ARDS

1. ACUTE LUNG INJURYACUTE LUNG INJURY
AND ACUTEAND ACUTE
RESPIRATORY DISTRESSRESPIRATORY DISTRESS
SYNDROMESYNDROME
Eric Cucchi MS, PA-CEric Cucchi MS, PA-C
CAQ, Hospital MedicineCAQ, Hospital Medicine

2. HISTORYHISTORY
►First scientific paper in 1821, “A Treatise onFirst scientific paper in 1821, “A Treatise on
Disease of the Chest.” Laennec describedDisease of the Chest.” Laennec described
idiopathic anasarca of the lungs withidiopathic anasarca of the lungs with
pulmonary edema without heart failure.pulmonary edema without heart failure.
►““Respirator Lung” because people livedRespirator Lung” because people lived
longer enough on respirators to describe thelonger enough on respirators to describe the
disease.disease.
►““DaNang Lung,” “Shock Lung,” “Post-DaNang Lung,” “Shock Lung,” “Post-
Traumatic Lung.”Traumatic Lung.”

3. HISTORYHISTORY
►First described in 1967 by Asbaugh,First described in 1967 by Asbaugh,
Bigelow, Petty et. al. asBigelow, Petty et. al. as acuteacute respiratoryrespiratory
distress syndrome.distress syndrome.
►In 1971 Petty and Asbaugh again describedIn 1971 Petty and Asbaugh again described
ARDS but referred to it asARDS but referred to it as adultadult respiratoryrespiratory
distress syndrome to differentiate fromdistress syndrome to differentiate from
infant respiratory distress syndrome (IRDS).infant respiratory distress syndrome (IRDS).

4. HistoryHistory
► In 1994 an AmericanIn 1994 an American
and Europeanand European
Consensus decidedConsensus decided
upon diagnostic criteriaupon diagnostic criteria
for ALI and for ARDS,for ALI and for ARDS,
(Bernard, Artigas,(Bernard, Artigas,
Brigham et al, 1994 )Brigham et al, 1994 )
ALIALI ARDSARDS
Acute OnsetAcute Onset Acute OnsetAcute Onset
Presence of aPresence of a
predisposingpredisposing
conditioncondition
(pneumonia, trauma,(pneumonia, trauma,
sepsis, etc)sepsis, etc)
Presence of aPresence of a
predisposingpredisposing
conditioncondition
(pneumonia,(pneumonia,
trauma, sepsis, etc)trauma, sepsis, etc)
B/l infiltrates onB/l infiltrates on
frontal CXRfrontal CXR
B/l infiltrates onB/l infiltrates on
frontal CXRfrontal CXR
PAOPPAOP ≤ 18 and no≤ 18 and no
clinical evidence ofclinical evidence of
left atrial HTNleft atrial HTN
PAOPPAOP ≤ 18 and no≤ 18 and no
clinical evidence ofclinical evidence of
left atrial HTNleft atrial HTN
PaO2/FiO2< 300PaO2/FiO2< 300 PaO2/FiO2 < 200PaO2/FiO2 < 200

5. 2011 Berlin Criteria2011 Berlin Criteria
http://www.scielo.br/scielo.php?pid=S0021-
75572013000600003&script=sci_arttext&tlng=e
n

6. ALI/ARDSALI/ARDS
►Acute lung injury (ALI) and acute respiratoryAcute lung injury (ALI) and acute respiratory
distress syndrome (ARDS) are considered adistress syndrome (ARDS) are considered a
spectrum of disease.spectrum of disease.
►ALIALI  ARDSARDS
►This is why we essentially call everythingThis is why we essentially call everything
ARDS of varying severity instead of ALI orARDS of varying severity instead of ALI or
ARDS.ARDS.

7. Progression ofProgression of
DiseaseDisease

8. Day 1Day 1

9. Day 2Day 2

10. Day 3Day 3

11. Day 4Day 4

12. Day 5Day 5

13. Day 6Day 6

14. Day 7Day 7

15. Day 8Day 8

16. Day 9Day 9

17. So what is going on inSo what is going on in
the Lungs?the Lungs?

18. 1980s1980s
► Brought that advent ofBrought that advent of
computer tomographycomputer tomography
(CT) scanning and with(CT) scanning and with
it that world of ARDSit that world of ARDS
changed.changed.

