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Updated: May 27 2021

Adult Respiratory Distress Syndrome

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  • Summary
    • Adult respiratory distress syndrome (ARDS) is a pulmonary condition that can arise after polytrauma and long bone fractures leading to acute lung injury and progressive respiratory distress, refractory hypoxemia and pulmonary edema.
    • Diagnosis is made in the polytrauma patient by calculation of hypoxemia defined by PaO2 / FIO2 ratio < 200 mm Hg with chest x-ray revealing diffuse bilateral pulmonary infiltrates with pulmonary edema.
    • Treatment is focused on prevention with early stabilization of long bone fractures and PEEP ventilation when ARDS develops.
  • Etiology
    • Pathophysiology
      • acute endothelial damage resulting from
        • aspiration
        • infection
        • pancreatitis
        • multiple blood transfusions
        • lung injury
        • sepsis or shock
        • major trauma
        • large surface area burns
        • fat emboli
        • thromboembolism
        • multi-system organ failure
      • pathoanatomy
        • injury cascade leads to
          • non-cardiogenic pulmonary edema
          • respiratory distress
          • refractory hypoxemia
          • decreased lung compliance
  • Classification
    • ARDS is represented by three phases
      • 3 phases of ARDS
      • Exudative phase
      • Initially
      • Hyaline membrane comprised of fibrin form
      • Proliferative phase
      • 3 days
      • Alveolar exudate resolves or organizes
      • Fibrotic phase
      • 3-4 weeks
      • Alveolar ducts and spaces undergo fibrosis
  • Presentation
    • Symptoms
      • acute onset (12-48 hours) of
        • dyspnea
        • fever
        • mottled or cyanotic skin
    • Physical exam
      • resistant hypoxia
      • intercostal retractions
      • rales/crackles and ronchi
      • tachypnea
  • Evaluation
    • Hypoxemia is refractory to O2
      • 3 different categories of ARDS based on degree of hypoxemia
      • PaO2 / FIO2 ratio < 300 mm Hg= mild
        • classified as acute lung injury (ALI)
      • PaO2 / FIO2 ratio < 200 mm Hg= moderate
        • values below 200 classified as ARDS
      • PaO2 / FIO2 ratio < 100 mm Hg= severe
    • Chest xray
      • shows patchy pulmonary edema (air space disease)
      • diffuse bilateral pulmonary infiltrates
        • normal sized heart
          • makes CHF less likely
    • Respiratory compliance (<40 mL/cm H20)
    • Positive end-expiratory pressure (>10cm H20)
    • Corrected expired volume per minute (>10L/min)
  • Differential
    • Cardiogenic pulmonary edema (i.e. CHF or MI), bilateral pneumonia, SARS
  • Treatment
    • Nonoperative
      • PEEP ventilation and steroids
      • treat the underlying pathology/disease
    • Operative
      • early stabilization of long bone fractures (femur)
    • Prevention
      • closely monitor PEEP in patients at-risk of ARDS
      • serial X-rays in concerning patients can assist in early identification and intervention
  • Complications
    • Pneumothorax
      • secondary to ventilator with high PEEP
  • Prognosis
    • High mortality rate (50% overall) is associated with ARDS even in setting of ICU
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