CURRENT UPDATES IN

GENERAL APPROACH OF
ACUTE RESPIRATORY
DISTRESS SYNDROME

dr. Yusrizal Djam’an Saleh, Sp.P. FCCP

EMERGENCY MEDICINE IN GENERAL PRACTICE

10-11 March 2018
Eastparc Hotel,Yogyakarta
I. INTRODUCTION
• 1821, Laennec described fatal “idiopathic pulmonary
edema”.
• The first and second World wars provided evidence
that several traumatic insult could result edematous
lung injury [4], so that and the term “shock lung”.
• 1967, Ashbaugh and colleagues published 12 patients
that developed respiratory failure after a variety of
insults [1], providing the first systematic description of
Adult Respiratory Distress Syndrome.
Other names–
▫ Acute respiratory distress syndrome
▫ Adult hyaline membrane disease
▫ Shock lung
▫ Stiff lung syndrome
▫ Non-cardiogenic pulmonary edema
▫ Ventilator-associated lung injury
▫ Traumatic wet lung
▫ Transfusion wet lung
▫ Post perfusion lung (Transplant lung: reperfusion
pulmonary edema)
Acute respiratory distress syndrome
• State of acute, diffuse alveolar damage by increased
capillary permeability, pulmonary edema and refractory
hypoxemia.
• It is characterized by
▫ acute onset of severe hypoxemia
▫ signs of respiratory distress (dyspnoea, tachypnoea)
▫ diffuse bilateral infiltrates in the CXR
▫ no evidence of left atrial hypertension (PAWP<18mmHg).
 II. DEFINITION

• The European Society of Intensive Care Medicine

convened an international expert panel in 2011 in Berlin,
“Berlin definition” of ARDS [3] (Table 1): acute form of
diffuse lung injury occurring in patients with a
predisposing risk factor, meeting the following criteria:
TABLE 1. COMPARISON BETWEEN AECC DEFINITION (1994),
AND THE BERLIN DEFINITION OF ACUTE RESPIRATORY
DISTRESS SYNDROME (2012).
III. EPIDEMIOLOGY
• A high variability in both epidemiology and clinical outcomes
• ARDS 1.5 - 79 cases per 100000, with European countries
reporting a lower incidence than USA [6].
• Brazil 1.8 - 31 per 100 000 [7,8].
• LUNG SAFE trial, Incidence ARDS across 459 (ICUs) in 50
countries [9]. Among 4499 patients who developed acute
hypoxaemic respiratory failure, ARDS occurred in 10.4% of
total ICU admissions and in 23.4% of patients requiring
mechanical ventilation.
• ARDS still elevated overall incidence, and with an attributable
mortality ranging from 40% - 60%.
IV. DIAGNOSTIC EVALUATION

• Critical factor for a favourable outcome of ARDS

patients is an adequate treatment of the
underlying cause
• Undoubtedly, pneumonia still remains leading
cause of ARDS [11],
TABLE 2. MOST COMMON PATHOGENS RESPONSIBLE FOR ARDS GENESIS
TABLE 3.1. CONDITIONS ASSOCIATED WITH NON CARDIOGENIC PULMONARY
EDEMA OR ACUTE LUNG INJURY

Direct Lung Injury Indirect Lung Injury

Pneumonia Sepsis
Aspiration of Gastric contents Severe trauma with multiple
transfusions
Pulmonary contusion Cardiopulmonary bypass
Fat or air emboli Drug overdose or toxic ingestions
Near drowning Acute pancreatitis
Inhalational injury Transfusion of blood products
Reperfusion injury
IV.1. OTHER PATHOGENS RESPONSIBLE FOR ALI/ARDS GENESIS.

• TB is a very highly prevalent disease particularly in the

developing world. In India one person dies of
tuberculosis every minute.
• But TB as a primary cause of respiratory failure
requiring mechanical ventilation is an uncommon
occurrence.
• Among patients with Pulmonary TB, those with miliary
or disseminated disease or having comorbidities like
(AIDS) are especially prone to develop acute
respiratory distress syndrome (ARDS) (12-27).
• Common: negative sputum (AFB) and negative tuberculin
test.
• Various studies sputum smear positivity 20-40% and a few
patients AFB positivity after initiation of steroid therapy.
• Tuberculin test negative 30-60% patients [16].
• Chest X-ray may or may not be helpful.
• The initial X-ray usually shows reticulo-nodular shadows
indicative of miliary TB.
• Good history and clinical examination will help in DD.
• Later, in the course of illness, there is coalescence of
pulmonary infiltrates and pulmonary opacification which
manifests, clinically, as respiratory distress
• (HRCT) of chest may be helpful when diagnosis of
miliary TB is in doubt : diffuse, small, nodular densities
measuring up to 3 mm may help in establishing a
diagnosis of miliary tb in suspected cases .
• A strong clinical suspicion on the basis of history and a
suggestive X-ray / CT scan help in establishing the
diagnosis of miliary tb in suspected cases when they
present as ARDS.
V. PATHOPHYSIOLOGY ARDS

