Acute Respiratory Distress Syndrome - PACCM @...
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Courtesy of Drs. Faraaz Shah and Bryan McVerry Acute Respiratory Distress Syndrome Although not included in the Berlin Definition, the underlying pathophysiology is important to remember in the management of ARDS ARDS is under-recognized, how can we better identify patients at risk for ARDS? Lung Injury Prediction Score (LIPS) Predisposing Conditions Points Risk Modifiers Points Sepsis 1.5 Alcohol use 1 Shock 1.5 Tobacco use 0.5 Trauma 0.5 Hypoalbuminemia 2 Pneumonia 0.5 Diabetes -1.5 Aspiration 1.5 Chemotherapy 2 Pancreatitis 1.5 FiO2 > 0.35 1 Elective Surgery 1.5 Tachypnea 1 Emergency Surgery 2 LIPS < 4 has a high negative predictive value, odds of ARDS increase with higher scores Trigger Inflammatory and Chemical Mediators Alveolar Injury • Epithelial • Endothelial Surfactant dysfunction Capillary leak Capillary thrombi Vasoconstriction Shunt- Hypoxemia Decreased compliance Increased dead space Decreased aerated lung Berlin Definition Timing Within 1 week of a known clinical insult, or new or worsening respiratory symptoms Chest Imaging Bilateral opacities not fully explained by effusions, lobar collapse, or lung nodules Origin of Edema Respiratory failure not fully explained by cardiac failure or fluid overload (an objective assessment [ex- TTE] to exclude hydrostatic edema is warranted if no trigger is identified) Oxygenation Mild: 200 < P/F ratio ≤ 300 with PEEP ≥ 5 or CPAP ≥ 5 Moderate: 100 < P/F ratio ≤ 200 with PEEP ≥ 5 Severe: P/F ratio ≤ 100 with PEEP ≥ 5
Transcript of Acute Respiratory Distress Syndrome - PACCM @...
Courtesy of Drs. Faraaz Shah and Bryan McVerry Acute Respiratory Distress Syndrome
Although not included in the Berlin Definition, the underlying pathophysiology is important to remember in the management of ARDS
ARDS is under-recognized, how can we better identify patients at risk for ARDS?
Lung Injury Prediction Score (LIPS)
Predisposing Conditions Points Risk Modifiers Points Sepsis 1.5 Alcohol use 1 Shock 1.5 Tobacco use 0.5 Trauma 0.5 Hypoalbuminemia 2 Pneumonia 0.5 Diabetes -1.5 Aspiration 1.5 Chemotherapy 2 Pancreatitis 1.5 FiO2 > 0.35 1 Elective Surgery 1.5 Tachypnea 1 Emergency Surgery 2 LIPS < 4 has a high negative predictive value, odds of ARDS increase with higher scores
Trigger Inflammatory and Chemical Mediators
Alveolar Injury• Epithelial• Endothelial
Surfactant dysfunction
Capillary leakCapillary thrombiVasoconstriction
Shunt- HypoxemiaDecreased complianceIncreased dead space
Decreased aerated lung
Berlin Definition
Timing Within 1 week of a known clinical insult, or new or worsening respiratory symptoms
Chest Imaging Bilateral opacities not fully explained by effusions, lobar collapse, or lung nodules
Origin of Edema Respiratory failure not fully explained by cardiac failure or fluid overload (an objective assessment [ex- TTE] to exclude hydrostatic edema is warranted if no trigger is identified)
Oxygenation Mild: 200 < P/F ratio ≤ 300 with PEEP ≥ 5 or CPAP ≥ 5
Moderate: 100 < P/F ratio ≤ 200 with PEEP ≥ 5
Severe: P/F ratio ≤ 100 with PEEP ≥ 5
Courtesy of Drs. Faraaz Shah and Bryan McVerry ARDS is under-treated, start appropriate treatments early instead of as salvage therapies
Effects of ARDS last long after the inciting event, start thinking of your patients as survivors when they enter the ICU
Mortality In-hospital mortality globally ~ 40%
1 year mortality in survivors is 20-25%
Lung function Spirometry and DLCO recover to normal levels at 1 year
Survivors will still report dyspnea and difficulty with exertion
Cognitive deficits Discharge- 70-100% of survivors report some cognitive impairment
1 year: 45-80%
5 year: 20%
Psychiatric disease New or worsened psychiatric disease including depression, PTSD, and anxiety is reported in 40-60% of survivors and persists 2+ years in many studies
Physical function Musculoskeletal weakness has been observed in 35-70% of survivors at hospital discharge and is associated with worse 1 and 5 year survival.
