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PubMed2006

Mechanism of injury influences quality of life in survivors of acute respiratory distress syndrome.

OBJECTIVE: Growing evidence suggests that acute respiratory distress syndrome (ARDS) occurring as a consequence of primary (direct) lung injury differs from that resulting from secondary (indirect) lung injury in terms of radiographic appearance, response to interventions, and outcomes. We examined whether there are differences in quality of life (QOL) in survivors of ARDS attributable to the mechanism of underlying lung injury. DESIGN AND SETTING: Prospective observational cohort study in 54 intensive care units in Canada and the United States. PATIENTS AND PARTICIPANTS: Survivors of ARDS (n=73) were grouped according to underlying cause of ARDS (i.e., primary vs. secondary lung injury) and followed prospectively for 12months. MEASUREMENTS AND RESULTS: QOL was assessed using the Medical Outcomes Study 36-item Short Form Health Survey (SF-36) and the St. George's Respiratory Questionnaire (SGRQ), and spirometry was performed at each outpatient follow-up visit. At 3months mortality and QOL outcomes were similar between the groups, but by 12months patients with primary lung injury had significantly better QOL scores in four of eight SF-36 domains and in two of three domains of the SGRQ. Differences were not attributable to duration of ICU or hospital length of stay, duration of mechanical ventilation, comorbidities prior to the index illness, or differences in spirometry during the follow-up period. CONCLUSIONS: QOL in survivors of ARDS appears to be influenced by the mechanism of lung injury (primary vs. secondary), lending support to the concept that ARDS is a heterogeneous condition.

Canada↗

PubMed2000

Radiographic findings in patients with acute respiratory distress syndrome.

Since its description in 1967, acute respiratory distress syndrome (ARDS) has become a widely recognized, if somewhat imperfectly understood, entity. This article reviews the imaging characteristics of ARDS as demonstrated on plain chest radiography, CT scan, radionuclide imaging, and MR imaging. The abnormalities displayed on these modalities are well understood even though there may be some dispute as to their relative importance in diagnosing and managing patients.

Barotrauma↗

PubMed1995

Prospective validation of an acute respiratory distress syndrome predictive score.

We derived an Acute Respiratory Distress Syndrome Score (ARDS Score) from previously described training set data. To validate its diagnostic accuracy for identifying a complicated course (early death or prolonged intubation) in acute lung injury, 50 patients were prospectively scored using an ARDS Score decision threshold of > or = 2.5 to discriminate between an uncomplicated (successful extubation after < or = 14 d) and complicated course. Predictor factors incorporated in the ARDS Score were collected on Day 4 and Day 7 of ARDS and included PaO2/PAO2 ratio, required positive end-expiratory pressure (PEEP), and chest radiograph progression. The diagnostic accuracy of the ARDS Score for determining a complicated course as well as overall survival was compared with three other available indices. Using receiver operating characteristic (ROC) analysis, the ARDS Score and Lung Injury Score (LIS) had the greatest diagnostic accuracy for determining a complicated course, but the Simplified Acute Physiology Score (SAPS Score) (score > or = 14) more accurately identified survival. The LIS components of static respiratory system compliance (Crs) and chest radiograph description did not differ between patient groups. The interobserver concordance of the dynamic chest radiograph interpretation included in the ARDS Score was significant (p < 0.05). We conclude that the previously derived ARDS Score has valid diagnostic accuracy for identifying patients with ARDS who will follow a complicated course.

Acute Disease↗

PubMed1986

Respiratory distress syndrome.

Increasing knowledge of the pathophysiology of respiratory distress syndrome has led to improvements in clinical management. Future advances in prevention and therapy, including administration of agents to prevent prematurity or to accelerate lung maturation, provision of surfactant replacement, and new techniques of mechanical ventilation, will further decrease mortality and morbidity.

Animals↗

PubMed2005

Monitoring of pulmonary mechanics in acute respiratory distress syndrome to titrate therapy.

