ACUTE RESPIRATORY DISTRESS SYNDROME by Nick Mark MD ONE onepagericu.

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ETIOLOGY: THE EIGHT P’S FOR ARDS TREATMENT:
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An acute and life-threatening inflammatory pulmonary Mild Moderate Severe
reaction to systemic insult or injury. Causes: Protective ventilation & Peeing
• Pneumonia (bacterial or viral)
Paralysis & Proning & Prednisone
• Non-pulmonary sepsis
• Major trauma (esp. if ≥3 long bone fractures) Prostacyclin & ECMO
• Aspiration of gastric contents PEEP / LUNG PROTECTIVE VENTILATION (LPV) Use low TV to stay
• Pulmonary contusion Mxn: High PEEP low tidal volume ventilator strategy avoids VILI by limiting volumes & pressure, below UIP
• Pancreatitis and keeping alveoli open w/ PEEP. Reduces mortality.
• Inhalational injury Approach:
• Severe burns

Volume
• Set RR to maintain MV; adjusting rate up to 35 to maintain goal pH > 7.3
• (Non-cardiogenic) shock

PEEP
• Initial Tidal Volume (TV) = 6 cc/kg PBW; Measure Plateau Pressure (Pplat) every 4 hours and
• Drug overdose adjust TV for goal Pplat < 30 cmH2O, decreasing TV down to 4 cc/kg PBW if Pplat elevated; if pH
• Transfusion related (TRALI) is <7.2, may need to increase TV and Pplat may need to be higher than 30 cmH2O. Use PEEP to stay
• Pulmonary vasculitis CXR showing severe ARDS • Adjust PEEP and FiO2 for goal SpO2 > 90% or PaO2 > 55 mmHg; use either a LOW or HIGH above LIP
• near-Drowning due to COVID-19 PEEP “ladder” to protocolize PEEP/FiO2 titration Pressure
DEFINITION: (requires all 4) PARALYSIS (e.g. NEUROMUSCULAR BLOCKADE) PRONE POSITIONING
• Timing - within one week of known insult Mxn: Improves ventilator compliance; decreases oxygen Mxn: By moving from a supine to prone position, we can
• Imaging - bilateral opacities not explained by consumption; most effective if initiated early reduce dependent edema, increases lung volumes (from
another process Approach: reduced atelectasis), and improve secretion clearance
• Origin of Edema - respiratory failure not explained • Sedate deeply (e.g. RASS -4) Approach: follow a checklist
entirely by volume overload or CHF • Use infusion of cisatracurium or vecuronium to achieve • Apply soft pads, secure all tubes/lines, place pillows on
• Impaired Oxygenation PaO2/FiO2 (P/F) ratio < 300 and maintain neuromuscular blockade (NMB) chest and wrap with sheets (e.g. burrito technique)
• Repeat clinical assessments including train of four • Using a team (ideally 6 or more people) rotate the patient
SEVERITY of ARDS is determined by P/F ratio stimulation to avoid excess NMB. Wean dose as tolerated as a unit; supinate once per day for 4-6 hrs
• Mild (200-300)
• Moderate (100-200) INHALED PROSTACYCLIN/iNO PLEURAL EVACUATION PEEING (e.g. DIURESIS)
• Severe (<100) Mxn: Dilates blood vessels in areas of (THORACENTESIS) Mxn: reduce extravascular water in lungs by
the lungs that are well ventilated, Mxn: Improves oxygenation by minimizing Ins & maximizing outs. (dry lungs
PATHOPHYSIOLOGY: ARDS lungs develop reduced compliance; improves V/Q matching. reducing collapsed lung due to are happy lungs) Approach:
making ventilation difficult. Mechanical ventilator can cause Approach: effusions. • Use a conservative fluid strategy if
Normal further damage; Ventilator • Start inhaled EPO at high dose and Approach: possible (e.g. concentrate IV meds, use PO
Induced Lung Injury (VILI) causes: wean as tolerated. If patients respond, • Look for large pleural effusions electrolyte repletion, and avoid blood
Volume

• Barotrauma ! too much they generally have >20% increase in using POCUS; if present consider product transfusions unless essential.)
ARDS
pressure PaO2 within 10 min. drainage using thoracentesis. • Begin diuresis as hemodynamics permit.
• Volutrauma ! too much volume
• Atelectrauma ! repetitive PERIPHERAL OXYGENATION (ECMO) PREDNISONE (e.g. CORTICOSTEROIDS)
cycles of alveoli recruiting/de- Mxn: directly oxygenate blood, remove carbon dioxide, and Mxn: the anti-inflammatory & immunomodulatory effects
Pressure
recruiting provide mechanical circulatory support (VA ECMO only). It of glucocorticoids may mitigate the early exudative phase
should be used for selected patients who have the highest of ARDS. Approach:
Consider conditions that can mimic ARDS
probability of benefit; consider using a scoring system to Start early in ARDS (e.g. within 14 days)
• Acute Eosinophilic pneumonia (AEP) - idiopathic, drugs
assess the potential risk/benefit: RESPscore (VV ECMO) or • Methylprednisone 1 mg/kg for 21 days then taper or

v1.1 2020-10-01
• Acute Interstitial pneumonia (AIP) – idiopathic, CVD, drugs SAVEscore (VA ECMO) • Dexamethasone 20 mg daily for 10 days then 10mg
• Organizing Pneumonia (BOOP) – CVD, drugs, radiation, infxn Approach daily for 5 days.
• Diffuse Alveolar Hemorrhage (DAH) – vasculitis, ABMA, CVD • ECMO should be performed by experienced providers; There is evidence for lower doses in COVID19 (e.g. 6 mg
consider transfer if local experience/resources are insufficient Dexamethasone IV or PO daily)