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Respiratory Distress Syndrome, Acute (ARDS)

para>Supportive care while identifying the underlying cause of ARDS continues to be important in the management of pregnant women with ARDS. However, fetal well-being, possible need for delivery, and physiologic changes associated with pregnancy must be considered. пїЅ пїЅ

INPATIENT CONSIDERATIONS

Admission Criteria/Initial Stabilization

All patients with ARDS should be managed in an ICU setting. пїЅ пїЅ

  • Consider prone positioning.
  • Identify and treat underlying condition.
  • Circulatory support, adequate fluid volume, and nutritional support
  • Supplemental oxygen
  • Monitoring blood gases, pulse oximetry, bedside pulmonary function test
  • Support ventilation using lung-protective strategies and PEEP.
  • Monitor for systemic hypotension and hypovolemia without fluid overload.
  • BP support, if necessary
  • Vasopressor agents
  • Fluid management with IV crystalloid solutions while monitoring pulmonary status
  • Pulmonary catheter pressure monitoring
  • Treat underlying disease process.
  • Prevent complications.

IV Fluids

  • Maintain the intravascular volume at the lowest level consistent with adequate perfusion (assessed by metabolic acid " пїЅbase balance and renal function).
  • If perfusion is inadequate after restoration of intravascular volume (e.g., septic shock), vasopressor therapy is indicated.
  • Increase oxygen content with packed erythrocyte transfusions as necessary.
  • Provide appropriate nutritional support with enteral or parenteral nutrition.
  • Steroid therapy

Nursing

May include any or all of the following: пїЅ пїЅ

  • Skin, eye, and mouth care
  • DVT prophylaxis
  • GI prophylaxis
  • Suctioning
  • Ensure adequate level of sedation and/or paralysis while on mechanical ventilation.
  • Oxygen supplementation
  • Nebulizer therapy
  • Chest physiotherapy
  • Tracheostomy care
  • Explain all procedures to patient and family; reduce anxiety.

Discharge Criteria

  • Supplemental oxygen
  • Nutrition counseling
  • Family monitoring of signs and symptoms of respiratory distress

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Patient Monitoring

  • Vital capacity and static lung compliance are important measures of lung mechanics.
  • Daily labs are needed until the patient is no longer critical.
  • CXRs to assess endotracheal tube placement, the presence of progressing infiltrates, catheter placement, and complications of mechanical ventilation (e.g., air leaks)
  • A Swan-Ganz catheter to assess oxygen delivery, oxygen consumption, and cardiac output may be helpful but has not been shown to improve survival.

DIET

  • Nutritional support
  • Conservative fluid management shortens ventilator and ICU time but does not affect survival.

PATIENT EDUCATION

ARDS support center and brochure titled "Learn About ARDS " пїЅ: www.ards.org пїЅ пїЅ

PROGNOSIS

  • Mortality rate is 43% (10).
  • Survivors may have pulmonary sequelae with mild abnormalities in oxygenation, diffusion, and lung mechanics, as well as some pulmonary symptoms of cough and dyspnea.
  • The prognosis worsens with elevated cardiac troponin-T levels in ARDS patients (11).

COMPLICATIONS

  • Permanent lung disease
  • Oxygen toxicity
  • Barotrauma
  • Superinfection
  • Multiple organ dysfunction syndrome
  • Death

