ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) .BY DR.Mohammad Abdeljawad

ACUTE RESPIRATORY DISTRESS
SYNDROME
Done by: Mohammad Abdeljawad
12/3/2022
1

Acute respiratory distress syndrome (ARDS) It is a clinical syndrome
characterized by an acute, diffuse, inflammatory form of lung injury resulting
from diffuse injury to the alveolo-capillary membranes. , (characterized by
increased pulmonary vascular permeability, and loss of aerated tissue, increased work of
breathing and impaired gas exchange.)
Definition
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Ranieri VM, Rubenfeld GD, Thompson BT, et al; ARDS Definition Task Force. Acute respiratory distress syndrome: the Berlin
Definition. JAMA. 2012;307(23):2526-2533

First described by Ashbaugh in 1967, the syndrome was initially termed
the adult respiratory distress syndrome,
to distinguish it from the respiratory distress syndrome of neonates.
However, with the recognition that ARDS can occur in children, the
term acute has replaced adult in the nomenclature in recognition of
the typical acute onset that defines the syndrome
Ashbaugh DG, Bigelow DB, Petty TL, Levine BE. Acute respiratory distress in adults. Lancet 1967;2:319-23.
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Approximately 10 to 15 percent of patients admitted to intensive care units
have ARDS. up to 23 percent of mechanically ventilated patients meet
criteria for ARDS .(1)
The incidence of ARDS rises with age, ranging from 16 per 100,000 person-years among
individuals 15 to 19 years of age to 306 per 100,000 person-years among individuals 75 to 84 years
of age. (2)
(1)- Bellani G, Laffey JG, Pham T, et al. Epidemiology, Patterns of Care, and Mortality for Patients With Acute Respiratory Distress
Syndrome in Intensive Care Units in 50 Countries. JAMA 2016; 315:788.
(2)- Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence and outcomes of acute lung injury. N Engl J Med 2005;
353:1685.
EPIDEMIOLOGY

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However, the incidence of ARDS appears to be decreasing likely due to
improvements in health care such as use of protective ventilation strategies,
reduced transfusion-related acute lung injury ALI (TRALI) and better management of
sepsis and advances in post trauma critical care (1)
1. Guangxi L, Malinchoc M, Cartin-Ceba R, et al. Eight year trend of acute respiratory distress syndrome: a population-based study in Olmsted County, Minnesota. Am J Respir
Crit Care Med. 2011; 183:59–66.
Several studies suggest a decline in the incidence of ARDS over time. For example, a large prospective cohort of
trauma patients at risk for ARDS and multisystem organ failure collected from 1997 to 2004 showed that the incidence
of ARDS decreased from 43% in 1997 to 12% in 2004, a finding that may reflect advances in post trauma critical care
(2)
2. Ciesla DJ, Moore EE, Johnson JL, Cothren CC, Banerjee A, Burch JM, et al. Decreased progression of postinjury lung dysfunction to the acute respiratory distress
syndrome and multiple organ failure. Surgery 2006;14:640-7; discussion 7-8

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For many years the mortality for ARDS was reported to be ~60%.
Bellani G, Laffey JG, Pham T, et al. Epidemiology, patterns of care, and mortality for patients with acute respiratory
distress syndrome in intensive care units in 50 countries. JAMA. 2016;315: 788–800
data from 459 ICUs from 50 countries reports hospital mortality as 34.9% for those with mild, 40.3% for
moderate, and 46.1% for severe ARDS.
Mortality

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ETIOLOGIES AND PREDISPOSING
FACTORS

Clinical Risks for Development of the Acute
Respiratory Distress Syndrome
LEONARD D. HUDSON, JOHN A. MILBERG, DOREEN ANARDI, and RICHARD J. MAUNDER
Division of Pulmonary and Critical Care Medicine, Harborview Medical Center; and Department of Medicine, University of
Washington School of Medicine, Seattle, Washington
695 patients admitted to intensive
care units.
ARDS occurred in 179 of the 695
patients (26%). The highest incidence
of ARDS occurred in patients with
sepsis syndrome (75 of 176; 43%)
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Sepsis is the most common cause of ARDS. It should be the first etiology
considered whenever ARDS develops in a patient who is predisposed to
serious infection or in association with a new fever or hypotension.(1).(2)
with an overall risk of progression to ARDS of approximately 30% to 40% among patients
with severe sepsis requiring intensive care unit (ICU) admission (3)
(1) Hudson LD, Milberg JA, Anardi D, Maunder RJ. Clinical risks for development of the acute respiratory distress syndrome. Am J Respir Crit Care
Med 1995; 151:293
(2) Fowler AA, Hamman RF, Good JT, et al. Adult respiratory distress syndrome: risk with common predispositions. Ann Intern Med 1983; 98:593.
(3) Pepe PE, Potkin RT, Reus DH, Hudson LD, Carrico CJ. Clinical predictors of the adult respiratory distress syndrome. Amer J Surg
1982;144:124-30.

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In addition to sepsis itself being a risk factor for ARDS
development, the site of infection may also influence the risk of lung
injury. In patients admitted to an ICU with sepsis, patients who had
pneumonia as the source of sepsis had an increased risk of ARDS
compared to those with infections at other sites (abdomen, skin, soft
tissue, etc.)
Sheu CC, Gong MN, Zhai R, Bajwa EK, Chen F, Thompson BT, et al. The influence of infection sites
on development and mortality of ARDS. Intensive Care Med 2010;36:963-70

The influence of infection sites on development and mortality of
ARDS
Chau-Chyun Sheu, Michelle N. Gong, Rihong Zhai, Ednan K. Bajwa, Feng ChenB. Taylor Thompson,.
Study population included 1,973 consecutive patients admitted to ICUs with
bacteremia, pneumonia or sepsis. During follow-up, 549 patients developed
ARDS and 212 of them died within 60 days
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The distribution of infection sites in ARDS patients was: lung (77.2%), abdomen
(19.3%), skin/soft tissues (6.0%), urinary tract (4.7%), unknown (2.6%), and
multiple sites (17.7%).
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No association was found between individual infection site and ARDS mortality

Conclusions—In critically ill infected patients, pulmonary infection is
associated with higher risk of ARDS development than are infections at
other sites. Pulmonary versus non pulmonary
infection significantly affects ARDS development but not mortality
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Secondary factors may also increase the risk.
Such factors include chronic lung disease, chronic or acute alcohol abuse,
cigarette smoking, increasing age, transfusion of blood products,
lung resection, and obesity
By contrast, several studies have shown that patients with diabetes are less likely to
develop ARDS
Frank JA, Nuckton TJ, Matthay MA. Diabetes mellitus: a negative predictor for the development of acute respiratory distress syndrome from septic shock. Crit Care Med
2000;28:2645-6
Moss M, Guidot DM, Steinberg KP, Duhon GF, Treece P, Wolken R, et al. Diabetic patients have a decreased incidence of acute respiratory distress syndrome. Crit Care Med
2000;28:2187-92.