19. http://medicaldirect.jp/archives/3928
HeterogenesityHeterogenesity

20. Inflammatory ProcessInflammatory Process
► Platelet activation and aggregationPlatelet activation and aggregation
► MicrothrombiMicrothrombi
► Intraalveolar fibirinIntraalveolar fibirin
► Decreased Protein C and SDecreased Protein C and S
► Pulmonary neutrophilsPulmonary neutrophils
► Tumor Necrosis FactorTumor Necrosis Factor
► Interleukin-1 and -8Interleukin-1 and -8
► CytokinesCytokines
► ElastasesElastases

21. EpidemiologyEpidemiology
►NIH “guessed” in 1977 that there wereNIH “guessed” in 1977 that there were
150,000 incidences a year in the United150,000 incidences a year in the United
States.States.
►In 2003 Rubenfield suggested that theIn 2003 Rubenfield suggested that the
incidences of ARDS ranges between 15,000incidences of ARDS ranges between 15,000
and 200,000 per year.and 200,000 per year.

22. MortalityMortality
►In the beginning the mortality of pts withIn the beginning the mortality of pts with
ARDS was 50-70% and could range fromARDS was 50-70% and could range from
hours to, with the advent of mechanicalhours to, with the advent of mechanical
ventilation, days to weeks.ventilation, days to weeks.
►Recently the mortality has improved to 35-Recently the mortality has improved to 35-
40% with modern medicine.40% with modern medicine.
►Then came…Then came…

23. * Based on ideal body weight
ARDSNetARDSNet
►In 2000, the NIH and NHLBI compared lowIn 2000, the NIH and NHLBI compared low
tidal volume therapy (6-8 mL/kg*) vstidal volume therapy (6-8 mL/kg*) vs
conventional therapy (10-12 mL/kg*).conventional therapy (10-12 mL/kg*).
►Mortality was decreased by 22 % by usingMortality was decreased by 22 % by using
the low tidal volume therapy.the low tidal volume therapy.

25. AnalysisAnalysis
►Primary outcome was mortalityPrimary outcome was mortality
►Second primary outcome was ventilator-freeSecond primary outcome was ventilator-free
days between day 1 and 28. Meaningdays between day 1 and 28. Meaning
without any assistance for at least 48 hours.without any assistance for at least 48 hours.
►Secondary outcomes were organ failure andSecondary outcomes were organ failure and
barotrauma.barotrauma.
►Pts were monitored for mortality rates up toPts were monitored for mortality rates up to
180 days.180 days.

26. ► Figure 2.Figure 2. Mean (+SE) Mortality Rate among 257 Patients with Acute Lung Injury and the Acute RespiratoryMean (+SE) Mortality Rate among 257 Patients with Acute Lung Injury and the Acute Respiratory
Distress Syndrome Who Were Assigned to Receive Traditional Tidal Volumes and 260 Such Patients Who WereDistress Syndrome Who Were Assigned to Receive Traditional Tidal Volumes and 260 Such Patients Who Were
Assigned to Receive Lower Tidal Volumes, According to the Quartile of Static Compliance of the RespiratoryAssigned to Receive Lower Tidal Volumes, According to the Quartile of Static Compliance of the Respiratory
System before Randomization. The interaction between the study group and the quartile of static compliance atSystem before Randomization. The interaction between the study group and the quartile of static compliance at
base line was not significant (P=0.49).base line was not significant (P=0.49).

27. ResultsResults
► Probablity of survival, being discharged home, andProbablity of survival, being discharged home, and
breathing without assistance within 180 days wasbreathing without assistance within 180 days was
much higher in the low tidal volume group than themuch higher in the low tidal volume group than the
traditional arm.traditional arm.
► Mortality in the traditional group was 39.8%Mortality in the traditional group was 39.8%
► Mortality in the low tidal volume group was 31.0%Mortality in the low tidal volume group was 31.0%
► (P = 0.007; 95 % confidence for the difference(P = 0.007; 95 % confidence for the difference
between the two groups, 2.4 to 15.3%)between the two groups, 2.4 to 15.3%)

28. ResultsResults
►MortalityMortality
►Vent-free daysVent-free days
►Organ failureOrgan failure
free daysfree days
►Incidence ofIncidence of
BarotraumaBarotrauma

29. ► Figure 1.Figure 1. Probability of Survival and of Being Discharged Home and Breathing without AssistanceProbability of Survival and of Being Discharged Home and Breathing without Assistance
during the First 180 Days after Randomization in Patients with Acute Lung Injury and the Acuteduring the First 180 Days after Randomization in Patients with Acute Lung Injury and the Acute
Respiratory Distress Syndrome. The status at 180 days or at the end of the study was known for allRespiratory Distress Syndrome. The status at 180 days or at the end of the study was known for all
but nine patients. Data on these 9 patients and on 22 additional patients who were hospitalized at thebut nine patients. Data on these 9 patients and on 22 additional patients who were hospitalized at the
time of the fourth interim analysis were censored.time of the fourth interim analysis were censored.