3 Phases :
1. Exudative/Inflammatory
2. Proliferative
3. Fibrotic
V.1.PATHOPHYSIOLOGY ARDS IN TUBERCULOSIS
• ARDS in TB after initiation of therapy is rarer.
• Varying degrees of hypoxemia and alveolar arterial oxygen gradient,
reflecting inequalities of ventilation, perfusion and impaired diffusion of
oxygen has been reported in early miliary TB (38).
• Signs of ARDS are commonly met within autopsy studies in pts miliary TB.
• In untreated miliary TB, injury to the alveolar capillary membrane result from
intense and widespread peri focal inflammatory reaction, interstitial
granulomatous inflammation, and obliterative endarteritis [38].
• Initially, local vascularity is increased and later, alveoli are filled with dense
exudative material.
• Ultimately, air spaces may be replaced by caseating granulomas.
Postulate mechanism ARDS in TB
• Massive release mycobacteria into pulmonary
circulation resulting in widespread inflammatory
reaction, infiltration and obliterative endarteritis
[38].
• Volume overload, embolization of platelets, fibrin
aggregates in pulmonary capillaries resulting
endothelial damage and leukocyte activation
resulting in increased vascular permeability [39].
• Later, the alveoli are filled with exudative material
leading to the clinical manifestations of ARDS
• On molecular level, Lipoarabinomannan, a component
mycobacterial cell wall, thought to act similar to
lipopolysaccharides in Gram negative sepsis so as to
activate macrophages.
• activated macrophages release (TNF-) and IL–1,are
key to causation of endothelial lung injury as shown in
flow diagram below [40,41].
• The endothelial cells also are made more susceptible
to the toxic effects of TNF by Mycobacterium
tuberculosis
Figure 2. Indian Journal of Tuberculosis 2002
VI. MANAGEMENT/GENERAL APPROACH
• Treatment mainly supportive, depicted in table 4 (42).
• Invasive mechanical ventilation with lung protective
strategies is the mainstay of ARDS treatment, although may
carry a high rate of complications, such
- VAP
- Delirium and
- Critical illness myopathy and neuropathy.
• Non-invasive ventilation (NIV) and the application (CPAP) is
contemplated in mild ARDS, although its use in acute
hypoxaemic respiratory failure remains controversial and the
choice of the interface device is still debated [43, 44, 45].
Table 4. Management of acute respiratory distress syndrome (ARDS)
(Cited European Respiratory Rev 2017, 26: 160116)
• An Official American Thoracic Society/European Society
of Intensive Care Medicine/Society of Critical Care
Medicine Clinical Practice Guideline, recommend that
adult patients with ARDS receive mechanical ventilation
with strategies that limit tidal volumes (4–8 ml/kg PBW)
and inspiratory pressures (plateau pressure, 30 cm H2O)
[46].
VII. SUMMARY
• ARDS still remains elevated overall incidence,
mortality 40% - 60%.
• To allow for a better accuracy of the clinical diagnosis,
its definition has been reviewed several times, the last
in Berlin, 2011.
• In order to ensure a rapid etiologic therapy, a rapid
identification of the underlying cause is mandatory,
and the use of a systematic approach to diagnosis may
help the clinicians.
• Several molecules have been shown to be candidate biomarkers
of this disease, However, none of these candidates have been
clinically applied for diagnosis or prediction of disease severity,
response to therapy, and prognosis in patients with ARDS.
• An Official ATS/ESICM/SCCM Clinical Practice Guideline,
recommend that adult patients with ARDS receive mechanical
ventilation with strategies that limit tidal volumes (4–8 ml/kg
PBW) and inspiratory pressures (plateau
pressure , 30 cm H2O)
[46].
• Pulmonary and Miliary TB constitutes one of the rare causes of
ARDS with acute and atypical clinical presentation. Awareness ,
early diagnosis and prompt treatment of the disease is essential
to prevent mortality, and should be considered as a possibility of
ARDS in the developing world even in the absence of co
morbidities or immune suppression [27].
VIII.CONCLUSION
The management strategies for ARDS patients, should focus on :
1. Lung protective ventilation strategy
- Low Tidal volume (4–8 ml/kg PBW) & inspiratory pressures
(plateau pressure, 30 cm H2O)
- Optimal peep and P plat
- Oxygenation goal PaO2 55-80 mmHg/SpO2 88-95 %
2. Conservative Fluid management
3. Treat the Underlying cause.
TERIMA KASIH