PULMONARY GRAND ROUNDS

Acute Respiratory Distress Syndrome

20 April 2006, AVR

OBJECTIVES
To review

the criteria for the diagnosis

of ARDS/ALI
To review the epidemiology and
pathogenesis of ALI/ARDS
To discuss the issues on the
management of ALI/ ARDS among
patients with sepsis
Acute Respiratory Distress Syndrome

What is Acute Respiratory Distress

Syndrome?

NEJM, May 2000

Acute Respiratory Distress Syndrome

What is Acute Respiratory Distress

Syndrome?

American European Consensus Conference on ARDS, 1994

Acute Respiratory Distress Syndrome

Epidemiology
1972

NIH Estimate annual incidence of

75 per 100,000 population
accurate estimation hindered by
differences in definition, heterogeneity
of causes
Variable accounts of epidemiologic
studies across
Acute Respiratory Distress Syndrome

Epidemiology
Author

Publication Patient (per

Year
100,000
population

Incidence

Mortality
rate

Fowler

1983

88

5.2

65

Webster

1988

139

4.5

38

Evans

1988

62

25

60

Thomsen

1995

110/ 89

8.8/ 4.8

Lewandowski

1995

17

Acute Respiratory Distress Syndrome

58.8

Review of Pathogenesis:
Acute Phase

Acute Respiratory Distress Syndrome

Radiologic Correlation:
Acute Phase

Diffuse bilateral
alveolar opacities
consistent with
pulmonary edema

Acute Respiratory Distress Syndrome

Radiographic Correlation: Acute

Phase

Acute Respiratory Distress Syndrome

Histologic Correlation:
Acute Phase

Acute Respiratory Distress Syndrome

Pathogenesis:
Fibrosing Alveolitis

Acute Respiratory Distress Syndrome

Radiographic Correlation: Fibrosing

Alveolitis Phase

Acute Respiratory Distress Syndrome

Radiographic Correlation

Acute Respiratory Distress Syndrome

Pathogenesis: Resolution

Acute Respiratory Distress Syndrome

Who are at risk for ARDS?

Ability

to identify who are at risk is

important if therapies are to be
developed to prevent the disorder

Acute Respiratory Distress Syndrome

Who are at Risk for ARDS?

NEJM, May 2000

Acute Respiratory Distress Syndrome

SEPSIS AND ARDS

prospectively identified 695 patients admitted
to intensive care units from 1983 - 1985
ARDS: 179 of the 695 patients (26%).
Highest incidence:
sepsis syndrome (75 of 176; 43%)
multiple emergency transfusions (>
or = 15 units in 24 h) (46 of 115; 40%)
Hudson et. al., Am Jour of Respir Crit Care Med, 1998

Acute Respiratory Distress Syndrome

Mechanical Ventilation in sepsis

induced acute lung injury/ acute
respiratory distress syndrome: An
evidence based review
Critical Care Med 2004

Acute Respiratory Distress Syndrome

MODIFIED DELPHI
METHODOLOGY
Grading of Evidence
I. Large, randomized trials with clear-cut results; low
risk of false-positive (alpha) error or false-negative
(beta) error
II. Small, randomized trials with uncertain results;
moderate-to-high risk of false-positive (alpha) and/or
false-negative (beta) error
III. Nonrandomized, contemporaneous controls
IV. Nonrandomized, historical controls and expert
opinion
V. Case series, uncontrolled studies, and expert opinion
Acute Respiratory Distress Syndrome

MODIFIED DELPHI
METHODOLOGY
Grading of Recommendations
A. Supported by at least two level I
investigations
B. Supported by one level I investigation
C. Supported by level II investigations only
D. Supported by at least one level III
investigation
E. Supported by level IV or V evidence
Acute Respiratory Distress Syndrome

MANAGEMENT ISSUE #1: Intubation

and Mechanical Ventilation
Does

placement of an ET tube or
institution of mechanical ventilation
improve outcome in respiratory failure
secondary to sepsis?

Acute Respiratory Distress Syndrome

MANAGEMENT ISSUE #1: Intubation

and Mechanical Ventilation
Mechanical

ventilation is the mainstay of

supportive care for ALI/ ARDS
- Reduces work of breathing

Weigh benefit of endotracheal intubation

compared to NIPPV
- Increased complications in patients with
hypotension on NIPPV favors endotracheal
intubation
Acute Respiratory Distress Syndrome

MANAGEMENT ISSUE #1: Intubation

and Mechanical Ventilation
Does

placement of an ET tube
/mechanical ventilation improve
outcome in respiratory failure
secondary to sepsis?
ET tube No, Grade E
MV - Yes, Grade E

Acute Respiratory Distress Syndrome

Management Issue #2: NIPPV

Can

non-invasive positive pressure

ventilation (NIPPV) be safely used in
patients with ALI/ARDS?

