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PubMed1999

Management of patients with acute respiratory distress syndrome.

Acute respiratory distress syndrome is a complex clinical syndrome of respiratory failure that presents a challenge to every critical care team. Since the first clear description by Ashbaugh et al more than 30 years ago, much has been learned about the pathophysiologic process that occurs within the lungs after they suffer either a direct or indirect injury. Unfortunately, little success has been achieved in improving outcomes; however, hope is on the horizon. Current research evaluating optimal ventilator management, ECMO, the use of inhaled nitric oxide, and other experimental management strategies will hopefully combine to produce improved outcomes.

Critical Care↗

PubMed2003

Respiratory system mechanics in acute respiratory distress syndrome.

Respiratory mechanics research is important to the advancement of ARDS management. Twenty-eight years ago, research on the effects of PEEP and VT indicated that the lungs of ARDS patients did not behave in a manner consistent with homogenously distributed lung injury. Both Suter and colleagues] and Katz and colleagues reported that oxygenation continued to improve as PEEP increased (suggesting lung recruitment), even though static Crs decreased and dead-space ventilation increased (suggesting concurrent lung overdistension). This research strongly suggested that without VT reduction, the favorable effects of PEEP on lung recruitment are offset by lung overdistension at end-inspiration. The implications of these studies were not fully appreciated at that time, in part because the concept of ventilator-associated lung injury was in its nascent state. Ten years later. Gattinoni and colleagues compared measurements of static pressure-volume curves with FRC and CT scans of the chest in ARDS. They found that although PEEP recruits collapsed (primarily dorsal) lung segments, it simultaneously causes overdistension of non-dependent, inflated lung regions. Furthermore, the specific compliance of the aerated, residually healthy lung tissue is essentially normal. The main implication of these findings is that traditional mechanical ventilation practice was injecting excessive volumes of gas into functionally small lungs. Therefore, the emblematic low static Crs measured in ARDS reflects not only surface tension phenomena and recruitment of collapsed airspaces but also overdistension of the remaining healthy lung. The studies reviewed in this article support the concept that lung injury in ARDS is heterogeneously distributed, with resulting disparate mechanical stresses, and indicate the additional complexity from alterations in chest wall mechanics. Most of these studies, however, were published before lung-protective ventilation. Therefore, further studies are needed to refine the understanding of the mechanical effects of lung-protective ventilation. Although low-VT ventilation is becoming a standard of care for ARDS patients, many issues remain unresolved; among them are the role of PEEP and recruitment maneuvers in either preventing or promoting lung injury and the effects of respiratory rate and graded VT reduction on mechanical stress in the lungs. The authors believe that advances in mechanical ventilation that may further improve patient outcomes are likely to come from more sophisticated monitoring capabilities (ie, the ability to measure P1 or perhaps Cslice) than from the creation of new modes of ventilatory support.

Humans↗

PubMed2000

Continuous distending airway pressure for respiratory distress syndrome in preterm infants.

BACKGROUND: Respiratory distress syndrome (RDS) is the single most important cause of morbidity and mortality in preterm infants (Greenough 1998, Bancalari 1992). Intermittent positive pressure ventilation (IPPV) with surfactant is the standard treatment for the condition. The major difficulty with IPPV is that it is invasive, resulting in airway and lung injury and contributing to the development of chronic lung disease. OBJECTIVES: In spontaneously breathing preterm infants with RDS, to determine if continuous distending airway pressure (CDAP) reduces the need for IPPV and associated morbidity without adverse effects. SEARCH STRATEGY: The standard search strategy of the Neonatal Review group was used. This included searches of the Oxford Database of Perinatal Trials, Cochrane Controlled Trials Register, MEDLINE, previous reviews including cross references, abstracts, conference and symposia proceedings, expert informants, journal hand searching mainly in the English language. SELECTION CRITERIA: All trials using random or quasi-random patient allocation of newborn infants with RDS were eligible. Interventions were continuous distending airway pressure including continuous positive airway pressure (CPAP) by mask, nasal prong, nasopharnygeal tube, or endotracheal tube, or continuous negative pressure (CNDP) via a chamber enclosing the thorax and lower body, compared with standard care. DATA COLLECTION AND ANALYSIS: Standard methods of the Cochrane Collaboration and its Neonatal Review Group, including independent assessment of trial quality and extraction of data by each author, were used. MAIN RESULTS: CDAP is associated with a lower rate of failed treatment (death or use of assisted ventilation), overall mortality, and mortality in infants with birthweights above 1500 g. The use of CDAP is associated with an increased rate of pneumothorax. REVIEWER'S CONCLUSIONS: In preterm infants with RDS the application of CDAP either as CPAP or CNDP is associated with some benefits, particularly in infants with birthweights over 1500 gms. The extent of this benefit is difficult to assess given the outdated methods to administer CDAP, low use of antenatal corticosteroids, non-availability of surfactant and the intensive care setting of the 1970's in which these trials were done. Where resources are limited, such as in developing countries, CPAP for RDS may have a clinical role. Further research is required to determine the best mode of administration and its role in modern intensive care settings