PURPOSE OF REVIEW: This paper reviews recent findings regarding the respiratory mechanics during acute respiratory distress syndrome as a tool for tailoring its ventilatory management. RECENT FINDINGS: The pressure-volume curve has been used for many years as a descriptor of the respiratory mechanics in patients affected by acute respiratory distress syndrome. The use of the sigmoidal equation introduced by Venegas for the analysis of the pressure-volume curve seems to be the most rigorous mathematical approach to assessing lung mechanics. Increasing attention has been focused on the deflation limb for titration of positive end-expiratory pressure. Based on physiologic reasoning, a novel parameter, the stress index, has been proposed for tailoring a safe mechanical ventilation, although its clinical impact has still to be proved. Evidence has confirmed that a variety of underlying pathologies may lead to acute respiratory distress syndrome, making unrealistic any attempt to unify the ventilatory approach. Although extensively proposed to tailor mechanical ventilation during acute respiratory distress syndrome, there is no evidence that the pressure-volume curve may be useful in setting a lung-protective strategy in the presence of different potentials for recruitment. SUMMARY: The Venegas approach should be the standard analysis of pressure-volume curves. In any patient, the potential for recruitment should be assessed, as a basis for tailoring the most effective mechanical ventilation. Further studies are needed to clarify the potential use of the pressure-volume curve to guide a lung-protective ventilatory strategy.

Humans↗

PubMed1980

Adult respiratory distress syndrome and gonococcemia.

A case of adult respiratory distress syndrome (ARDS) is described that was secondary to conococcal septicemia. The patient had severe hypoxemia and diffuse pulmonary infiltrates. The diagnosis of disseminated gonorrhea was confirmed by the isolation of Neisseria gonorrhoeae from one of several typical appearing skin lesions. The patient did not require mechanical ventilation and made a prompt recovery after a regimen of antibiotics was started. The association between ARDS and gonococcemia is extremely rare. It occurrence may be related to unusual properties of the gonococcal endotoxin or to the host response.

Adult↗

PubMed2024

Inflammatory and tissue injury marker dynamics in pediatric acute respiratory distress syndrome.

BACKGROUNDThe molecular signature of pediatric acute respiratory distress syndrome (ARDS) is poorly described, and the degree to which hyperinflammation or specific tissue injury contributes to outcomes is unknown. Therefore, we profiled inflammation and tissue injury dynamics over the first 7 days of ARDS, and associated specific biomarkers with mortality, persistent ARDS, and persistent multiple organ dysfunction syndrome (MODS).METHODSIn a single-center prospective cohort of intubated pediatric patients with ARDS, we collected plasma on days 0, 3, and 7. Nineteen biomarkers reflecting inflammation, tissue injury, and damage-associated molecular patterns (DAMPs) were measured. We assessed the relationship between biomarkers and trajectories with mortality, persistent ARDS, or persistent MODS using multivariable mixed effect models.RESULTSIn 279 patients (64 [23%] nonsurvivors), hyperinflammatory cytokines, tissue injury markers, and DAMPs were higher in nonsurvivors. Survivors and nonsurvivors showed different biomarker trajectories. IL-1α, soluble tumor necrosis factor receptor 1, angiopoietin 2 (ANG2), and surfactant protein D increased in nonsurvivors, while DAMPs remained persistently elevated. ANG2 and procollagen type III N-terminal peptide were associated with persistent ARDS, whereas multiple cytokines, tissue injury markers, and DAMPs were associated with persistent MODS. Corticosteroid use did not impact the association of biomarker levels or trajectory with mortality.CONCLUSIONSPediatric ARDS survivors and nonsurvivors had distinct biomarker trajectories, with cytokines, endothelial and alveolar epithelial injury, and DAMPs elevated in nonsurvivors. Mortality markers overlapped with markers associated with persistent MODS, rather than persistent ARDS.FUNDINGNIH (K23HL-136688, R01-HL148054).

Humans↗

PubMed1997

Neonatal respiratory distress syndrome in Karachi: some epidemiological considerations.