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Role of Diabetes in the Development of Acute
Shun Yu, BS1; David C. Christiani, MD, MPH2,3; B. Taylor Thompson, MD2; Ednan K. Bajwa, MD, MPH2; Michelle
Ng Gong, MD, MS1,4
Conclusions: Diabetes is
associated with a lower rate of
acute respiratory distress
syndrome development
(but not with mortality among patients
with ARDS.)

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DIAGNOSIS
Clinical Criteria
Several clinical definitions have been used for diagnosis of ARDS since
it was first described in 1967. Before 1994, a variety of definitions were
used, including the Murray Lung Injury Score
Murray JF, Matthay MA, Luce JM, Flick MR. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis
1988;138:720-3.

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In 1994, the American European Consensus Conference (AECC) published new
clinical definitions for acute lung injury (ALI) and ARDS.
Bernard GR, Artigas A, Brigham KL, Carlet J, Falke K, Hudson L, et al. The American-European Consensus Conference on ARDS. Definitions,
mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994;149:818-24.

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These definitions were recently modified, and the modified version,
referred to as the Berlin definition.
Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson ND, Caldwell E, Fan E, et al. Acute respiratory distress syndrome: the Berlin
definition. JAMA 2012;307:2526-33

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.
First, the new definition dispenses with the term acute lung injury (ALI) and
only uses ARDS, which is now characterized as either mild, moderate or
severe based on the degree of hypoxemia.
It differs from the AECC definition in a few important ways

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Second, it specifies that the onset of ARDS, including bilateral infiltrates on
chest radiograph, occurs within 1 week of a known precipitant.

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To meet the definition, patients must be receiving ≥5 cm H2O of
continuous positive airway pressure; for mild ARDS, this airway pressure
can be delivered by noninvasive positive pressure ventilation.

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Severity is classified based on the degree of hypoxemia as mild,
moderate, or severe

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In all patients with suspected ARDS, an underlying cause of acute
lung injury should be sought
.In the absence of an identifiable underlying cause, particular attention should be
given to the possibility of other causes of pulmonary infiltrates and hypoxemia
such as hydrostatic (cardiogenic) pulmonary edema

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the Berlin definition recognizes that elevated vascular filling pressures
and ARDS can coexist; there is no absolute requirement in the Berlin
definition to rule out a cardiac cause of pulmonary edema unless a
patient’s respiratory failure cannot be explained fully by an ARDS risk
factor
In these instances, objective cardiac testing such as echocardiography or pulmonary
artery catheterization can be used.
Finally

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One potential limitation of the Berlin definition is the need for
arterial blood gas sampling to calculate a Pao2/Fio2 ratio

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Recent work has shown good correlation between the Spo2/Fio2
ratio (measured by pulse oximetry) and the Pao2/Fio2 ratio
Pandharipande PP, Shintani AK, Hagerman HE, St Jacques PJ, Rice TW, Sanders NW, et al. Derivation and validation of Spo2/Fio2 ratio to impute for Pao2/Fio2 ratio
in the respiratory component of the Sequential Organ Failure Assessment score. Crit Care Med 2009;37:1317-21.
Rice TW, Wheeler AP, Bernard GR, Hayden DL, Schoenfeld DA, Ware LB. Comparison of the SpO2/ FiO2 ratio and the PaO2/FiO2 ratio in patients with acute
lung injury or acute respiratory distress syndrome. Chest 2007;132:410-7
with an Spo2/Fio2 ratio of 235 corresponding to a Pao2/Fio2 ratio of 200 and an Spo2/Fio2 ratio
of 315 correlating to a Pao2/Fio2 ratio of 300.
These correlations are valid only when the Spo2 is less than 98% because the oxyhemoglobin dissociation
curve is flat above this level.

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Clinical Characteristics and Outcomes Are Similar in ARDS
Diagnosed by Oxygen Saturation/F io 2 Ratio Compared With
Pa o2 /F io2 Ratio
Wei Chen , MD ; David R. Janz , MD , MSCI ; Ciara M. Shaver , MD , PhD ; Gordon R. Bernard , MD ; Julie A. Bastarache , MD ; and Lorraine B.
Ware , MD

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CONCLUSIONS: Patients with ARDS diagnosed by SF ratio have very
similar clinical characteristics and outcomes compared with patients
diagnosed by PF ratio. These findings suggest that SF ratio could be
considered as a diagnostic tool for early enrollment into clinical trials

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Although the standardization of ARDS definitions has been of
enormous value for both clinical diagnosis and clinical research, the nature of ARDS is such that any definition will have
shortcomings.
First, the Berlin definition is based solely on clinical criteria because
currently there is no laboratory test that allows clinical assessment of
the presence or absence of ARDS.
Second, the presence or absence of multiorgan dysfunction, an important
determinant of outcome, is not specified.
Finally, although the presence of bilateral infiltrates has
major prognostic significance and is clearly a hallmark of the syndrome,
the radiographic findings are not specific for ARDS.
Rubenfeld GD, Caldwell E, Granton J, Hudson LD, Matthay MA. Interobserver variability in applying a radiographic definition for ARDS. Chest 1999;116:1347-53

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de Hemptinne Q, Remmelink M, Brimioulle S, et al. ARDS: A clinicopathological confrontation. Chest 2009; 135:944–94
The information in this table is from an autopsy study of patients who died
with a premortem diagnosis of ARDS, and the postmortem diagnoses are
listed in the table along with the prevalence of each diagnosis.
376 patients met the ARDS criteria. Of these, 169 patients (45%)died, and a postmortem examination was performed in
69 of them (41%).

