ARDS

REF – PAUL MARINO ICU BOOK

4ED
THE WASHINGTON MANUAL
OF CRITICAL CARE 2ND ED
OVERVIEW
• DEFINITION
• PATHOPHYSIOLOGY
• CAUSES
• IMPORTANT DDs
• VENTILATOR STRATEGIES
• NON VENTILATOR STRATEGIES
DEFINITION
• INCIDENCE – 2L /yr in USA
• MORTALITY- 35 to 40 % (1980s- 70%)
• 1994 AMERICAN EUROPEAN CONSENSUS CONF –
ALI/ ARDS – PaO2/FiO2 <300 AND <200, PCWP<18
• 2012- BERLIN criteria– ALI eliminated, PCWP
eliminated
CRITERIA FOR DIAGNOSIS
1. APPROPRIATE CLINICAL SETTING WITH ACUTE ONSET <72 HRS
2. DEVELOPMENT OF BILATERAL INFILTRATES ON FRONTAL CXR
3. PaO2/ FiO2 < 300
4. NO CLINICAL EVIDENCE OF LVD OR VOLUME OVERLOAD
PATHOPHYSIOLOGY
• INFLAMMATION – NEUTROPHILLIC- non
cardiogenic increased permeability form of PE,
vascular endothelium and alv memb- type I and II
Pneumocytes
• THREE STAGES
▫ Exudative – 3 to 7 days – hyaline memb, destruction of
type I cells, intra alveolar hmrg
▫ Proliferative – 2 to 3 weeks – inc in type II cells, clearing
of debris, liberation from Venti
▫ Fibrosis- after 2 to 3 weeks – interstitial and alveolar
fibrosis- emphys bullae
CONT…
• INHOMOGENOUS DISTRIBUTION
• VOLUTRAUMA
• ATELECTRAUMA
• BIOTRAUMA
DIAGNOSIS
• CXR
• ABG
• CT
• BAL
• INVESTIGATIONS FOR UNDERLYING CAUSE
IMP DIFFERENTIAL DIAGNOSIS
• CARDIOGENIC PE
• DIFFUSE ALV HMRG
• ACUTE INTERSTITIAL PNEUMONIA
• ACUTE EOSINOPHILIC PNEUMONIA
• MILIARY TB
• DISSEMINATED CA
• CRYPTOGENIC ORGANISING PNEUMONIA
CAUSES
• DIRECT LUNG INJURY
▫ PNEUMONIA
▫ ASPIRATION
▫ INHALATIONAL INJURY
▫ BLUNT PULMONARY TRAUMA
▫ DROWNING
• INDIRECT LUNG INJURY
▫ SEPSIS
▫ PANCREATITIS
▫ HAEMORRHAGIC SHOCK, MASSIVE BT >15 UNITS
▫ POLY TRAUMA
▫ REPERFUSION AFTER CABG
ARDS NETWORK
• Lung protective ventilation is one of the few measures that has
been shown to improve survival in ARDS.
• The largest and most successful trial of lung protective
ventilation was conducted by the ARDS Network, and enrolled
over 800 ventilator-dependent patients with ARDS who were
randomly assigned to receive tidal volumes of 6 mL/kg or 12
mL/kg (using predicted body weight).
• Ventilation with the lower tidal volume (6 mL/kg), and an end-
inspiratory plateau pressure (Ppl) ″30 cm H2O, was associated
with a shorter duration of mechanical ventilation and a 9%
absolute reduction in mortality rate (40% to 31%, P=0.007).
VENTILATOR STRATEGIES
GOALS-
PaO2 55 – 80, SaO2>88%
PP<30 CM H2O
Fi02 < 0.6
PH 7.3 – 7.45
PP q 4 H with 0.5 SEC EIP

TV 6ML/KG
IF PP > 30 , DEC TV BY 1ML/KG
PEEP 5 CM H2O UPTO 4ML/KG TO ACHIEVE PP<30
INC PEEP WHILE TRYING TO KEEP
RR<35 Fi02<0.7
IF PH IS 7.15 TO 7.3, INC RR TO >35
CALCULATE UPTO paCO2 25, IF PaCO2 < 25, GIVE
PBW BICARB
IF PH < 7.15 AFTER RR=35, BICARB
START MV IN GIVEN, INC TV BY 1ML/KG EVEN IF
PP>30
AC MODE

IF GOALS NOT MET

IF GOALS MET – GO
GO TO RESCUE
TO FLUID
THERAPY AND FLUID
MANAGEMENT
MANAGEMENT
 FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0

PEEP 5 5-8 8-10 10 10-14 14 14-18 18-23

However, it is important to emphasize that increases in PEEP can reduce the
cardiac output, and if the goal of increasing PEEP is to maintain the same SpO2 at a lower FIO2, the
reduced cardiac output will reduce the systemic O2 delivery.
FLUID MANAGEMENT
• Avoiding a positive fluid balance will prevent unwanted
fluid accumulation in the lungs, which could aggravate
the respiratory insufficiency in ARDS.
• Clinical studies have shown that avoiding a positive
fluid balance in patients with ARDS can reduce the time
on mechanical ventilation and can even reduce mortality
• However, it is also important to avoid fluid deficits and
maintain intra-vascular volume because the positive
intrathoracic pressures during MV will magnify the
tendency for the CO to decrease in response to deficits in
intravascular volume.
• Watch MAP (>60), CVP 4-9 - FLUID BOLUS, 10-13,
DOBUT AND FRUSEMIDE depending on CI < or> 2.5
and UO
STEROIDS
1 TO 7 DAYS, preferred < 72 hrs, no concomitant paralytics

• Methyl prednisolone 1mg/kg bolus@30 mins, F/B 1 mg/kg /

24 hrs as infusion x 14 days
•Stop if no physiologic or radiologic benefit in 3 to 5 days
•Taper in two weeks by 0.5 mg / kg /day X 7 days F/B
•0.25 mg/kg/day X 7 days

7 to 14 days, if not started earlier, benefit less certain

• same protocol, discontinue if no benefit in 3 to 5 days

14 days, no role for steroids, may cause increase in mortality

RESCUE THERAPIES
IF FiO2 > OR = 0.7, OR PP > 30 cm H2O
• INHALED EPOPRSTENOL, NITRIC OXIDE, PG
I2
• PRONE VENTILATION
• INVERSE RATIO VENTILATION
• HFOV, 1 to 2 ml TV, with rapid pressure
oscillations of 300 cycles/min
• ECMO
TRIALS
VENTILATOR STRATEGIES
GOALS-
PaO2 55 – 80, SaO2>88%
TV 6ML/KG PP<30 CM H2O
CALCULATE PBW
PEEP 5 CM H2O Fi02 < 0.6
START MV IN AC MODE
RR<35 PH 7.3 – 7.45
PP Q 4 H MITH 0.5 SEC
EIP

INC RR TO >35 UPTO

paCO2 25, IF PaCO2 < 25, IF PH IS 7.15 TO 7.3 IF GOALS NOT MET
GIVE BICARB

IF GOALS MET- FLUID

IF PP > 30 , DEC TV BY INC PEEP WHILE MANAGEMENT
1ML/KG UPTO 4ML/KG TRYING TO KEEP
TO ACHIEVE PP<30 Fi02<0.7 IF GOALS NOT MET –
RESCUE THERAPIES