Although respiratory distress syndrome (RDS) is a leading cause of neonatal morbidity and mortality in the west, there are few data on the prevalence and spectrum of RDS from developing countries. Available evidence suggests that the disorder may be less common than the overall 1% incidence reported from developed countries. In a prospective study of the prevalence of RDS in a consecutive 10,134 births at the Aga Khan University Hospital, we documented the disorder in 127 (1.2% births), with a prevalence of 12.8% among low birthweight infants. The overall mortality for this group was 39%, with the highest mortality rate (68%) among newborn infants < or = 1000 g birthweight. Our data from a large and relatively well-nourished hospital-born population in Karachi suggest that RDS is a significant cause of morbidity and mortality in preterm infants with a similar prevalence rate to western figures.

Female↗

PubMed1994

Role of selectins in development of adult respiratory distress syndrome.

The acute lung injury of adult respiratory distress syndrome (ARDS) is characterised by inflammatory cell accumulation and activation in the lung. Selectins are a family of adhesion molecules implicated in leucocyte-endothelial adhesion, whose receptors can exist in a cleaved, soluble form. We investigated whether circulating soluble selectin adhesion molecules, obtained from ARDS at-risk patients, were associated with subsequent ARDS development. 82 patients, at risk of ARDS, were enrolled from three well-defined groups (multiple trauma, pancreatitis, perforated bowel). Plasma samples were obtained on hospital presentation and soluble L, E, and P, selectins were quantified with a sandwich enzyme-linked immunosorbent assay (ELISA). 14 patients subsequently developed ARDS. Initial plasma soluble L-selectin (sL-selectin) levels were significantly lower in patients who progressed to ARDS compared to those who did not (p = 0.0001; 95% Cl for mean in ARDS patients as percent of that in non-ARDS patients, 27-61%). Moreover concentrations were lower than in 62 normal volunteers (range 0.37-6.55, median 1.83 micrograms/mL, n = 62), suggesting that a selective reduction of sL-selectin correlates with susceptibility. In addition, a significant correlation was found between low values of sL-selectin and indices of subsequent lung injury including requirement for ventilation (p = 0.0001) and degree of respiratory failure (p = 0.0001). A significant correlation was also found between low values of sL-selectin and patient mortality (p = 0.002). These results elucidate the inflammatory cell endothelial interactions in the early stages of ARDS and may be of prognostic value.

Acute Disease↗

PubMed1998

Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease. Different syndromes?

To assess the possible differences in respiratory mechanics between the acute respiratory distress syndrome (ARDS) originating from pulmonary disease (ARDSp) and that originating from extrapulmonary disease (ARDSexp) we measured the total respiratory system (Est,rs), chest wall (Est,w) and lung (Est,L) elastance, the intra-abdominal pressure (IAP), and the end-expiratory lung volume (EELV) at 0, 5, 10, and 15 cm H2O positive end-expiratory pressure (PEEP) in 12 patients with ARDSp and nine with ARDSexp. At zero end-expiratory pressure (ZEEP), Est,rs and EELV were similar in both groups of patients. The Est,L, however, was markedly higher in the ARDSp group than in the ARDSexp group (20.2 +/- 5.4 versus 13.8 +/- 5.0 cm H2O/L, p < 0.05), whereas Est,w was abnormally increased in the ARDSexp group (12.1 +/- 3.8 versus 5.2 +/- 1.9 cm H2O/L, p < 0.05). The IAP was higher in ARDSexp than in ARDSp (22.2 +/- 6.0 versus 8.5 +/- 2.9 cm H2O, p < 0.01), and it significantly correlated with Est,w (p < 0. 01). Increasing PEEP to 15 cm H2O caused an increase of Est,rs in ARDSp (from 25.4 +/- 6.2 to 31.2 +/- 11.3 cm H2O/L, p < 0.01) and a decrease in ARDSexp (from 25.9 +/- 5.4 to 21.4 +/- 55.5 cm H2O/L, p < 0.01). The estimated recruitment at 15 cm H2O PEEP was -0.031 +/- 0.092 versus 0.293 +/- 0.241 L in ARDSp and ARDSexp, respectively (p < 0.01). The different respiratory mechanics and response to PEEP observed are consistent with a prevalence of consolidation in ARDSp as opposed to prevalent edema and alveolar collapse in ARDSexp.