Humans↗

PubMed1993

Intratracheal perfluorocarbon administration as an aid in the ventilatory management of respiratory distress syndrome.

BACKGROUND: Respiratory distress syndrome carries a high morbidity and mortality when treated with mechanical ventilation with positive end-expiratory pressure. Perfluorocarbon liquids are employed in liquid ventilation due to low surface tension and high gas solubility. To assess whether intratracheal administration of the perfluorocarbon, perflubron, in combination with conventional mechanical ventilation could be of therapeutic benefit in respiratory distress syndrome, the authors tested the effects of different doses of intratracheal perflubron administration on gas exchange and lung mechanics in adult animals with respiratory failure during a 6-h observation period. METHODS: Respiratory failure was induced in 30 rabbits by saline lung lavage (arterial oxygen tension < 100 mmHg at 100% oxygen with the following ventilator settings: tidal volume, 12 ml.kg-1; respiratory frequency, 30 per min; inspiratory/expiratory ratio, 1:2; and positive end-expiratory pressure of 6 cm H2O). Twenty-four rabbits were treated with different perfluorocarbon doses (3, 6, 9, and 12 ml.kg-1), and the remaining six served as controls while mechanical ventilation was continued with the aforementioned settings. Additionally, in ten healthy rabbits who were used as healthy controls, the lungs were mechanically ventilated either alone or in combination with intratracheal perfluorocarbon administration (3 ml.kg-1) for 6 h. RESULTS: In all treatment groups, arterial oxygen pressure increased significantly (P < 0.0001) in a dose-related fashion (193 +/- 40, 320 +/- 70, 353 +/- 125, and 410 +/- 45 mmHg at 15 min), and peak airway pressures decreased significantly (range, 18-23%; P < 0.0001) from pretreatment values. These findings were in contrast to those for the control group. The improvements were time-dependent in all four tested perfluorocarbon doses. However, the improvements in pulmonary parameters could be extended to 6 h only in groups treated with 9 ml.kg-1 and 12 ml.kg-1 perflubron. At the end of the 6-h period, the data for these two groups showed significantly higher arterial oxygen pressure (230 +/- 84 and 197 +/- 130 mmHg, respectively; P < 0.05) and lower inflation pressures than the pretreatment data for these groups and the data for the control group at 6 h. There were no clinically significant changes in pulmonary parameters in healthy animals due either to mechanical ventilation alone or mechanical ventilation in combination with intratracheal perfluorocarbon administration for 6 h. CONCLUSIONS: The results of this study imply that there is no association between the lung mechanics and gas exchange parameters for mechanical ventilation in combination with intratracheal perfluorocarbon administration. The data suggest that this type of perfluorocarbon administration with conventional mechanical ventilation offers a simple, alternative treatment of respiratory distress syndrome. With this technique, adequate pulmonary gas exchange can be maintained at relatively low airway pressures with high perfluorocarbon doses for several hours.