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For these reasons, diagnostic uncertainty in ARDS is common, is a
major barrier to initiation of appropriate therapy, and is one of the
main reasons why clinicians fail to initiate lung protective ventilation in
clinically appropriate patients.

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Differentiation between ARDS and hydrostatic edema can be difficult, and there may be significant overlap in these
syndromes

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Diagnosis
In the majority of patients, the initial diagnosis of ARDS is made
clinically. Invasive procedures for diagnosis of ARDS are of limited
clinical utility and the benefits often do not outweigh the risks
Invasive Methods

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Bronchoscopy
Bronchoscopy may be indicated in the early
phases of ARDS in patients for whom there is no identifiable
predisposing risk factor and in the immunosuppressed. history of TB
exposure. risk factors for fungus. alveolar hemorrhage.( Diffuse alveolar
hemorrage syndromes .)

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Bronchoalveolar Lavage
In normal subjects, neutrophils make up less than 5% of the cells
recovered in lung lavage fluid, whereas in patients with ARDS, as
many as 80% of the recovered cells are neutrophils
A low neutrophil count in lung lavage fluid can be used to exclude the diagnosis of ARDS, while a high
neutrophil count is evidence of ARDS.

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Because inflammatory exudates are rich in proteinaceous material,
lung lavage fluid that is rich in protein is used as evidence of ARDS.
When the protein concentration in lung lavage fluid is expressed as
a fraction of the protein concentration in plasma, the following criteria
can be applied
Hydrostatic Edema: Lavage fluid [protein] / plasma [protein] <0.5
ARDS: Lavage fluid [protein] / plasma [protein] > 0.7

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Chest sonography: a useful tool to differentiate acute cardiogenic
pulmonary edema from acute respiratory distress syndrome
Roberto Copetti*1, Gino Soldati2 and Paolo Copetti1
From January 2005 to April 2007, 18 among the patients consecutively admitted to the intensive care unit Conference diagnostic
criteria for the diagnosis of ALI/ARDS[2]. During the same period 40 patients were consecutively admitted with the diagnosis of
acute pulmonaryedema (APE)

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Ultrasound pleuropulmonary findings were considered with respect to the
presence of the following signs:
1) Alveolar-interstitial syndrome (AIS) defined as the presence of more than 3 ULCs
or "white lung" appearance for each examined area.
2) Pleural lines abnormalities defined as thickenings greater than 2 mm, evidence
of small subpleural consolidations or coarse appearance of the pleural line.
3) Areas with absent or reduced "sliding" sign with respect to adjacent or
controlateral zones at the same level on the opposite hemithorax.

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4) "Spared areas" defined as areas of normal lung pattern
in at least one intercostal space surrounded by areas of
AIS.
5) Consolidations defined as areas of hepatisation (tissue
pattern) with presence of air bronchograms
6) Pleural effusion defined as anechoic dependent collections
limited by the diaphragm and the pleura
7) "Lung pulse" defined as absence of lung sliding with the perception of
heart activity at the pleural line

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Development of a convolutional neural network to differentiate
among the etiology of similar appearing
pathological B lines on lung ultrasound: a deep learning study
Robert Arntfield ,1 Blake VanBerlo,2 Thamer Alaifan ,1 Nathan Phelps,3 Matthew White,1 Rushil Chaudhary,4 Jordan Ho,2 Derek Wu2

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The trained CNN performance on the independent
dataset showed an ability to discriminate between COVID
, NCOVID (AUC 0.934) and HPE

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Chest sonography has recently found an extensive use in
pleuropulmonary disorders in Emergency and ICU settings
Pleuroparenchimal patterns in ALI/ARDS accurately described
by CT scan do find a characterization even through ultrasonographic
lung scan. In critically ill patients ultrasound demonstration of a dyshomogeneous AIS with spared
areas, pleural line modifications and lung consolidations is strongly predictive, in an early phase, of
a non cardiogenic pulmonary edema.
Conclusion

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Treatment of Predisposing Factors
First and foremost, a search for the underlying cause of
ARDS should be undertaken
Appropriate treatment for any precipitating infection
such as pneumonia or sepsis is critical to enhance the chance of survival.

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In a patient with sepsis and ARDS of unknown source, an
intraabdominal process should be considered
Timely surgical management of intraabdominal sepsis is associated with
better outcomes.
. Anderson ID, Fearon KC, Grant IS. Laparotomy for abdominal sepsis in the critically ill. Br J Surg 1996;83:535-9.

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Fluid Management
avoiding a positive fluid balance will prevent unwanted fluid accumulation
in the lungs, which could aggravate the respiratory insufficiency in ARDS
Clinical studies have shown that avoiding a positive fluid balance in patients with ARDS can reduce
the time on mechanical ventilation , and can even reduce mortality .

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The Importance of Fluid Management in Acute Lung Injury Secondary to
Septic Shock
Claire V. Murphy, PharmD; Garrett E. Schramm, PharmD;
Joshua A. Doherty, BS; Richard M. Reichley, RPh; Ognjen Gajic, MD, FCCP; Bekele Afessa, MD, FCCP; Scott T. Micek, PharmD; and
Marin H. Kollef, MD, FCCP
The study cohort was
made up of 212 patients
with ALI complicating
septic shock
Adequate initial fluid resuscitation (AIFR) was defined
as the administration of an initial fluid bolus of > 20
mL/kg prior to and achievement of a central venous
pressure of > 8 mm Hg within 6 h after the onset of
therapy with vasopressors. Conservative late fluid
management (CLFM) was defined as even-
tonegative fluid balance measured on at least 2
consecutive days during the first 7 days afterseptic
shock onset

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Results: The study cohort was made up of 212 patients with ALI complicating septic shock.
Hospital mortality was statistically lowest for those achieving both AIFR and CLFM and
higher for those achieving only CLFM, those achieving only AIFR, and those achieving
neither (17 of 93 patients [18.3%] vs 13 of 31 patients [41.9%] vs 30 of 53 patients [56.6%] vs
27 of 35 [77.1%], respectively;
Conclusions:
Both early and late
fluid management of
septic shock
complicated by ALI
can influence patient
outcomes

