ACUTE RESPIRATORY
DISTRESS SYNDROMES:
NEWBORN +ADULT
Definition:
Respiratory failure occuring within 1 week of a known
clinical insult with bilateral opacities on chest imaging, not
fully explained by effusions, atelectasis, cardiac failure, or
fluid overload.
It is graded based on the severity of the changes in arterial
blood oxygenation.
It is a disease of prematurity in newborn
Characterized by deficiency of pulmonary surfactant
(produced by Type II pneumocytes)
Risk factors
◦ Premature birth
<28 wks – 60% incidence
>37 wks - <5% incidence
◦ Excessive sedation of the mother,
◦ Fetal head injury during delivery,
◦ Aspiration of blood or amniotic fluid,
◦ Intrauterine hypoxia
◦ Maternal diabetes
◦ Twin gestation
◦ Male baby > female baby
Deficiency of Surfactant → alveoli tend to collapse →
more inspiratory effort required → baby rapidly tires from
breathing → generalized atelectasis sets in → Hypoxemia
and acidosis → Pulmonary vasoconstriction → This leads
to damage
◦ to endothelium → leakage of plasma protein
◦ to epithelium → necrosed epithelial cells
Hyaline membrane formed
Deficiency of Surfactant
Alveoli Collapse
Atelectasis
Hypoxemia and Acidosis
Pulmonary Vasoconstriction
Damage to Damage to
Epithelium Endothelium
Necrosed epithelial cells Leakage of plasma protein
HYALINE MEMBRANE FORMED
GROSS
• Normal size but are heavy and airless
• Mottled purple color
MICROSCOPICALLY
• Alternative atelectatic and dilated alveoli.
• Characteristic eosinophilic hyaline membranes
– Necrotic epithelial cells admixed with extravasated plasma proteins
– Lining the respiratory bronchioles, alveolar ducts and alveoli
• Congestion and hemorrhage
• Inflammation is minimal
HMD
Often normal at birth
Severe respiratory distress develops within a few hours
Tachypnea, Hypoxemia, Cyanosis, Acidosis
Prevention
◦ Amniotic fluid L/S ratio >2 = fetal maturity
◦ Corticosteroid for lung maturity
◦ Delay birth till lung maturity
Treatment
◦ Surfactant replacement and 100% O2
Prognosis
◦ Overall – good after prompt treatment
Acute Respiratory Distress
Syndrome
(ARDS )
Synonym –
◦ Diffuse alveolar damage,
◦ Shock lung syndrome,
◦ Acute alveolar injury
Definition –
It is a clinical syndrome characterized by
–Diffuse damage of alveolar epithelium or capillaries or
both
–Clinically resulting in acute progressive respiratory
failure that is often unresponsive to O2 treatment
Pulmonary infections
Shock due to
◦ Sepsis by Gm negative bacteria
◦ Severe Trauma
◦ Burn
Aspiration of gastric contents
DIC
Radiation injury
Oxygen toxicity
Inhalation of toxic gas
Drugs – e.g., narcotics
Injury → Macrophage activated:
◦ Release IL8, IL1 , TNF
◦ Neutrophils come from capillaries to alveoli
(chemotaxis)
◦ Damage and activation of capillary endothelium
◦ Activation of Neutrophils
Activated Neutrophils (main role in tissue injury) release:
◦ Protease , Leukotriene, O2 radicals, PAF
◦ Damage to the alveolar epithelium and maintain the
inflammation
Some role of inactivation of anti-inflammatory mediators
In one word - pathogenesis is based on
imbalance between pro-inflammatory and anti-
inflammatory mediators
As a result ,
◦ Increased capillary permeability
◦ Pulmonary edema
◦ Damage to Type I and II pneumocytes
◦ Loss of surfactant
◦ Alveoli unable to expand – “collapse”
If patient survives
◦ Attempts at regeneration by proliferation of Type II
cells
◦ Fibrosis – intra-alveolar & inter-alveolar ( interstitial )
NORMAL ALVEOLUS ACUTE LUNG INJURY
GROSS
• Heavy, Airless, Firm, Noncompliant
• Dark red due to congestion
• At autopsy – lung sinks in water
MICRO
• Inter-Alveoli and Intra-Alveoli -
–Edema, Inflammation, Congestion, H’ge, Necrosis
• HYALINE MEMBRANE formation – characteristic
–Lining the distended alveolar duct
–fibrin-rich edema fluid + necrotic epithelial cells
• Later in the course – fibrosis
10X
40X
Acute onset of dyspnea
Hypoxemia
Cyanosis
Tachypnea
Pulmonary edema (without left heart failure)
Chest X-ray - bilateral pulmonary infiltrates
Prognosis – grim – more than 50% - death
Treatment by
◦ PEEP ( positive end expiratory pressure) and ventilation support
◦ Initiating cause – e.g. sepsis - should be treated