Animals↗

PubMed2002

Respiratory reovirus 1/L induction of diffuse alveolar damage: a model of acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a clinical syndrome that is characterized by diffuse alveolar damage usually secondary to an intense host inflammatory response of the lung to a pulmonary or extrapulmonary infectious or noninfectious insult. In this report we describe a unique animal model in which CBA/J mice infected with reovirus serotype 1, strain Lang develop ARDS. This model recapitulates the histopathological changes observed in human ARDS, which consists of the overlapping phases of exudation including the formation of hyaline membranes, regeneration, and healing via resolution and/or repair with fibrosis. While the consequences of a number of infectious and noninfectious insults in various animal systems have been developed as models of human ARDS, they are models of acute lung injury and are of short-term duration. Therefore, they do not recapitulate all of the clinical and pathological phases observed in human ARDS. Thus, study of the cellular and molecular factors involved in these distinct phases of the disease have been limited. Reovirus 1/L infection of CBA/J mice will allow investigations of the pathophysiology of ARDS as it progresses from the initial stages of edema and neutrophilia to fibrotic lesion development in late stages.

Acute Disease↗

PubMed1978

Adult respiratory distress syndrome.

Adult respiratory distress syndrome is a common respiratory emergency which follows a variety of severe direct and indirect lung insults. Major features are severe respiratory distress, diffuse pulmonary infiltrations, reduced compliance and refractory hypoxemia due to shunt effect. Surfactant abnormalities may play a role in the mechanical derangement of lung function. Supportive care with mechanical ventilation and positive end expiratory pressure results in survival of approximately 50 percent of patients. Only minimal abnormalities in lung function are found in long-term survivors.

Adult↗

PubMed1984

T-lymphocyte analysis in the early diagnosis of adult respiratory distress syndrome.

Adult respiratory distress syndrome occurs concomitantly with a number of clinical conditions but has no known cause. At present, there is no generally acceptable method for establishing the early diagnosis. In the course of studying immune aberrations by means of monoclonal antibody staining and fluorescence-activated cell sorting in injured patients, we noted an apparent specific T-lymphocyte response to this syndrome in one patient. There was an increase in suppressor T-cells and a decrease in helper/suppressor T-lymphocyte ratio (normal = 1.57). When the patient recovered, the helper/suppressor ratio rose to above 3.0. T-lymphocyte analysis offers a promising means of evaluating patients considered highly susceptible to adult respiratory distress syndrome, i.e., victims of massive trauma. Further studies will be required to fully elucidate this possibility.

Adult↗

PubMed2002

Acute respiratory distress syndrome.

Acute respiratory distress syndrome is the clinical manifestation of severe, acute lung injury. It is characterized by the acute onset of diffuse, bilateral pulmonary infiltrates secondary to noncardiogenic pulmonary edema, refractory hypoxia, and decreased lung compliance. Acute respiratory distress syndrome occurs most frequently in the setting of sepsis, aspiration of gastric contents, trauma, or multiple transfusions. Its complex pathophysiology involves an inciting local or systemic event that initiates pulmonary endothelial and epithelial damage and subsequent increased permeability. Tachypnea, hypoxia, and respiratory alkalosis are typical early clinical manifestations, and they are usually followed by the appearance of diffuse pulmonary infiltrates and respiratory failure within 48 hours. Early identification and treatment of the underlying disorder, along with aggressive supportive care, are essential. Experimental therapies, including those using nitric oxide and surfactant, have not been shown to improve mortality in patients with ARDS, but new therapeutic approaches such as low-volume ventilation have been shown to decrease mortality. Many patients who survive ARDS have permanent, mild to moderate impairment of lung function. Quality of life after hospitalization with ARDS may be poorer than that in similar patients without ARDS.

Family Practice↗

PubMed1984

Intralipid causing adult respiratory distress syndrome.

Adult respiratory distress syndrome developed in a patient after he was administered intralipid. Intralipid was implicated as the causal agent after careful assessment of the complete clinical picture. To the authors' knowledge this is the first documented case of intralipid-induced adult respiratory distress syndrome. Clinicians should be aware of the possibility of its occurrence.

Aged↗

PubMed2003

Acute respiratory distress syndrome.