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Comparison of Two Fluid-Management
Strategies in Acute Lung Injury
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome
(ARDS) Clinical Trials Network*
The new england journal o f medicine
Herbert P. Wiedemann, M.D., Cleveland Clinic, Cleveland; Arthur P. Wheeler, M.D., and Gordon R. Bernard, M.D., Vanderbilt University, Nashville; B. Taylor Thompson, M.D., and
Douglas Hayden, M.A., Massachusetts General Hospital, Boston; Ben deBoisblanc, M.D., Louisiana State University Health Sciences Center, New Orleans; Alfred F. Connors, Jr.,
In a randomized study, we compared conservative
and a liberal strategy of fluid management using
explicit protocols applied for seven days in 1000
patients withacute lung injury. The primary end point
was death at 60 days. Secondary end points included
the number of ventilator-free days and organ-failure–
free days and measures of lung physiology
The mean (±SE) cumulative fluid balance
during the first seven days was –136±491 ml in
the conservative-strategy group and
6992±502 ml in the liberal-strategy group

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The mean (±SE) cumulative fluid
balance during the first seven days
was –136±491 ml in the
conservative-strategy group and
6992±502 ml in the liberal-strategy
group

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Conclusions
Although there was no significant difference in the primary outcome of 60-daymortality, the conservative
strategy of fluid management improved lung function and shortened the duration of mechanical ventilation
and intensive care without increasing nonpulmonary-organ failures. These results support the use of a
conservative strategy of fluid management in patients with acute lung injury

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the recommended strategy is to aim to achieve the lowest intravascular
volume that maintains adequate tissue perfusion as measured by urine output,
other organ perfusion, and metabolic acid-base status using central venous
pressure monitoring to direct therapy

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Once shock has resolved, patients should be managed with a conservative
fluid strategy with the goal of driving the CVP < 4 to keep each patient’s fluid
balance net zero during the ICU stay.

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Sodium balance, not fluid balance, is associated with respiratory dysfunction in
mechanically ventilated patients: a prospective, multicentre study
Shailesh Bihari, Sandra L Peake, Shivesh Prakash, Manoj Saxena, Victoria Campbell and Andrew Bersten
The distribution of water between intracellular and extracellular compartments is strongly influenced by sodium concentration and its relative
restriction to the extracellular fluid space
The potential for excess sodium to exacerbate interstitial oedema in the systemic and pulmonary circulations,

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Fifty patients (33 men [66%]). By
Day 3 after enrolment, the median
cumulative fluid balance was
2668mL (IQR, 875–3507mL) and
the cumulative sodium balance
was +717mmol ..
A positive sodium balance was
associated with a reduction in the
next day’s PaO2/FiO2 ratio and
an increased length of MV
We included patients receiving invasive MV for less than 48 hours who were anticipated to be on MV for at least another
48 hours

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Large positive sodium balances, independent of fluid balance, may lead to
expanded extracellular fluid volumes and adverse clinical outcomes in
the critically ill, including impaired oxygenation

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sodium is the main contributor to extracellular tonicity and a driving
force for fluid shifts across the cellular membrane towards
the interstitium
Large positive sodium balances, independent of fluid balance, may lead to expanded extracellular fluid volumes and
adverse clinical outcomes in
the critically ill, including impaired oxygenation

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If organ perfusion cannot be maintained in the setting of adequate
intravascular volume, then administration of vasopressors and/or inotropes
should be used to restore end organ perfusion.
Matthay MA, Broaddus VC. Fluid and hemodynamic management in acute lung injury. Semin Respir Crit Care Med 1994;15:271-88
Available evidence does not support the use of one particular vasopressor or combination of
vasopressors

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Nutrition
Standard supportive care for the patient with ARDS includes the provision of adequate nutrition
The enteral route is preferred to the parenteral route and is associated with less infectious
complications.
a high-fat, low-carbohydrate diet reduced the duration of mechanical
ventilation in patients with acute respiratory failure
. al-Saady NM, Blackmore CM, Bennett ED. High fat, low carbohydrate, enteral feeding lowers PaCO2 and reduces the period of ventilation in artificially
ventilated patients. Intensive Care Med 1989;15:290-5.

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High fat, low carbohydrate, enteral feeding lowers PaC02 and reduces the
period of ventilation in artificially ventilated patients
N.M. A1-Saady 1, C.M. Blackmore 2 and E.D. Bennett t
I Department of Medicine and 2Department of Dietetics, St. George's Hospital Medical School, London, UK

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The percentage energy profiles of the two feeds were as follows:
Pulmocare: protein 16.7 (62.6g/1) fat 55.2 (92.1g/1), carbohydrate
28.1 (105.7 g/l);
Ensure Plus: protein 16.7 (62.6 g/l), fat 30 (50 g/l), carbohydrate 53.3
(200 g/l).

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A study of clinical outcomes in 1000 ARDS patients randomized to full calorie versus trophic (10 cc/hr) enteral feeds did not show
any difference in mortality or other clinical outcomes.
Rice TW, Wheeler AP, Thompson BT, Steingrub J, Hite RD, Moss M, et al. Initial trophic vs full enteral feeding in patients with acute lung injury: the
EDEN randomized trial. JAMA 2012;307:795-803
Although the mechanism of this beneficial effect was postulated to be due to reduction of the
respiratory quotient and a resultant fall in carbon dioxide production, the most common cause of a
high respiratory quotient in critically ill patients is not dietary composition but simply overfeeding.

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Initial Trophic vs Full Enteral Feeding in Patients With Acute
Lung Injury:
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network

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Conclusion—
In patients with acute lung injury, compared with full enteral feeding, a strategy of initial trophic
enteral feeding for up to 6 days did not improve ventilator-free days, 60-day mortality, or
infectious complications but was associated with less gastrointestinal intolerance

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there is still no compelling evidence to support the use of anything other than
standard (enteral) nutritional support, with avoidance of overfeeding,
in patients with ARDS.

