AUTHOR: Jorge Mercado, MD
Acute respiratory distress syndrome (ARDS) is a form of noncardiogenic pulmonary edema that results from acute damage to the alveoli. It is characterized by diffuse infiltrative lung lesions with resulting interstitial and alveolar edema, severe hypoxemia, and respiratory failure.1-3 The cardinal feature of ARDS, refractory hypoxemia, is caused by formation of protein-rich alveolar edema after damage to the integrity of the lungs alveolar-capillary barrier.
The initial definition of ARDS was based on the American-European Consensus Conference (AECC) from 1994 and included the following components:
The 2012 Berlin definition of ARDS (Table 1) addresses some of the limitations of the AECC definition and establishes the criteria for ARDS:
TABLE 1 2012 Berlin Definition of Acute Respiratory Distress Syndrome (All Components Must Be Present)
Timing | Within 1 wk of a known clinical insult or new/worsening respiratory symptoms | ||
Chest imaging | Bilateral opacities: Not fully explained by effusions, lobar/lung collapse, or nodules | ||
Origin of edema | Respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment (e.g., echocardiography) to exclude hydrostatic edema if no risk factor for ARDS is present | ||
Oxygenation | Mild ARDS | Moderate ARDS | Severe ARDS |
200 <PaO2/FiO2 ≤300 with PEEP or CPAP ≥5 cm H2O | 100 <PaO2/FiO2 ≤200 PEEP ≥5 cm H2O | PaO2/FiO2 ≤100 with PEEP ≥5 cm H2O |
ARDS, Acute respiratory distress syndrome; CPAP, continuous positive airway pressure; PEEP, positive end-expiratory pressure.
From Weinberger SE: Principles of pulmonary medicine, ed 7, Philadelphia, 2019, Elsevier.
TABLE 3 Risk Factors Associated with Development of Acute Lung Injury and Acute Respiratory Distress Syndrome
Direct Lung Injury | Indirect Lung Injury | ||
---|---|---|---|
Pneumonia | Sepsis | ||
Aspiration of gastric contents | Multiple trauma | ||
Pulmonary contusion | Cardiopulmonary bypass | ||
Fat, amniotic fluid, or air emboli | Drug overdose | ||
Near-drowning | Acute pancreatitis | ||
Inhalational injury | Transfusion of blood products | ||
Reperfusion pulmonary edema |
From Vincent JL et al: Textbook of critical care, ed 6, Philadelphia, 2011, Saunders.
TABLE 2 Conditions Associated with Acute Respiratory Distress Syndrome by Possible Mechanisms of Injury
Direct Injury (Pulmonary) | Indirect Injury (Nonpulmonary) | ||
---|---|---|---|
Pneumonia (bacterial, viral [e.g., influenza, COVID-19]) | Sepsis Major trauma | ||
Aspiration | Multiple blood transfusions | ||
Pulmonary contusion | Pancreatitis | ||
Toxic inhalation | Cardiopulmonary bypass | ||
Near-drowning | Drug overdose | ||
Reperfusion injury (e.g., post-lung transplant) | Adverse effects of medication |
COVID-19, Coronavirus disease 2019.
From Broaddus VC et al: Murray & Nadels textbook of respiratory medicine, ed 7, Philadelphia 2022, Elsevier.
The search for an underlying cause should focus on treatable causes (e.g., infections such as sepsis or pneumonia).
Chest x-ray examination (Fig. 1).
Figure 1 Acute respiratory distress syndrome.
X-ray of a young man who had sustained severe trauma and blood loss in a road traffic accident; the lungs cover a period of 5 days from a relatively normal x-ray (A), to bilateral infiltrates (B), to bilateral whiteout (C), accompanied by severe hypoxemia. A Swan-Ganz catheter for measurement of pulmonary artery wedge pressure (as a reflection of left atrial pressure) can be seen in situ on the x-ray film in C. The patient died shortly after the last film.
Treatment of ARDS is supportive. There is no specific pharmacotherapy for ARDS. Management principles are summarized in Table 4.
