Podcasts · Core EM - Emergency Medicine Podcast

Episode 195: ARDS

· Episode 195

Episode Episode 195: ARDS

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We review Acute Respiratory Distress Syndrome

Hosts: Sadakat Chowdhury, MD Brian Gilberti, MD

https://media.blubrry.com/coreem/content.blubrry.com/coreem/ARDS.mp3

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Show Notes

• Definition of ARDS:

• Non-cardiogenic pulmonary edema characterized by acute respiratory failure. • Berlin criteria for diagnosis include acute onset within 7 days, bilateral pulmonary infiltrates on imaging, not fully explained by cardiac failure or fluid overload, and impaired oxygenation with PaO2/FiO2 ratio <300 mmHg, even with positive end-expiratory pressure (PEEP) >5 cm H2O.

• Severity based on oxygenation (Berlin criteria):

• Mild: PaO2/FiO2 200-300 mmHg • Moderate: PaO2/FiO2 100-200 mmHg • Severe: PaO2/FiO2 <100 mmHg

• Epidemiology:

• Occurs in up to 23% of mechanically ventilated patients. • Mortality rate of 30-40%, primarily due to multiorgan failure.

• Differentiation from Cardiogenic Pulmonary Edema:

• Chest CT shows diffuse edema and pleural effusion in cardiogenic edema; patchy edema, dense consolidation in ARDS. • Ultrasound may show diffuse B lines in cardiogenic edema; patchy B lines and normal A lines in ARDS.

• Pathophysiology:

• Exudative phase: Immune-mediated alveolar damage, pulmonary edema, cytokine release. • Proliferative phase: Reabsorption of edema fluid. • Fibrotic phase: Potential for prolonged ventilation.

• Etiology:

• Direct lung injury (pneumonia, toxins, aspiration, trauma, drowning) and indirect causes (sepsis, pancreatitis, transfusion reactions, certain drugs).

• Diagnostics:

• Comprehensive workup including imaging (chest X-ray, CT), laboratory tests (complete blood count, basic metabolic panel, blood gases), and specialized tests depending on suspected etiology.

• Management Strategies:

• Steroids: Beneficial in certain etiologies of ARDS, with specifics on dosing and duration. • Fluid Management: Conservative fluid strategy, diuresis guided by patient condition. • Ventilation: Non-invasive ventilation (NIV) preferred in specific cases; mechanical ventilation strategies to ensure lung-protective ventilation. • Proning: Used in severe ARDS to improve oxygenation. • Inhaled Vasodilators: Used for refractory hypoxemia and specific complications like right heart failure. • Extracorporeal Membrane Oxygenation (ECMO): Considered for severe ARDS as salvage therapy. • Supportive Care: Includes monitoring and management of complications, nutrition, and physical therapy.

• Ventilation Specifics:

• Tidal volume and pressure settings aim for lung-protective strategies to prevent ventilator-induced lung injury. • Permissive hypercapnia, plateau pressure, PEEP, and ventilation mode adjustments based on patient response. • ARDSnet Table: ventilator_protocol_2008-07

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