syndrome.
  11. ↑ Guttmann J et al. Automatic tube compensation (ATC). Minerva Anestesiol. 2002 May;68(5):369-77.
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