Acute Respiratory Distress Syndrome

Management Issue #2: NIPPV

NIPPV

may be effective for COPD

patients and cardiogenic pulmonary
edema
It is however less likely of help in
hypoxic respiratory failure
Critical Care Medicine 2004

Acute Respiratory Distress Syndrome

Management Issue #2: NIPPV

Contraindicated among patients with

hypotension, altered sensorium, increased
secretions
Consider its use in cases of ALI/ARDS with
duration of 48-72 hours
Consider its use in immunosuppressed
patients without hypotension considering the
risk of VAP among this patients if placed on
ET.
Critical Care Medicine 2004
Acute Respiratory Distress Syndrome

Management Issue #2: NIPPV

Can

non-invasive positive pressure

ventilation (NIPPV) be safely used in
patients with ALI/ARDS?
Uncertain, Grade B

Acute Respiratory Distress Syndrome

Management Issue #3: LOW TIDAL

VOLUMES
Does

the use of small tidal volume

ventilation affect outcome in ALI/ARDS
related to Sepsis?

Acute Respiratory Distress Syndrome

Management Issue #3: LOW TIDAL

VOLUMES

ARDS Network Trial, 2000

Acute Respiratory Distress Syndrome

Management Issue #3: LOW TIDAL

VOLUMES
Mortality

substantially reduced from

40% (traditional strategy) to 31% (lower
lung volume strategy)
More ventilator free days
More organ failure free days
ARDS Network Trial, 2000

Acute Respiratory Distress Syndrome

Management Issue #3: LOW TIDAL

VOLUMES
Most of the tidal volume in ALI/ARDS
are directed to a relatively small amount
of aerated lung
Traditional approaches to mechanical
ventilation exacerbate or perpetuate
lung injury by excessive stretch of
aerated regions during inspiration
Acute Respiratory Distress Syndrome

Management Issue #3: LOW TIDAL

VOLUMES
TV

reduced further to 5-4 ml/k if

necessary to maintain Pplat less than or
equal to 30

Acute Respiratory Distress Syndrome

NIH ARDS NETWORK LOWER TIDAL

VOLUME VENTILATION PROTOCOL
SUMMARY
Variable
Protocol
Ventilator Mode

Volume Assist Control

TV

Less than or equal to 6 ml/k predicted BW

Plateau
Pressure

Less than equal to 30 cm H2O

Rate

6-35/min adjusted to achieve arterial pH Above or

equal to 7.3

IE

1:1 to 1:3

Oxygenation
goal

PaO2 above or equal to 55 mm Hg or Sats between 88

to 95%

FiO2/ PEEP
combinations

0.3/5, 0.4/5, 0.4/8, 0.5/8, 0.5/10, 0.6/10, 0.7/10, 0.7/12,

0.7/14, 0.8/14, 0.9/14, 0.9/16, 0.9/18, 1.0/18, 1.0/22,
1.0/24

Acute Respiratory Distress Syndrome

Management Issue #3: LOW TIDAL

VOLUMES
Does

the use of small tidal volume

ventilation affect outcome in ALI/ARDS
related to Sepsis?
Yes, Grade B

Acute Respiratory Distress Syndrome

Management Issue #4:

Applying Positive Airway Pressure
Do

manipulations of airway pressure

improve oxygenation?
Does it improve outcome in patients
with sepsis
Should Positive End-Expiratory
Pressure (PEEP) be used to prevent
lung collapse at end expiration?
Acute Respiratory Distress Syndrome

Management Issue #4:

Applying Positive Airway Pressure
No

detectable oxygen toxicity occurred

in normal subjects at FiO2 <50%
Impaired gas exchange at 100% O2 for
approximately 40 h
PEEP minimizes potential for oxygen
induced lung injury from toxic levels of
inspired oxygen
FiO2 <60 is considered safe
Acute Respiratory Distress Syndrome

Management Issue #4:

Applying Positive Airway Pressure
PEEP

reduces intrapulmonary shunt

and improves arterial oxygenation
Adverse effects: increased pulmonary
edema formation, decreased cardiac
outputs, increased dead space,
increased resistance, increased lung
volumes and stretch during inspiration
which may cause further injury or
barotrauma
Acute Respiratory Distress Syndrome

Management Issue #4:

Applying Positive Airway Pressure
Best

strategy for using PEEP and FiO2

are not yet defined
Consensus among investigators at the
NIH ARDS Network Centers since 1995
Goal of therapy: maintain a PaO2 >5860 mmHg or an O2 Saturation of 90%

