ARDS

AN ACUTE, DIFFUSE,

INFLAMMATORY LUNG INJURY

THAT LEADS TO INCREASED

PULMONARY VASCULAR

PERMEABILITY, INCREASED LUNG

WEIGHT, AND A LOSS OF AERATED

TISSUE
 ARDS DIAGNOSTIC CRITERIA

• ACUTE ONSET

• PREDISPOSING CONDITION

• BILATERAL INFILTRATES

• PULMONARY CAPILLARY WEDGE PRESSURE ≤ 18 MM HG OR NO

CLINICAL EVIDENCE INCREASE IN LA PRESSURE

CAUSES
 DIRECT LUNG INJURY
• PNEUMONIA

• ASPIRATION

• PULMONARY CONTUSION

• PULMONARY EMBOLISM

• INHALATION INJURY

• REPERFUSION INJURY

• CHEST TRAUMA WITH LUNG CONTUSION

• NEAR-DROWNING
 INDIRECT LUNG INJURY
• SEPSIS

• BLOOD TRANSFUSIONS WITH TRANSFUSION-RELATED ACUTE LUNG INJURY

(TRALI)

• TRAUMA WITH MULTIPLE FRACTURES AND THE FAT-EMBOLI SYNDROME

• BURNS

• ACUTE PANCREATITIS

• POST-CARDIOPULMONARY BYPASS
PATHOPHYSIOLOGY
IN NORMAL, HEALTHY LUNGS THERE

IS A SMALL AMOUNT OF FLUID THAT

LEAKS INTO THE INTERSTITIUM. THE

LYMPHATIC SYSTEM REMOVES THIS

FLUID AND RETURNS IT INTO THE

CIRCULATION KEEPING THE ALVEOLI

DRY
CONSEQUENCE OF AN ALVEOLAR INJURY WHICH PRODUCES DIFFUSE
ALVEOLAR DAMAGE

THE INJURY CAUSES THE RELEASE OF PRO-INFLAMMATORY

“CYTOKINES”

CYTOKINES RECRUIT NEUTROPHILS

DAMAGE TO THE CAPILLARY ENDOTHELIUM AND ALVEOLI EPITHELIUM

CONSEQUENCE OF AN ALVEOLAR INJURY WHICH PRODUCES DIFFUSE
ALVEOLAR DAMAGE

THE INJURY CAUSES THE RELEASE OF PRO-INFLAMMATORY

“CYTOKINES”

CYTOKINES RECRUIT NEUTROPHILS

DAMAGE TO THE CAPILLARY ENDOTHELIUM AND ALVEOLI EPITHELIUM

 ALLOWS PROTEIN TO ESCAPE FROM THE VASCULAR SPACE

REDUCED ONCOTIC PRESSURE; FLUID POURS INTO THE INTERSTITIUM,

OVERWHELMING THE LYMPHATIC SYSTEM

BREAKDOWN OF THE ALVEOLAR EPITHELIAL BARRIER ALLOWS THE AIR

SPACES TO FILL WITH BLOODY, PROTEINACEOUS EDEMA FLUID

FUNCTIONAL SURFACTANT IS LOST, RESULTING IN ALVEOLAR COLLAPSE

 PATHOPHYSIOLOGICAL CHANGES

• FIBROSIS

• ‘ WET OR BABY’ LUNG

• INTRAPULMONARY SHUNTING

• SECONDARY ALTERATIONS IN FUNCTION OF SURFACTANT

• INCREASED PULMONARY VASCULAR RESISTANCE

• DECREASED PULMONARY COMPLIANCE

 STAGES OF ARDS
• EXUDATIVE

• PROLIFERATIVE

• FIBROTIC
 EXUDATIVE STAGE (0-6 DAYS)

ACCUMULATION OF EXCESSIVE FLUID IN THE LUNGS DUE

TO EXUDATION (LEAKING OF FLUIDS) AND ACUTE INJURY.

