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Acute respiratory distress syndrome

Acute respiratory distress syndrome (ARDS), also known as respiratory distress syndrome (RDS) or adult respiratory distress syndrome (in contrast with IRDS) is a serious reaction to various forms of injuries to the lung. This is the most important disorder resulting in increased permeability pulmonary edema. more...

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ARDS is a severe lung disease caused by a variety of direct and indirect insults. It is characterized by inflammation of the lung parenchyma leading to impaired gas exchange with concomitant systemic release of inflammatory mediators causing inflammation, hypoxemia and frequently resulting in multiple organ failure. This condition is life threatening and often lethal. So it usually requires mechanical ventilation and admission to an intensive care unit. A less severe form is called acute lung injury (ALI).

ARDS formerly most commonly signified adult respiratory distress syndrome to differentiate it from infant respiratory distress syndrome in premature infants. However, as this type of pulmonary edema also occurs in children, ARDS has gradually shifted to mean acute rather than adult. The differences with the typical infant syndrome remain.

Definition

Historical background

Acute respiratory distress syndrome was first described in 1967 by Ashbaugh et al. Initially there was no definition, resulting in controversy over incidence and mortality. In 1988 an expanded definition was proposed which quantified physiologic respiratory impairment.

In 1994 a new definition was recommended by the American-European Consensus Conference Committee. It had two advantages: 1 it recognizes that severity of pulmonary injury varies, 2 it is simple to use..

ARDS was defined as the ratio of arterial partial oxygen tension (PaO2) as fraction of inspired oxygen (FiO2) below 200 mmHg in the presence of bilateral alveolar infiltrates on the chest x-ray. These infiltrates may appear similar to those of left ventricular failure, but the cardiac silhouette appears normal in ARDS. Also, the pulmonary capillary wedge pressure is normal (less than 18 mmHg) in ARDS, but raised in left ventricular failure.

A PaO2/FiO2 ratio less than 300 mmHg with bilateral infiltrates indicates acute lung injury (ALI). Although formally considered different from ARDS, ALI is usually just a precursor to ARDS.

Consensus after 1967 and 1994

ARDS is characterized by:

  • Acute onset
  • Bilateral infiltrates on chest radiograph
  • Pulmonary artery wedge pressure < 18 mmHg (obtained by pulmonary artery catheterization)
  • if PaO2:FiO2 < 300 acute lung injury (ALI) is considered to be present
  • if PaO2:FiO2 < 200 acute respiratory distress syndrome (ARDS) is considered to be present

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Methylprednisolone infusion in patients with early Acute Respiratory Distress Syndrome significantly improves lung function: results of a Randomized Controlled
From CHEST, 10/1/05 by Gianfranco U. Meduri

PURPOSE: To determine the effects of prolonged methylprednisolone infusion (PMPI) in patients with early ARDS.

METHODS: Patients were stratified by medical and surgical ARDS. Treatment: methylprednisolone (MP) loading 1 mg/kg I.V. was followed by PMPI at 1 mg/kg/day (days 1-14), 0.5 mg/kg/day (days 15-21), 0.25 mg/kg/day (days 22-25), and 0.125 mg/kg/day (days 26-28). Patients failing to improve lung injury score (LIS) by study day 7-9 (unresolving ARDS) received open label MP (2mg/kg/day) treatment as previously reported (JAMA 1998; 280: 159). Infection surveillance and avoidance of paralysis were integral components of the protocol. The primary end-point to terminate the study was a 1-point reduction in lung injury score (LIS) by study day 7.

RESULTS: 91 patients entered the study (intention to treat--ITT)and 79 were eligible for analysis (55 treated and 24 control) on study day 7. The two groups had similar characteristics at study entry (Table 1). By day 7 (Table 2), the response of the two groups clearly diverged with almost twice the proportion of treated patients achieving al-point reduction in LIS (69.8% vs. 37.5%; P = 0.002)and about 50%more treated patients breathing without assistance (53.9% vs. 25.0%; P = 0.01). Treated patients had a significant reduction in C-reactive protein levels and by day 7 had significantly lower LIS and multiple organ dysfunction syndrome (MODS) score. Treatment was associated with a reduction in the duration of MV, ICU staynd ICU mortality. The treatment group developed more frequently hyperglycemia (52.5% vs. 28.6%; P = 0.06), and polyneuropathy (2 vs. 0). Among treated patients, infection surveillance identified most nosocomial infections (65%) in the absence of fever.

CONCLUSION: PMPI was associated with significantly improved lung function and reduced duration of mechanical ventilation. These findings are consistent with the effects of prolonged glucocorticoid treatment previously reported in patients with unresolving ARDS (2 RCTs) and severe community-acquired pneumonia (AJRCCM 2005; 171; 242-248).

CLINICAL IMPLICATIONS: The findings of this study support the use of PMPI in association with infection surveillance and avoidance of paralysis in patients with ARDS.

DISCLOSURE: Gianfranco Meduri, None.

Gianfranco U. Meduri MD * Emmel Golden MD Amado X. Freire MD Edwin Taylor MD Mohamad Zaman MD Stephanie J. Carson MD Mary Gibson MD Reba Umberger MD University of Tennessee Health Science Center, Memphis, TN

COPYRIGHT 2005 American College of Chest Physicians
COPYRIGHT 2005 Gale Group

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