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Mechanical Ventilation
Lung Protective Ventilation
Although historically a tidal volume of 12 to 15 mL per kg was
recommended in patients with ARDS, it is now clear that a low–tidal
volume, plateau pressure–limited ventilatory strategy reduces mortality
the inhospital mortality rate was 40% in the 12-mL/kg group and 31%
in the 6-mL/kg group, a 22% reduction

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VENTILATION WITH LOWER TIDAL VOLUMES AS COMPARED WITH
TRADITIONAL TIDAL VOLUMES FOR ACUTE LUNG INJURY AND THE ACUTE
RESPIRATORY DISTRESS SYNDROME
THE ACUTE RESPIRATORY DISTRESS SYNDROME NETWORK

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Conclusions
In patients with acute
lung injury and the
acute respiratory
distress syndrome,
mechanical
ventilation with a lower
tidal volume than is
traditionally
used results in
decreased mortality
and increases
the number of days
without ventilator use

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Higher levels of PEEP may be beneficial in preventing alveolar collapse and
minimizing injurious repeated opening and closing of alveoli
On the other hand, higher PEEP may overdistend and injure more complaint
areas of the lung.
The optimal level of PEEP in ARDS has been controversial

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Higher versus Lower Positive End-Expiratory Pressures in Patients with the
Acute Respiratory Distress Syndrome
The National Heart, Lung, and Blood Institute ARDS Clinical Trials Network

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conclusions
These results suggest that
in patients with acute lung
injury and ARDS who
receive mechanical
ventilation with a tidal-
volume goal of 6 ml per
kilogram of predicted body
weight and an end-
inspiratory plateau-
pressure limit of 30 cm of
water, clinical outcomes
are similar whether lower
or higher PEEP levels are
used.

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Meta-analysis of major clinical trials using protective VT and
comparing higher and lower PEEP scales did not find an overall
improvement in outcome with higher PEEP, although rescue
therapies were required less often. However, patients with mild
ARDS tended to have worse outcomes with higher PEEP, and
those with moderate to severe ARDS had better outcomes
. Briel M, Meade M, Mercat A, et al. Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic
review and meta-analysis. JAMA. 2010;309:865–873.

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High levels of PEEP of leads to high lung stress, with increased cytokine
release, which can be ameliorated by using lower levels of PEEP.
. Grasso S, Stripoli T, De Michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am
J Respir Crit Care Med. 2007;176: 761–767.

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Given the lack of compelling data favoring either a high PEEP or low PEEP
strategy, current recommendations are to adjust the PEEP within an
acceptable range to achieve adequate oxygenation at a given Fio2
These data suggest individual patients may benefit from a tailored approach

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Driving pressure
This is defined as the difference between the end-inspiratory plateau
pressure and the total PEEP.
driving pressure (ΔP = VT/CRS),
. Amato MBP, Meade O, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372: 747–
755
In a meta-analysis of nine randomised controlled trials of protective ventilation strategies (lower VT,
lower Pplat, and higher PEEP), Amato and colleagues identified the driving pressure as the variable
most robustly associated with improved outcome.

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Driving Pressure and Survival in the Acute
The new england journal o f medicine
Marcelo B.P. Amato, M.D., Maureen O. Meade, M.D., Arthur S. Slutsky, M.D., Laurent Brochard, M.D., Eduardo L.V. Costa, M.D., David A. Schoenfeld, Ph.D.,
Thomas E. Stewart, M.D., Matthias Briel, M.D., Daniel Talmor, M.D., M.P.H., Alain Mercat, M.D., Jean-Christophe M. Richard, M.D., Carlos R.R. Carvalho,
M.D., and Roy G. Brower, M.D.
Using a statistical tool known as multilevel mediation analysis to analyze
individual data from 3562 patients with ARDS enrolled in nine previously
reported randomized trials, we examined ΔP as an independent variable
associated with survival
derived a survival-prediction model with the use of data from a cohort of 336 patients with ARDS from four early randomized clinical trials testing various
strategies of volume-limited ventilation. next tested and refined this model with data from a validation cohort of 861 patients from a large, randomized trial2
comparing lower versus higher VT values. Finally, we retested the model with data from a more recent validation cohort of 2365 patients with ARDS enrolled
in four randomized trials comparing higher-PEEP versus lower-PEEP strategies

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CONCLUSIONS
We found that ΔP was the ventilation variable that best stratified risk. Decreases
in ΔP owing to changes in ventilator settings were strongly associated with
increased survival

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Effect of Conservative vs Conventional Oxygen Therapy on Mortality
Among Patients in an Intensive Care Unit The Oxygen-ICU Randomized
Clinical Trial
Massimo Girardis, MD; Stefano Busani, MD; Elisa Damiani, MD; Abele Donati, MD; Laura Rinaldi, MD; Andrea Marudi, MD; Andrea Morelli, MD; Massimo
Antonelli, MD; Mervyn Singer,MD, FRCA

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lower ICU mortality
with target PaO2
values of 70–100
mm Hg versus
values up to 150
mm Hg.
CONCLUSIONS
Among critically ill patients with an
ICU length of stay of 72
hours or longer, a conservative
protocol for oxygen therapy vs
conventional therapy resulted in
lower ICU mortality

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There is an increasing tendency to use pressure-controlled ventilation (PC)
or pressure-regulated volume control (PRVC), as Ppk is lower than volume-
controlled (VC) ventilation with a constant inspiratory flow pattern.
MODE OF VENTILATION
a moderate-sized randomised study found no difference in outcome
However, there may be differences in lung stress due to greater viscoelastic build-up
with VC.

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Prospective Randomized Trial Comparing Pressure-Controlled
Ventilation and Volume-Controlled Ventilation in ARDS
Andre´s Esteban, MD, PhD; Inmaculada Alı´a, MD; Federico Gordo, MD; Rau´ l de Pablo, MD; Jose´ Suarez, MD; Gumersindo Gonza´ lez, MD; and
Jesu´ s Blanco, MD; for the Spanish Lung Failure Collaborative Group†

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Conclusions: The increased number of extrapulmonary organ failures developed in patients
of the VCV group was strongly associated with a higher mortality rate. The development of
organ failures was probably not related to the ventilatory mode.

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109
Effect of Inspiratory Flow Pattern and Inspiratory to Expiratory Ratio on
Nonlinear Elastic Behavior in Patients with Acute Lung Injury
Cyrus Edibam, Albert J. Rutten, Daniel V. Collins, and Andrew D. Bersten
Department of Critical Care Medicine, Flinders Medical Centre, Bedford Park, South Australia
Eighteen ALI patients (67 16 years), of whom seven patients (38%) had a direct etiology, were studied Their
lung injury score at nclusion was 2.5 0.5, and nine (50%) died. All patients were. studied within 5 days of the
onset of ALI.