Adult↗

PubMed1982

Adult respiratory distress syndrome: definition and historical perspective.

The adult respiratory distress syndrome is a reaction of the lung to a variety of severe direct or indirect pulmonary insults. It is characterized by acute respiratory distress, severe hypoxemia requiring high oxygen fractions, and "stiff lungs" requiring approaches to ventilatory management cited elsewhere in this issue of Clinics in Chest Medicine. Increased shunt fraction and dead space ventilation and airless lungs with debris and hyaline membranes are hallmarks of the syndrome, even though the final common pathway, i.e., the mechanism, is not known. The characterization of ARDS creates an important pathological concept for which there is an organized approach to physiologically oriented management. Details of management are cited elsewhere in this issue.

Adult↗

PubMed1985

Quantification of asymmetric lung pathophysiology as a guide to the use of simultaneous independent lung ventilation in posttraumatic and septic adult respiratory distress syndrome.

The management of impaired respiratory gas exchange in patients with nonuniform posttraumatic and septic adult respiratory distress syndrome (ARDS) contains its own therapeutic paradox, since the need for volume-controlled ventilation and PEEP in the lung with the most reduced compliance increases pulmonary barotrauma to the better lung. A computer-based system has been developed by which respiratory pressure-flow-volume relations and gas exchange characteristics can be obtained and respiratory dynamic and static compliance curves computed and displayed for each lung, as a means of evaluating the effectiveness of ventilation therapy in ARDS. Using these techniques, eight patients with asymmetrical posttraumatic or septic ARDS, or both, have been managed using simultaneous independent lung ventilation (SILV). The computer assessment technique allows quantification of the nonuniform ARDS pattern between the two lungs. This enabled SILV to be utilized using two synchronized servo-ventilators at different pressure-flow-volumes, inspiratory/expiratory ratios, and PEEP settings to optimize the ventilatory volumes and gas exchange of each lung, without inducing excess barotrauma in the better lung. In the patients with nonuniform ARDS, conventional ventilation was not effective in reducing shunt (QS/QT) or in permitting a lower FIO2 to be used for maintenance of an acceptable PaO2. SILV reduced per cent v-a shunt and permitted a higher PaO2 at lower FIO2. Also, there was x-ray evidence of ARDS improvement in the poorer lung. While the ultimate outcome was largely dependent on the patient's injury and the adequacy of the septic host defense, by utilizing the SILV technique to match the quantitative aspects of respiratory dysfunction in each lung at specific times in the clinical course, it was possible to optimize gas exchange, to reduce barotrauma, and often to reverse apparently fixed ARDS changes. In some instances, this type of physiologically directed ventilatory therapy appeared to contribute to a successful recovery.

Adolescent↗

PubMed2006

Supportive care in acute respiratory distress syndrome.

Although the central focus of acute respiratory distress syndrome (ARDS) is the pathology within the lung, ARDS is very much a systemic disease. As such, the whole body needs care and support while the disease process within the lung runs its course. The issues of pain management, sedation, fluid balance, nutrition, metabolic and hormonal processes, infection control, and patient positioning are important for any patient in a critical care setting. For patients with ARDS, the required ventilatory support and ARDS-associated systemic inflammation mandate the above supportive measures.

Procedural Sedation↗

PubMed1981

Diagnosis of adult respiratory distress syndrome associated with underlying severe emphysema.

Adult respiratory distress syndrome (ARDS) notably produces bilateral homogeneous alveolar infiltrates and decreased lung compliance. We encountered a patient whose severe underlying emphysema altered these distinctive clinical features. The chest roentgenogram showed bilateral infiltrates containing multiple radiolucencies that simulated a cavitary process. Also, lung-chest wall compliances measured during mechanical ventilation were higher than usually observed in patients with ARDS. We suggest that the pathologic features of the emphysematous lung with multiple blebs and decreased elastic recoil properties impart these unique findings. When ARDS develops in a patient with severe underlying emphysema, an atypical presentation may produce a confusing clinical picture.

