ARDS

Acute Respiratory Distress Syndrome

Adair Locke

Definition

1994 American-European Consensus Conference (AECC) on ARDS definition:

Acute

onset of symptoms Ratio of PaO2 to FIO2 of 200 mm Hg or less Bilateral infiltrates on CXRs Pulmonary arterial wedge pressure of 18 mm Hg or less or no clinical signs of left atrial hypertension

Clinical features
Tachypnea, tachycardia, hypoxia, and respiratory alkalosis are typical early clinical manifestations Usually followed by the appearance of diffuse pulmonary infiltrates and respiratory failure within 48 hours.

Risk Factors

Primary pulmonary etiologies

aspiration pneumonia toxic inhalation pulmonary

contusion

Extrapulmonary etiologies:
sepsis DIC

pancreatitis multiple blood transfusions Multiple trauma drugs (heroin)

Course of disease

Exudative phase:
Occurs

within hours after initial pulmonary

insult Usually lasts 2-7 days Hyaline membranes, loss of the alveolar epithelium, edema, & hemorrhage

Proliferative phase
Usually

7-28 days after initial pulmonary insult Proliferation of type 2 pneumocytes, widening of septa & interstitial fibroblast proliferation

Course of disease

Late proliferative or fibrotic phase:

Deposition

of collagen and proteoglycans. Fibroblast proliferation

Interstitial fibrosis develops in some patients.

Radiographic abnormalities

Due to alveolar epithelial injury, or diffuse alveolar damage, that causes leakage of protein-rich fluid into the alveolar spaces.

Chest X-ray

Exudative phase: progression from diffuse bilateral interstitial infiltrates to diffuse, fluffy, alveolar opacities +/- air bronchograms
White

out Ground glass opacities

Proliferative and fibrotic phase: a more heterogeneous, linear or reticular pattern.

Chest X-Ray
To help distinguish from cardiogenic pulmonary edema: often a lack cardiomegaly, obvious pleural effusions, and vascular redistribution. Radiographic findings tend to stabilize and if further worsening occurs after 5-7 days, another process should be considered.

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http://www.lumen.luc.edu/lumen/MedEd/Radio/curriculum/Mechanisms/ards.htm

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 Copyright 2005, eMedicine.com, Inc.

CT
The diffuse and nonspecific consolidation on CXRs is revealed to actually be more heterogeneous on CT scans. Alveolar opacities in the gravitydependent areas of the lung

CT
ARDS due to pulmonary disease tends to be asymmetric, with a mix of consolidation and ground-glass opacification ARDS due to extrapulmonary causes has predominantly symmetric ground-glass opacification. Pleural effusions and air bronchograms are common with both

 Copyright 2005, eMedicine.com, Inc.

Management

Treat underlying cause Nutrition Low tidal volumes (6ml/kg) PEEP partial liquid ventilation high-frequency oscillatory ventilation Prone positioning