Acute Respiratory Distress Syndrome

NIH ARDS NETWORK LOWER TIDAL

VOLUME VENTILATION PROTOCOL
SUMMARY
Variable
Protocol
Ventilator Mode

Volume Assist Control

TV

Less than or equal to 6 ml/k predicted BW

Plateau
Pressure

Less than equal to 30 cm H2O

Rate

6-35/min adjusted to achieve arterial pH Above or

equal to 7.3

IE

1:1 to 1:3

Oxygenation
goal

PaO2 above or equal to 55 mm Hg or Sats between 88

to 95%

FiO2/ PEEP
combinations

0.3/5, 0.4/5, 0.4/8, 0.5/8, 0.5/10, 0.6/10, 0.7/10, 0.7/12,

0.7/14, 0.8/14, 0.9/14, 0.9/16, 0.9/18, 1.0/18, 1.0/22,
1.0/24

Acute Respiratory Distress Syndrome

Management Issue #4:

Applying Positive Airway Pressure
Do

manipulations of airway pressure

improve oxygenation? Yes, Grade C
Does it improve outcome in patients
with sepsis? Uncertain, Grade B
Should Positive End-Expiratory
Pressure (PEEP) be used to prevent
lung collapse at end expiration? Yes,
Grade E
Acute Respiratory Distress Syndrome

Management Issue #5: Permissive

Hypercapnea
Is

normalization of the pH or PCO2

necessary in ALI/ ARDS?
Should permissive hypercapnea be
used in patients with ALI/ARDS?

Acute Respiratory Distress Syndrome

Management Issue #5: Permissive

Hypercapnea

Acute rises in PCO2 can cause vasodilation,

increased heart rate, BP and cardiac output

Allowing modest hypercapnea in conjunction

with limiting tidal volume and minute
ventilation has been demonstrated to be safe
Hickilng et. al., N Engl J Med 2000
Tasker, Intensive Care Medicine 1998

Acute Respiratory Distress Syndrome

Management Issue #5: Permissive

Hypercapnea
Permissive

hypercapnea not a primary

treatment goal in ARDS Network Trial

No

upper limit for PCO2 has been

established
Maintain pH >7.2-7.25

Acute Respiratory Distress Syndrome

Management Issue #5: Permissive

Hypercapnea
Limited

use in patients with pre-existing

metabolic acidosis and is
contraindicated in those with increased
ICP

Acute Respiratory Distress Syndrome

Management Issue #5: Permissive

Hypercapnea
Is

normalization of the pH or PCO2

necessary in ALI/ ARDS? No, Grade D
Should permissive hypercapnea be
used in patients with ALI/ARDS? Yes,
Grade E

Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning
Does

prone positioning affect gas

exchange or outcome in sepsis related
ALI?

Should

prone position be used in

patients with ARDS requiring potentially
injurious levels of FiO2 or plateau
pressure?
Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning

Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning
In

facilities with adequate experience,

prone positioning should be considered
Crit Care Med, 2004

Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning

Investigations inexperimental pig models

Supine: pleural pressure were highest in the dorsal regions
due to hydrostatic gradients
Translated to atelectasis

Prone positioning
Uniform pleural pressures
Allowed dorsal regions to open up and participate in gas
exchange

Suggests probable protection from ventilator

associated lung injury
Equal distirbution of TV
Prevented repeated opening and collapse of small airways
Lamm, et. al. Am J Resp Crit Care Med, 1994
Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning

Lung mechanics and analyzed CT images of

ARDS

Decrease in chest wall compliance

TV tended to redistribute
Recruitment of dorsal lung regions
Improved arterial oxygenation
Potential lung protecting effect from overall
decrease in atelectasis at end expiration
Pelosi, AM J Resp Crit Care Med 1998

Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning
Requires

more personnel to safely

implement
Duration of prone positioning not
established
6 h no difference with supine position
ventilation (Gattinoni et. al., Lancet 1997)
No

clear guidelines on when it should

be initiated or discontinued
Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning
Expert

opinion: aggressive approach of

>20 h/d with relatively brief periods of
supine positioning for bathing servicing
vascular catheters started early in the
course and continued until weaning is
feasible
Albert, RK, Clinical Chest Med 2000

Acute Respiratory Distress Syndrome

Management Issue #6: Prone

Positioning

Does prone positioning affect gas exchange

or outcome in sepsis related ALI?
Gas Exchange, Yes Grade B
Sepsis Outcome, Uncertain, Grade B

Should prone position be used in patients

with ARDS requiring potentially injurious
levels of FiO2 or plateau pressure? Yes,
Grade E
Acute Respiratory Distress Syndrome