Humans↗

PubMed1994

[Short and mid-term outcome of a cohort of 1157 newborn infants with respiratory distress syndrome].

BACKGROUND: Data concerning neonates with acute respiratory distress syndrome (RDS) are still scarce. The characteristics and follow-up of a French cohort which has participated in an international trial concerning the efficacy of artificial surfactant have been studied. POPULATION AND METHODS: One thousand one hundred and fifty-seven neonates admitted from October 1990 to December 1991 in 27 French intensive care units because of RDS due to hyaline membrane disease were included in the study, whatever their birthweight and gestational age (GA). RESULTS: Three hundred and sixteen neonates (27.3%) were born from twin or multiple pregnancies. Fourty-five (5.5%) of the mothers had been given corticosteroids for the week preceding delivery. 55.5% were delivered by cesarean section. Mean GA was 31.0 +/- 2.9 weeks and mean birth-weight was 1,603 +/- 625 g. Two hundred and sixty-six neonates (23%) were small for GA. Two hundred and twenty-three died after a mean survival of 4.2 days (63% before the end of the first week and 80% before the end of the third week). Fifty percent of these deaths were due to respiratory distress, 28% to severe brain disorders and 9% to infections. The bronchopulmonary dysplasia rate was 21.7%. Early ultrasound scan of the brain showed major injuries in 19.5% of cases; the second scan performed in 822 infants was normal in 84.3%. CONCLUSIONS: Taking into account GA, mortality and morbidity rates were similar to those of the other non-French participating centres.

Birth Weight↗

PubMed1980

[Ultrastructural changes in the lung in acute adult respiratory distress syndrome].

Morphological alterations of the lung in respiratory distress syndrome of adults (ARDS) were analyzed in 10 cases with traumatic-and septic shock, laryngitis subglottica descendens and bronchopneumonia. For the better understanding of the pathomechanism of the disease in addition to the standard methods, first of all ultrastructural alterations were studied. Two phases of the morphologic alterations could be distinguished, the phase of the destruction and the phase of the repair. These two processes are not sharply distinguishable. Genesis of the characteristic histological alterations (damage to the epithelial and endothelial cells, formation of hyaline membranes, microcoagulation, proliferation of the type II pneumocytes and fibroblasts, fibrosis) is discussed, with regard to the data of the literature.

Acute Disease↗

PubMedDate not supplied

[Substitutive therapy with surfactants in premature infants with respiratory distress syndrome].

The main pathogenetic moment of the respiratory distress syndrome (RDS) is recognized to be the lack of alveolar surfactant. Many attempts of substitutive therapy with several kinds of surfactants have been tried (artificial, synthetic, from amniotic fluid, exosurf). After the considerable results obtained in animals, the use of substitutive surfactant proved to be useful also in human newborns with RDS. The authors report the personal data relative to the TA-surfactant (artificial surfactant made of phospholipids + DPPC + protein substances extracted from bovine lung). They analyse first results and, on this ground, they put forward some assumptions in order to obtain a more rational and efficient use.

Administration, Oral↗

PubMed2001

Bronchoscopic instillation of surfactant in acute respiratory distress syndrome.

Abnormalities of surfactant action in acute respiratory distress syndrome (ARDS) result in decreased lung compliance and significant hypoxemia. Several case reports and small studies suggest that there is an improvement in patients with ARDS following the administration of surfactant. However, there is no clear-cut ideal method for surfactant administration. The bronchoscopic administration of surfactant may represent an effective method of surfactant delivery in ARDS. Bronchoscopic instillation offers the theoretical advantages that the surfactant may be distributed directly to the desired regions of the lung, a more economical use of surfactant, and the opportunity to lavage leaked serum proteins prior to instillation. Surfactant has been administered in adults with success. We present a case of initial improvement in oxygenation index, ventilation index, and mechanical ventilatory support in a pediatric patient with ARDS following the bronchoscopic administration of surfactant.

Bronchoscopy↗