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there may be
differences in lung
stress due to greater
lung strain build-up with
VC

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111
Recruitment manoeuvres and open lung ventilation
Open lung ventilation refers to an approach where the lung is maximally
recruited, usually through application of higher PEEP, recruitment manoeuvres,
and efforts to minimise derecruitment
In theory, increased lung volume will result in less tidal overinflation and
improved outcome
However, despite alveolar recruitment overinflation may occur in previously normally aerated lung and hypotension
may occur due to reduced venous return if there is inadequate fluid loading

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During a typical recruitment manoeuvre, a high level of continuous
positive airway pressure (CPAP) (30–40 cm H2O) is applied for 30–40
seconds in an apnoeic patient, followed by return to a lower level of PEEP
and controlled ventilation

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A number of small trials have shown improvement in oxygenation
following recruitment manoeuvres; however, the largest clinical trial
failed to show an effect
. Brower RG, Morris A, Macintyre N, et al. Effects of recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome ventilated
with high positive end-expiratory pressure. Crit Care Med. 2003;31: 2592–2597

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114
PaO2/FIO2 increased 20 3% in 11
nonresponders and 175 23% in the
responders (11 patients).Before application
of the recruiting maneuver, VT (6.1 0.1 and
6.0 0.2 ml/kg) and PEEP (9.4 2.2 and 9.1
2.7 cm H2O) did not differ between
nonresponders and responders.
Twenty-two patients with ARDS
Effects of Recruiting Maneuvers in Patients with Acute Respiratory
Distress Syndrome Ventilated with Protective Ventilatory Strategy
Salvatore Grasso, M.D.,* Luciana Mascia, M.D.,† Monica Del Turco, M.D.,‡ Paolo Malacarne, M.D.,‡ Francesco Giunta, M.D.,§
Laurent Brochard, M.D., Arthur S. Slutsky, M.D.,# V. Marco Ranieri, M.D.**

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recruitment manoeuvres were effective only early in ARDS and with lower levels of baseline
PEEP, which probably explains the variable responses reported.
In conclusion, this study demonstrates
that application
of recruiting maneuvers is successful
in improving oxygenation only in
patients with early ARDS on the
ventilator for 1–2 days and without
impairment of chest wall mechanics.

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Although many believe that neuromuscular blockade
should be reserved for patients with severe hypoxemia, since the use
of paralytics may increase the risk of critical illness polyneuropathy
and myopathy,
one randomized clinical trial showed a 28-day mortality
benefit with use of neuromuscular paralysis with cisatracurium
besylate for the first 48 hours in severe ARDS (Pao2/Fio2 < 150).
. Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A, et al. Neuromuscular blockers in early acute respiratory distress syndrome. N Engl
J Med 2010;363:1107-16.

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Neuromuscular Blockers in Early Acute Respiratory
Distress Syndrome
Laurent Papazian, M.D., Ph.D., Jean-Marie Forel, M.D., Arnaud Gacouin, M.D., Christine Penot-Ragon, Pharm.D., Gilles Perrin, M.D., Anderson Loundou, Ph.D., Samir Jaber,
M.D., Ph.D., Jean-Michel Arnal, M.D., Didier Perez, M.D., ean-Marie Seghboyan, M.D., Jean-Michel Constantin, M.D., Ph.D., Pierre Courant, M.D., Jean-Yves Lefrant, M.D., Ph.D.,
Claude Guerin, M.D., Ph.D., Gwenael Prat, M.D., Sophie Morange, M.D., and Antoine Roch, M.D., Ph.D., for the ACURASYS Study Investigators*

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Conclusions
In patients with severe
ARDS, early administration
of a neuromuscular blocking
agent improved the
adjusted 90-day survival
and increased the time off
the ventilator
without increasing muscle
weakness

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120
Noninvasive Ventilation and High-Flow
Nasal Cannula
Noninvasive ventilation is commonly used in pediatric patients with ARDS
data from larger randomized clinical studies, a trial of noninvasive mechanical ventilation or high-
flow nasal cannula oxygen could be considered in a patient with ARDS who does not have a
severe oxygenation defect, hemodynamic instability, or altered mental status as long as the
patient can be closely observed and readily intubated if needed.
Randolph AG. Management of acute lung injury and acute respiratory distress syndrome in children. Crit Care Med 2009;37:2448-54.
A growing number of small studies suggest that bilevel NIV with pressure support ventilation and PEEP may
reduce the need for intubation and improve outcomes in selected patients with ARDS

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121
A multiple-center survey on the use in clinical practice of
noninvasive ventilation as a first-line intervention for acute
respiratory distress syndrome*
Massimo Antonelli, MD; Giorgio Conti, MD; Antonio Esquinas, MD; Luca Montini, MD; Salvatore Maurizio Maggiore, MD, PhD; Giuseppe Bello, MD; Monica
Rocco, MD; Riccardo Maviglia, MD; Mariano Alberto Pennisi, MD; Gumersindo Gonzalez-Diaz, MD; Gianfranco Umberto Meduri, MD
Between March 2002 and April 2004, 479
patients with ARDS were admitted to the
intensive care units. Three hundred and
thirty-two ARDS patients were already
intubated, so 147 were eligible for the study

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Conclusions:
In expert centers, NPPV
applied as first-line
intervention
in ARDS avoided intubation
in 54% of treated patients.
A
SAPS II >34 and the
inability to improve
PaO2/FIO2 after 1 hr of
NPPV were predictors of
failure.

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More recently, very high-flow nasal cannulas oxygen delivery has
been tested in patients with acute hypoxemic respiratory failure as an
alternative to immediate intubation
In a study of 310 patients with acute respiratory failure including some patients with ARDS, treatment with high-flow nasal
cannula increased ventilator-free days and reduced mortality compared to noninvasive or invasive mechanical ventilation.
Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al. High-flow oxygen through nasal cannula in acute hypoxemic respiratory failure. N Engl J
Med 2015;372:2185-96.