Acute respiratory distress syndrome is a manifestation of acute injury to the lung, commonly resulting from sepsis, trauma, and severe pulmonary infections. Clinically, it is characterized by dyspnea, profound hypoxemia, decreased lung compliance, and diffuse bilateral infiltrates on chest radiography. Provision of supplemental oxygen, lung rest, and supportive care are the fundamentals of therapy. The management of acute respiratory distress syndrome frequently requires endotracheal intubation and mechanical ventilation. A low tidal volume and low plateau pressure ventilator strategy is recommended to avoid ventilator-induced injury. Timely correction of the inciting clinical condition is essential for preventing further injury. Various medications directed at key stages of the pathophysiology have not been as clinically efficacious as the preceding experimental trials indicated. Complications such as pneumothorax, effusions, and focal pneumonia should be identified and promptly treated. In refractory cases, advanced ventilator and novel techniques should be considered, preferably in the setting of clinical trials. During the past decade, mortality has declined from more than 50 percent to about 32 to 45 percent. Death usually results from multisystem organ failure rather than respiratory failure alone.

Humans↗

PubMed2006

Mechanical ventilation and acute respiratory distress syndrome.

Acute respiratory distress syndrome continues to be a high-mortality condition. The role of mechanical ventilation remains primarily a supportive modality. Recent research has elucidated the adverse impact of traditional ventilation strategies on development of the disease and, ultimately, mortality. The institution of low tidal volume ventilation has been the only intervention that has resulted in definitive improvement in survival. Animal and human investigations that culminated in the Acute Respiratory Distress Syndrome Network low tidal volume study are reviewed. Current controversies in the application of mechanical ventilation including the use of positive end-expiratory pressure, recruitment maneuvers, and high frequency oscillatory ventilation are also addressed.

Animals↗

PubMed1987

Surfactant in adult respiratory distress syndrome.

Adult Respiratory Distress Syndrome is a catastrophic disease which is characterized by tachypnoea, arterial hypoxemia, reduced pulmonary compliance, and diffuse alveolar infiltrates. The pathology is that of diffuse alveolar damage which includes injury to both endothelial cells and type I epithelial cells. The major physiological abnormality is reduced pulmonary compliance. The available data indicate that one of the causes for the reduced compliance is altered surface tension in the distal airspaces. Pulmonary surface material isolated from patients with Adult Respiratory Distress Syndrome has an altered phospholipid composition. Part of the current therapy is to overcome the reduced compliance by mechanical ventilation while allowing the lung time to heal. In the future, exogenous surfactant may also be used as part of the therapy in selected severely ill patients.

Detergents↗

PubMed1986

[The adult respiratory distress syndrome].

Adult respiratory distress syndrome may be caused by a large number of injurious agents. In the pathogenesis the damage to endothelial cells and membranous pneumocytes is most important. While the etiology is diverse, the pathology may be rather uniform, beginning from acute "exudative" stage, characterized by protein-rich interstitial and alveolar edema, and progressing to a subacute "proliferative" stage, ending in interstitial, and sometimes intraalveolar fibroplasia, together with alveolar cell hyperplasia. But secondary lesions and complications make the proper diagnosis based on morphological criteria quite difficult. A retrospective study of 20 autopsies of patients who died from adult respiratory distress syndrome after various causes is dealt with. Some difficulties with diagnostic criteria based on morphologic features alone are discussed, and the necessity of clinical and pathological correlations is emphasized.

Adult↗

PubMed2002

Prone positioning in patients with acute respiratory distress syndrome.

Acute respiratory distress syndrome (ARDS) is a severe form of respiratory failure that is characterized by marked hypoxemia, bilateral infiltrates on chest radiograph, and no clinical evidence of left ventricular failure. Mechanical ventilation with positive end-expiratory pressure (PEEP) is a cornerstone therapy for ARDS patients. Because the fundamental aim of supportive treatment is to improve arterial oxygenation, several alternatives to mechanical ventilation with PEEP have been used. One of these alternative therapies is prone positioning, which has been used safely to improve oxygenation in many patients with ARDS. Despite encouraging results, however, the use of prone positioning is not widely accepted as an adjunct to therapy in hypoxemic patients because, aside from temporarily improving gas exchange, it does not seem to affect the outcome of these patients. This article reviews the rationale for using prone positioning in ARDS patients who require intubation and mechanical ventilation.