TABLE 4 ARDS Management Principles
Supportive Care | |||
Supplemental oxygen to ensure adequate oxygenation | |||
Lung-protective ventilation | |||
Reduce oxygen consumption if hypoxia is critical | |||
Support adequate perfusion for other organs; focus on both cardiac output and blood pressure | |||
Find and Treat Underlying Cause | |||
Consider infections, mimics | |||
Minimize Further Edema Accumulation | |||
Seek lowest pulmonary microvascular pressure that maintains adequate perfusion | |||
Diurese/reduce vascular volume while maintaining adequate perfusion | |||
Avoid Harm | |||
Volume- and pressure-limited ventilation strategy | |||
Avoid both hypotension and volume overload | |||
Goal-directed sedation with frequent reassessment | |||
Avoid hyperoxia | |||
Consider early physical rehabilitation | |||
Seek and treat neuromuscular, cognitive, and psychological impairments during recovery |
ARDS, Acute respiratory distress syndrome; FiO2, fractional concentration of oxygen in inspired gas; PaO2, partial pressure of arterial oxygen.
From Broaddus VC et al: Murray & Nadels textbook of respiratory medicine, ed 7, Philadelphia 2022, Elsevier.
ECG, Electrocardiogram; HR, heart rate; PaCO2, arterial partial pressure of carbon dioxide; PEEP, positive end-expiratory pressure; P/F, PaO2/FiO2; PSV, pressure support ventilation; RR, respiratory rate; SBP, systolic blood pressure; SpO2, oxygen saturation based on pulse oximeter; WOB, work of breathing.
From Goldman L, Shafer AI: Goldman-Cecil medicine, ed 26, Elsevier, 2020.
Several caveats should be considered in using the low tidal volume strategy. (1) Tidal volume (VT) is based on predicted body weight (PBW), not actual body weight; PBW tends to be about 20% lower than actual body weight. (2) The protocol mandates decreases in the VT lower than 6 mL/kg of PBW if the plateau pressure (Pplat) is greater than 30 cm H2O and allows small increases in VT if the patient is severely distressed or if there is breath stacking, as long as Pplat remains at 30 cm H2O or lower. (3) Because arterial carbon dioxide (CO2) levels will rise, pH will fall; acidosis is treated with increasingly aggressive strategies dependent on the arterial pH. (4) The protocol has no specific provisions for the patient with a stiff chest wall, which in this context refers to the rib cage and abdomen; in such patients, it seems reasonable to allow Pplat to increase to more than 30 cm H2O, even though it is not mandated by the protocol; in such cases, the limit on Pplat may be modified on the basis of analysis of abdominal pressure, which can be estimated by measuring bladder pressure. FiO2, Fraction of inspired oxygen; PaCO2, arterial partial pressure of carbon dioxide; PaO2, arterial partial pressure of oxygen; PBW, predicted body weight; Pplat, plateau pressure; PEEP, positive end-expiratory pressure; RR, respiratory rate; SpO2, oxygen saturation based on pulse oximeter; VT, tidal volume.
From Goldman L, Shafer AI: Goldman-Cecil medicine, ed 26, Elsevier, 2020.
Identify and treat precipitating conditions:
CVVH, Continuous venovenous hemofiltration; DVT, deep venous thrombosis; ECMO, extracorporeal membrane oxygenation; NIPPV, noninvasive positive pressure ventilation; PBW, predicted body weight; PEEP, positive end-expiration pressure; P/F, PaO2/FiO2; Pplat, plateau airway pressure; RR, respiratory rate; SpO2, arterial oxygen saturation; VT, tidal volume.
From Goldman L, Shafer AI: Goldman-Cecil medicine, ed 26, Elsevier, 2020.
Surgical referral for tracheostomy (see Acute General Rx).
Referral to ECMO team or center in severe cases when indicated.
Acute Respiratory Distress Syndrome (ARDS) (Patient Information)
Pneumonia, Viral (Related Key Topic)