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124
One benefit of high-flow nasal cannula is that it can provide a significant level of
PEEP noninvasively

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125
High-flow nasal oxygen therapy and noninvasive ventilation in the
management of acute hypoxemic respiratory failure
Jean-Pierre Frat, M.D., Arnaud W. Thille, M.D., Ph.D., Alain Mercat, M.D., Ph.D., Christophe Girault, M.D., Ph.D., Stéphanie Ragot, Pharm.D., Ph.D., Sébastien Perbet, M.D.,
Gwénael Prat, M.D., Thierry Boulain, M.D., Elise Morawiec, M.D., Alice Cottereau, M.D., Jér.me Devaquet, M.D., Saad Nseir, M.D., Ph.D., Keyvan Razazi, M.D., Jean-Paul
Mira, M.D., Ph.D., Laurent Argaud, M.D., Ph.D., Jean-Charles Chakarian, M.D., Jean-Damien Ricard, M.D., Ph.D.,

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128
In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-
flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly
different intubation rates. There was a significant difference in favor of high-flow oxygen in
90-day mortality
A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow–oxygen group, 47% (44 of
94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P = 0.18 for all comparisons). The number of ventilator-free days at day 28 was
significantly higher in the high-flow–oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P = 0.02 for all
comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P = 0.046)
and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen

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Pharmacologic Therapy
There is no specific pharmacologic therapy for ARDS. A variety
of treatment strategies have been investigated in large randomized
trials including antiinflammatory strategies, surfactant replacement,
vasodilation, novel anticoagulants, antioxidants, and strategies to
enhance the resolution of pulmonary edema

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130
Corticosteroid Therapy
There is a long history of clinical trials evaluating steroid therapy in
ARDS, and the aggregated results of these studies show no consistent
survival benefit associated with steroid therapy
Marik PE, Meduri GU, Rocco PRM, Annane D. Glucocorticoid treatment in acute lung injury and acute respiratory distress syndrome. Crit Care Clin 2011; 27:589–607

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131
Glucocorticoids in the treatment of acute respiratory distress
syndrome*
F. Roche-Campo · H. Aguirre-Bermeo · J. Mancebo
The primary endpoint was mortality at day 60. Secondary endpoint included days free from mechanical ventilation, changes in
biochemical markers, and the number of infectious complications. No differences in death rates at day 60 (29% in both groups) or
day 180 (32% in both) were observed.

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132
Efficacy and Safety of Corticosteroids for Persistent Acute Respiratory Distress
Syndrome
The National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network*

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134
Conclusions
These results do not support the routine use of methylprednisolone for persistent
ARDS despite the improvement in cardiopulmonary physiology. In addition, starting
methylprednisolone therapy more than two weeks after the onset of ARDS may
increase the risk of death

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135
However, there is evidence of other benefits provided by steroid therapy in
ARDS, and theseinclude a reduction in markers of inflammation (both
pulmonary and systemic inflammation), improved gas exchange, shorter
duration of mechanical ventilation, and shorter length of stay in the ICU

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136
Steroid therapy is currently recommended only in cases of early severe
ARDS and unresolving ARDS
Meduri GU, Headley AS, Golden E, Carson SJ, Umberger RA, Kelso T, et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress
syndrome: a randomized controlled trial. JAMA 1998;280:159-65

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137
SURFACTANT REPLACEMENT THERAPY
Surfactant dysfunction is an important and early abnormality
contributing to lung damage in ARDS.
Pulmonary surfactant reduces surface tension promoting alveolar
stability, reducing work of breathing and lung water

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138
Consequently, there has been considerable interest in exogenous surfactant
replacement therapy.
subgroup analysis of recombinant SP-C-based surfactant administered
intratracheally improved oxygenation in direct ARDS without an
improvement in mortality.
. Spragg RG, Lewis JF, Walmrath HD, et al. Effect of recombinant surfactant protein C-based surfactant on the acute respiratory
distress syndrome. N Engl J Med. 2004;351:884–892.

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139
REFRACTORY HYPOXEMIA
“rescue therapies”
A minority (10 to 15%) of patients with ARDS develop severe hypoxemia
that is refractory to oxygen therapy and mechanical ventilation
This condition is an immediate threat to life, and the following “rescue therapies” can produce an immediate
improvement in arterial oxygenation
The initial management of these patients includes increased sedation and neuromuscular paralysis to maintain adequate oxygenation.

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140
MANIPULATION OF THE PULMONARY CIRCULATION
(iNO and aerosolised prostacyclin (PGI2) )
Both iNO and PGI2 are delivered to well-ventilated lung; both vasodilate the
local pulmonary circulation and augment the effects of hypoxic pulmonary
vasoconstriction.
Intravenous almitrine is a selective pulmonary vasoconstrictor that reinforces hypoxic pulmonary vasoconstriction and,
although this may improve oxygenation alone, there is a synergistic effect with iNO.

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141
Effect of nitric oxide on oxygenation and mortality in acute
lung injury: systematic review and meta-analysis
Neill K J Adhikari, lecturer,1 Karen E A Burns, assistant professor,1 Jan O Friedrich, assistant professor,1 John T Granton, associate professor,1 Deborah J Cook,
professor,2 Maureen O Meade, associate professor2

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144
Results 12 trials randomly assigning 1237 patients met inclusion criteria. Overall methodological quality was good.
Using random effects models, we found no significant effect of nitric oxide on hospital mortality (risk ratio 1.10,
95% confidence interval 0.94 to 1.30), duration of ventilation, or ventilator-free days. On day one of treatment,
nitric oxide increased the ratio of partial pressure of oxygen to fraction of inspired oxygen (PaO2/ FiO2 ratio)
(13%, 4% to 23%) and decreased the oxygenation index (14%, 2% to 25%). Some evidence suggested that
improvements in oxygenation persisted until day four. There was no effect on mean pulmonary arterial pressure.
Patients receiving nitric oxide had an increased risk of developing renal dysfunction (1.50, 1.11 to 2.02).