Animals↗

PubMed2000

Pathophysiology and implications for treatment of acute respiratory distress syndrome.

Acute respiratory distress syndrome is a complex group of signs and symptoms caused by direct or indirect lung injury. In spite of decades of research, it is still associated with a high mortality rate. Pathogenesis of this disease is related to alveolar endothelial and epithelial cell injury and associated release and sequestration of inflammatory mediators and cells, including cytokines and neutrophils, respectively. Pharmacologic interventions have been largely unsuccessful, and ventilation strategies to support oxygenation while limiting ventilator associated lung injury have not demonstrated any significant reductions in the mortality rate. However, novel therapies are in development, based on the knowledge of the pathologic processes of acute respiratory distress syndrome. In this article an overview of the disease process and mediator involvement is presented, followed by a review of pharmacologic and ventilation treatments currently in use or under study.

Acute Disease↗

PubMed1993

Rapid improvement of static compliance after surfactant treatment in preterm infants with respiratory distress syndrome.

Respiratory mechanics were measured in 20 preterm infants before and in the 24-hr period after treatment with surfactant. All infants were enrolled in the rescue clinical trial with Curosurf carried out in the Neonatal Intensive Care Unit. They received a dose of 200 mg/kg lipid surfactant intratracheally after birth. Static compliance of the respiratory system (Crs) was measured by the single breath occlusion technique during both spontaneous and mechanical ventilation. Resistance of the respiratory system (Rrs) and expiratory time constant (Trs) were also measured. As early as 3 hr after surfactant administration a significant improvement of 45% in Crs measured during mechanical ventilation (CrsV) was noted (0.40 +/- 0.14 vs 0.58 +/- 0.17 mL/cm H2O/kg, P < 0.001), together with a significant improvement of the arterial/alveolar O2 tension ratio (Pa/AO2) (0.12 +/- 0.03 vs 0.30 +/- 0.16, P < 0.01). The improvement of CrsV and Pa/AO2 was confirmed 24 hr later (0.55 +/- 0.15 mL/cm H2O/kg and 0.33 +/- 0.18, respectively). A significant correlation was found between Crs and Pa/AO2 ratio (r = 0.56, P < 0.001). Time constant values were significantly higher after surfactant treatment (0.15 +/- 0.07 vs 0.09 +/- 0.03 sec; P < 0.01). Rrs remained unchanged. These data indicate that Curosurf given intratracheally after birth determines a rapid improvement of respiratory mechanics as soon as 3 hr after dosing, together with the improvement of oxygenation. From the findings obtained with the present study we show evidence that respiratory system mechanics may be a useful physiological measure to guide ventilatory strategy following surfactant therapy.

Airway Resistance↗

PubMedDate not supplied

Causes and treatment of neonatal respiratory distress syndrome.

Neonatal respiratory distress syndrome is a condition of advancing respiratory distress, commencing at or shortly after birth. The disease follows an acute course, with deterioration within 48 hours followed by stabilisation and improvement. Treatment is to support respiratory function and maintain good oxygenation.

Algorithms↗

PubMed2003

[Acute respiratory distress syndrome].

Acute respiratory distress syndrome (ARDS) is a non cardiogenic pulmonary edema that results from several pulmonary or extrapulmonary insults. ARDS respiratory manifestations, in fact, represent the expression of a complex and diffuse inflammatory process involving other organs. Mechanical ventilation is considered to be a cornerstone of treatment. Alterations in respiratory mechanic (decrease in compliance) mainly due to the reduction in non-atelectasis lung volume, are responsible for the high airway pressure observed during mechanical ventilation. Since mechanical ventilation, itself, could promote lung injury, a ventilatory strategy combining both, low volumes to limit distension and positive end expiratory pressure to recruit atelectasis may be beneficial. This hypothesis has been recently confirmed in a study involving more than 800 patients, demonstrating that a simple ventilatory strategy based on recent physiological knowledge may affect ARDS outcome.

Adult↗