REFERENCES

11 Ranieri пїЅ пїЅVM, Rubenfeld пїЅ пїЅGD, Thompson пїЅ пїЅBT, et al. Acute respiratory distress syndrome: the Berlin definition. JAMA. 2012;307(23):2526 " пїЅ2533.22 Riviello пїЅ пїЅED, Kiviri пїЅ пїЅW, Twagirumugabe пїЅ пїЅT, et al. Hospital incidence and outcomes of ARDS using the Kigali modification of the Berlin definition [published online ahead of print September 9, 2015]. Am J Respir Crit Care Med.33 Petrucci пїЅ пїЅN, Iacovelli пїЅ пїЅW. Ventilation with lower tidal volumes versus traditional tidal volumes in adults for acute lung injury and acute respiratory distress syndrome. Cochrane Database Syst Rev. 2004;(2):CD003844.44 Gu пїЅ пїЅXL, Wu пїЅ пїЅGN, Yao пїЅ пїЅYW, et al. Is high-frequency oscillatory ventilation more effective and safer than conventional protective ventilation in adult acute respiratory distress syndrome patients? A meta-analysis of randomized controlled trials. Crit Care. 2014;18(3):R111.55 Meduri пїЅ пїЅGU, Bridges пїЅ пїЅL, Shih пїЅ пїЅMC, et al. Prolonged glucocorticoid treatment is associated with improved ARDS outcomes: analysis of individual patients ' data from four randomized trials and trial-level meta-analysis of the updated literature [published online ahead of print October 27, 2015]. Intensive Care Med.66 Afshari пїЅ пїЅA, Brok пїЅ пїЅJ, M пїЅ пїЅller пїЅ пїЅAM, et al. Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) and acute lung injury in children and adults. Cochrane Database Syst Rev. 2010;(7):CD002787.77 Afshari пїЅ пїЅA, Brok пїЅ пїЅJ, M пїЅ пїЅller пїЅ пїЅAM, et al. Aerosolized prostacyclin for acute lung injury (ALI) and acute respiratory distress syndrome (ARDS). Cochrane Database Syst Rev. 2010;(8):CD007733.88 Duggal пїЅ пїЅA, Ganapathy пїЅ пїЅA, Ratnapalan пїЅ пїЅM, et al. Pharmacological treatments for acute respiratory distress syndrome: systematic review. Minerva Anestesiol. 2015;81(5):567 " пїЅ588.99 Lyu пїЅ пїЅG, Wang пїЅ пїЅX, Jiang пїЅ пїЅW, et al. Clinical study of early use of neuromuscular blocking agents in patients with severe sepsis and acute respiratory distress syndrome [in Chinese]. Zhonghua Wei Zhong Bing Ji Jiu Yi Xue. 2014;26(5):325 " пїЅ329.1010 Zambon пїЅ пїЅM, Vincent пїЅ пїЅJL. Mortality rates for patients with acute lung injury/ARDS have decreased over time. Chest. 2008;133(5):1120 " пїЅ1127.1111 Rivara пїЅ пїЅMB, Bajwa пїЅ пїЅEK, Januzzi пїЅ пїЅJL, et al. Prognostic significance of elevated cardiac troponin-T levels in acute respiratory distress syndrome patients. PLoS One. 2012;7(7):e40515.

ADDITIONAL READING

  • Cole пїЅ пїЅDE, Taylor пїЅ пїЅTL, McCullough пїЅ пїЅDM, et al. Acute respiratory distress syndrome in pregnancy. Crit Care Med. 2005;33(10)(Suppl):S269 " пїЅS278.
  • Wheeler пїЅ пїЅAP, Bernard пїЅ пїЅGR. Acute lung injury and the acute respiratory distress syndrome: a clinical review. Lancet. 2007;369(9572):1553 " пїЅ1564.

CODES

ICD10

J80 Acute respiratory distress syndrome пїЅ пїЅ

ICD9

518.52 Other pulmonary insufficiency, not elsewhere classified, following trauma and surgery пїЅ пїЅ

SNOMED

67782005 Adult respiratory distress syndrome (disorder) пїЅ пїЅ

CLINICAL PEARLS

  • ARDS is a syndrome characterized by an abrupt onset of diffuse lung injury with severe hypoxemia and bilateral pulmonary infiltrates.
  • Treatment of ARDS requires aggressive supportive care in an ICU setting while also addressing the underlying cause.
  • The benefit of invasive monitoring of vital signs, cardiac output, and PAWP has been questioned by large clinical trials.