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145
Conclusions
Nitric oxide is associated with limited improvement in oxygenation
in patients with ALI or ARDS but confers no mortality benefit and
may cause harm. We do not recommend its routine use in these
severely ill patients
the increase in arterial oxygenation is temporary (1– 4 days), and there is no associated
survival benefit

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146
High-frequency oscillatory ventilation (HFOV)
appeared to be promising in several small, randomized trials in patients
with ARDS, with improvements in oxygenation in patients with severe
hypoxemia.
High Frequency Oscillatory Ventilation
High frequency oscillatory ventilation (HFOV) delivers small tidal volumes (1– 2 mL/kg) using rapid pressure oscillations (300 cycles/min). The small
tidal volumes limit the risk of volutrauma, and the rapid pressure oscillations create a mean airway pressure that prevents small airway collapse and
limits the risk of atelectrauma

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147
High-Frequency Oscillatory Ventilation for Acute
Respiratory Distress Syndrome in Adults
Stephen Derdak, Sangeeta Mehta, Thomas E. Stewart, Terry Smith, Mark Rogers, Timothy G. Buchman, Brian Carlin, Stuart Lowson,
John Granton, and the Multicenter Oscillatory Ventilation for Acute
Respiratory Distress Syndrome Trial (MOAT) Study Investigators

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149
We conclude that high-frequency
oscillation is a safe and effective
mode of ventilation for the
treatment of acute respiratory
distress syndrome in adults

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150
However, two large, randomized clinical trials in
severe ARDS failed to show a benefit, and in one of the trials,
mortality was higher in the HFOV group.
. Young D, Lamb SE, Shah S, MacKenzie I, Tunnicliffe W, Lall R, et al. High-frequency oscillation for acute respiratory distress
syndrome. N Engl J Med 2013;368:806-13.

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151
High-Frequency Oscillation in Early Acute Respiratory
Distress Syndrome
Niall D. Ferguson, M.D., Deborah J. Cook, M.D., Gordon H. Guyatt, M.D., Sangeeta Mehta, M.D., Lori Hand, R.R.T., Peggy Austin, C.C.R.A., Qi Zhou, Ph.D., Andrea Matte,
R.R.T., Stephen D. Walter, Ph.D., Francois Lamontagne, M.D., John T. Granton, M.D., Yaseen M. Arabi, M.D., Alejandro C. Arroliga, M.D., Thomas E. Stewart, M.D., Arthur
S. Slutsky, M.D., and Maureen O. Meade, M.D., for the OSCILLATE Trial Investigators and the Canadian Critical Care Trials Group

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153
Conclusions
In adults with moderate-to-severe
ARDS, early application of HFOV,
as compared with
a ventilation strategy of low tidal
volume and high positive end-
expiratory pressure, does
not reduce, and may increase, in-
hospital mortality

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154
HFOV can improve arterial oxygenation, but there is
no documented survival benefit
For this reason, HFOV should only be used as a rescue therapy and only by experienced
operators

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155
Prone Position
Switching from the supine to prone position can improve pulmonary
gas exchange by diverting blood away from poorly aerated lung
regions in the posterior thorax and increasing blood flow in aerated
lung regions in the anterior thorax

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156
Gattinoni L, Tognoni G, Pesenti A, Taccone P, Mascheroni D, Labarta V, et al. Effect of prone positioning on the survival of patients with acute
respiratory failure. N Engl J Med 2001;345: 568-73
Taccone P, Pesenti A, Latini R, Polli F, Vagginelli F, Mietto C, et al. Prone positioning in patients with moderate and severe acute respiratory
distress syndrome: a randomized controlled trial. JAMA 2009;302:1977-84
 Guerin C, Reignier J, Richard JC, Beuret P, Gacouin A, Boulain T, et al. Prone positioning in severe acute
respiratory distress syndrome. N Engl J Med 2013;368:2159-68.

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157
Prone Positioning in Severe Acute Respiratory Distress
Syndrome
Claude Guérin, M.D., Ph.D., Jean Reignier, M.D., Ph.D., Jean-Christophe Richard, M.D., Ph.D., Pascal Beuret, M.D., Arnaud Gacouin, M.D., Thierry Boulain, M.D.,
Emmanuelle Mercier, M.D., Michel Badet, M.D., Alain Mercat, M.D., Ph.D., Olivier Baudin, M.D., Marc Clavel, M.D., Delphine Chatellier, M.D., Samir Jaber, M.D.,
Ph.D., Sylvène Rosselli, M.D., Jordi Mancebo, M.D., Ph.D., Michel Sirodot, M.D., Gilles Hilbert, M.D., Ph.D.,
Christian Bengler, M.D., Jack Richecoeur, M.D., Marc Gainnier, M.D., Ph.D., Frédérique Bayle, M.D.,

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Conclusions
In patients with severe ARDS, early application of prolonged prone-
positioning sessions significantly decreased 28-day and 90-day
mortality.
Notably, the study entry PFaiOO2 2 ratio was less than 150, enrolment was within 36 hours of commencing mechanical
ventilation

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Extracorporeal membrane oxygenation(ECMO)
has been used in patients with ARDS and severe hypoxemia. In
specialized centers ECMO has been used successfully to treat
patients with severe ARDS
Extracorporeal membrane oxygenation(ECMO)

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163
Extracorporeal Life Support for Severe Acute Respiratory
Distress Syndrome in Adults
Mark R. Hemmila, MD, Stephen A. Rowe, MD, Tamer N. Boules, MD, Judiann Miskulin, MD, John W. McGillicuddy, MD, Douglas J.
Schuerer, MD, Jonathan W. Haft, MD, Fresca Swaniker, MD, Saman Arbabi, MD, MPH, Ronald B. Hirschl, MD, and Robert H.
Bartlett, MD
From January 1989 to December 2003, 405 adult patients 17 years of age or older were placed on ECLS. Of these 405
patients, 255 had severe ARDS, 18 had pulmonary embolism, 7 had hypercarbic respiratory failure, and the
remaining 125 patients were placed on ECLS for cardiac failure or cardiopulmonary resuscitation (CPR). The patients
who formed the basis of this study were those placed on ELCS for severe ARDS

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The indications for ECLS (and the definition of “failure to improve on algorithm treatment”) were based
primarily on lung dysfunction measured as PaO2/FiO2 ratio 100 on FiO2 of 1.0, alveolar-arterial gradient
(AaDO2) 600 mm Hg,

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165
Conclusion:
Extracorporeal life support for severe
ARDS in adults is a successful therapeutic
option in those patients who do not
respond to conventional mechanical
ventilator strategies

ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) .BY DR.Mohammad Abdeljawad

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ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) .BY DR.Mohammad Abdeljawad