30. DiscussionDiscussion
►22 % decrease in mortality in the low tidal22 % decrease in mortality in the low tidal
volume arm compared to the pts in thevolume arm compared to the pts in the
traditional group.traditional group.
► Improved mortality in spite of increasedImproved mortality in spite of increased
need of PEEP and FiO2 and lowerneed of PEEP and FiO2 and lower
PaO2/FiO2 ratio.PaO2/FiO2 ratio.
►Decreased interluekin-6 levels suggest lessDecreased interluekin-6 levels suggest less
systemic inflammatory responsesystemic inflammatory response

31. Why does it work?Why does it work?
► http://images.google.com/imgres?http://images.google.com/imgres?
imgurl=http://bp2.blogger.com/_nFuCC8zhFBc/RuqdtaaVwZI/AAAAAAAAAN8/atELot90t8k/s400/08f2.jpg&imgrefurl=http://er119test.blogspot.com/2007_09_01_archive.html&h=314&w=400&sz=22&hl=en&start=18&tbnid=jFarUcOMknZ3_M:&tbnh=97&tbnw=124&prev=/imagimgurl=http://bp2.blogger.com/_nFuCC8zhFBc/RuqdtaaVwZI/AAAAAAAAAN8/atELot90t8k/s400/08f2.jpg&imgrefurl=http://er119test.blogspot.com/2007_09_01_archive.html&h=314&w=400&sz=22&hl=en&start=18&tbnid=jFarUcOMknZ3_M:&tbnh=97&tbnw=124&prev=/imag
es%3Fq%3DARDS%2Blow%2Btidal%2Bvolume%26gbv%3D2%26hl%3Denes%3Fq%3DARDS%2Blow%2Btidal%2Bvolume%26gbv%3D2%26hl%3Den

32. Why does it work?Why does it work?
►It is thought that the closing and opening ofIt is thought that the closing and opening of
alveoli causing increased inflammatoryalveoli causing increased inflammatory
response.response.
►Stenting the alveoli open with PEEPStenting the alveoli open with PEEP
decreases this “open and closing”decreases this “open and closing”
phenomenon of the alveoli decreasingphenomenon of the alveoli decreasing
inflammation.inflammation.

33. Alternative TreatmentsAlternative Treatments
(Or Are They?)(Or Are They?)
► Prone PositionProne Position
► High Flow Oscillatory VentilationHigh Flow Oscillatory Ventilation
► Pressure ControlPressure Control
► Bi-Level (Airway Pressure Release Ventilation).Bi-Level (Airway Pressure Release Ventilation).
► CorticosteriodsCorticosteriods
► Nitric OxideNitric Oxide
► SurfactantSurfactant
► Partial Liquid VentilationPartial Liquid Ventilation
► ECMOECMO

34. Prone PositionProne Position
http://medicaldirect.jp/archives/3928

35. SurviorsSurviors
►Long term disability is a real problem.Long term disability is a real problem.
►Many pts suffer neuropsychiatric andMany pts suffer neuropsychiatric and
neuromuscular weakness.neuromuscular weakness.
►These long term disabilities can range fromThese long term disabilities can range from
delayed return to work or school to notdelayed return to work or school to not
being able to perform ADLs.being able to perform ADLs.

36. TAKE HOMETAKE HOME
► Low tidal volume (6-8 mL/kg) saves livesLow tidal volume (6-8 mL/kg) saves lives
► ARDS effects the entire body not just the lungs.ARDS effects the entire body not just the lungs.
► The future of ARDS will be further research intoThe future of ARDS will be further research into
alternative treatments and standardizing therealternative treatments and standardizing there
use.use.
► ARDS can last a life time for some.ARDS can last a life time for some.

37. When to Refer?When to Refer?
►This is a medical emergency and will alwaysThis is a medical emergency and will always
need to be referred to a facility that canneed to be referred to a facility that can
manage this severe disease.manage this severe disease.

38. Questions???Questions???