 PROLIFERATIVE STAGE (7-10 DAYS)

• CONNECTIVE TISSUE AND OTHER STRUCTURAL ELEMENTS IN THE

LUNGS PROLIFERATE IN RESPONSE TO THE INITIAL INJURY

• THE TERMS "STIFF LUNG" AND "SHOCK LUNG" FREQUENTLY USED TO

CHARACTERIZE THIS STAGE.

 FIBROTIC STAGE ( >10-14 DAYS)
• INFLAMMATION RESOLVES.

• VARYING LEVELS OF PULMONARY FIBROTIC CHANGES ARE POSSIBLE.

CLINICAL FEATURES
• DEVELOPMENT OF ACUTE DYSPNEA

• HYPOXEMIA WITHIN HOURS TO DAYS OF AN INCITING EVENT

• TACHYPNEA, TACHYCARDIA

• FEBRILE OR HYPOTHERMIC

• BILATERAL RALES

• MANIFESTATIONS OF THE UNDERLYING CAUSE

• RESPIRATORY FAILURE
DIAGNOSIS
• ROUTINE BLOOD COUNTS

• CXR

• ABG

• CT CHEST

• 2D ECHO

• PCWP

• BRONCHEOALVEOLAR LAVAGE
 CARDIOGENIC V/S NON CARDIOGENIC
EDEMA
CARDIOGENIC NON-CARDIOGENIC

• PATCHY INFILTRATES IN BASES • HOMOGENOUS PLUFFY SHADOWS

• EFFUSIONS + • EFFUSIONS –

• KERLEY B LINES + • KERLEY B LINES –

• CARDIOMEGALY + • CARDIOMEGALY –

• EXCESS FLUID IN ALVEOLI • PROTEIN,INFLAMMATORY

CELLS,FLUID
MANAGEMENT
• LUNG PROTECTIVE MECHANICAL VENTILLATION

- LOW VOLUME HIGH PRESSURE

- TV @ RATE OF 6 - 7 ML/KG

- PEEP CAN BE RAISED UPTO 15 MM OF HG

- RATE MAY GO UPTO 35 B/MT

Tidal Volumes Over The Years…..

1990’s 2010’s
INDICATION FOR MECHANICAL VENTILATION
• INADEQUATE OXYGENATION ( PAO2- < 60 WITH FIO2 >=0.6)

• RISING OR ELEVATED PACO2 ( > 50MMHG)

• CLINICAL SIGNS OF INCIPIENT RESPIRATORY FAILURE

 ARDS PROTOCOL -WEANING

• SPONTANEOUS BREATHING TRIAL DAILY

• PAO2/FIO2-<8/<.4 OR <5/ <.5

• SYSTOLIC BP > 90 WITHOUT VASOPRESSORS

• NO NEUROMUSCULAR BLOCKADE

• 2 HR TRIAL- WITH T PIECE WITH 1-5CM WATER CPAP.

• ABG,RR,SPO2 MONITORING

• IF TOLERATED FOR 30 MT, CONSIDER EXTUBATION

“RESCUE” OR “SALVAGE” INTERVENTIONS USED IN
ARDS
• EXTRACORPOREAL CO2 REMOVAL (ECCO2R)/ EXTRACORPOREAL
MEMBRANE OXYGENATION (ECMO)

• PERMISSIVE HYPERCAPNIA

• HIGH FREQUENCY OSCILLATORY VENTILATION (HFOV)

• INHALED NITRIC OXIDE (NO) OR INHALED PROSTACYCLIN

• SIGH VENTILLATION

• PRONE POSITIONING

• RECRUITMENT MANEUVERS

- HIGH PEEP

- STEP LADDER PEEP

EXTRA CORPOREAL MEMBRANE
OXYGENATION (ECMO)
• CORTICOSTEROIDS

• FLUID MANAGEMENT

• HEMODYNAMIC STABILIZATION

• ANTIBIOTICS

• ALBUTEROL

• NSAIDS

• N-ACETYL CYSTEINE