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Acute respiratory distress syndrome is a serious lung condition that is rapidly progressive and commonly leads to lung failure. It occurs when the capillary membrane leaks fluid into the alveoli sac due to widespread inflammation or severe lung injury.2
ARDS can occur to anyone at any age including children.3 Despite advances in critical care, ARDS carries a high mortality rate of 43% and, even those who survive, have poorer quality of life with long morbidity and recovery periods leading many as 40%-52% of patients reporting re-hospitalization within one year.4
Conditions that increase the risk of ARDS are Sepsis, Pneumonia, Coronavirus disease, traumatic brain injuries, organ failure and alcohol and smoking abuse. Patients often experience severe shortness of breath leading to low oxygen in the blood (Hypoxia), followed by low blood pressure, confusion and dizziness.3,5
There is no way to completely prevent ARDS, however there are several safety measures to take to lessen the risks that lead to the development of ARDS.
|Lung protective ventilation||Limit tidal volumes & pressure swings, recruitment (body position/PEEP)|
|Aspiration precautions||Intubation supervised by experienced providers, elevaed head of the bed, oral care|
|Adequate antimicrobials & source control||According to site of infection, health care exposure, and immune suppression|
|Limiting fluid overload||Limit IV fluid, use diuretics|
|Restrictive transfusion||Hemoglobin target >7g/dL; minimize platelet transufions in the absence of active bleeding, male donor plasma|
|Prevention of new infections||Rapid weaning from ventilators (use noninvasive), devices and medications|
Acute respiratory distress syndrome is acknowledged to be a complex problem to solve in respiratory medicine. ARDS is under-diagnosed and results in a strikingly high mortality rate, and even those who survive still face complications.3
Early diagnosis and recognition of the symptoms are crucial to treat effectively and help your patients survive the highly dangerous disorder.8 It is important to note that ARDS is a rapidly progressive disorder that first appears as dyspnea, tachypnea, and hypoxemia and quickly evolves to respiratory failure.9
Diagnosing ARDS entails defining the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) of 300 or less.10 In addition, performing frontal chest radiography where bilateral infiltrates are seen; an applied PEEP of at least 5, and pulmonary artery wedge pressure of 18 mm Hg or less when measured.10
Treatment for ARDS mainly focuses on oxygen and fluid therapy to deliver enough oxygen in the blood and to prevent organs from failing.11 Depending on the level of severity, treatment for ARDS should vary. For mild ARDS, oxygen therapy via a mask or high flow nasal cannulae can be used; however, mechanical ventilation and even extracorporeal membrane oxygenation (ECMO) may be required for patients classified with moderate and severe ARDS.12,13
The Berlin criteria for ARDS have three levels of severity: mild, moderate, and severe:14
Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures and lower tidal volumes (VT) are the two most important variable that can improve the survival of patients on mechanical ventilators. 16 The modern standard of practice suggests the initiation of oxygen therapy with low tidal volumes of 6 mL per kg, rather than starting with traditional tidal volumes of 10 to 15 mL per kg.9 In addition, to maintain oxygenation, higher PEEP values (12 cm H2O or more) are associated with decreased mortality compared with lower values of 5 to 12 cm H2O.9 According to multilevel mediation analysis to analyze individual data from 3562 patients with ARDS, among ventilation variables, Driving pressure (ΔP) was most strongly associated with survival17. Individual changes in tidal volumes VT or PEEP after randomization were not independently associated with survival; they were associated only if they were among the changes that led to reductions in ΔP. 17
In addition, even though studies have showed thatlower tidal volumes’results in decreased mortality and increases the number of days without ventilator use, 16,17 it’s always wise to not generalize this approach as the standard practice of care as it can sometimes cause respiratory acidosis and decrease arterial oxygenation. An individualized approach to the management of the ARDS patient, where oxygenation, CO2, driving pressure, and haemodynamic targets are adjusted regularly at the bedside may be the best approach.18
Lastly and importantly, conservative fluid therapy (titrated to lower central pressures) and prone positioning (at least 12 hours per day) are recommended as adjunct treatments.9
Paediatric acute respiratory distress syndrome (PARDS) accounts for up to 10% of admissions to the paediatric intensive care unit (PICU) and the most common cause of death to children admitted to PICU. A large PARDS study found that neurologic failure and multi-system organ failure are the primary cause of death compared to the deaths attributed to hypoxemia. Overall, the PARDS mortality rate has decreased over the past few decades, and its mortality rate is still lower than the Adult ARDS mortality rate.19
Clinical evidence and recommendations for Paediatric acute respiratory distress syndrome Therapies are as follows:19
In Severe PARDS:
Other recommendations include:
ARDS develops within 42% of patients diagnosed with COVID-19 Pneumonia. Respiratory rate and SpO2 are two measures to indicate the early onset of ARDS. A patient whose measures fall within the following rates may have severely progressed with the COVID-19 ARDS disease: respiratory rate ≥ 30 breaths/min; SpO2 ≤ 92%; and PaO2/FiO2 ≤ 300 mm Hg.20
When COVID-19 enters the body, it often attaches to cells in the upper airway, and 42% of the time, the virus goes through beyond the upper airway and ends up in the alveolii of the lungs, causing both vascular and alveolar damage. You can expect COVID-19 ARDS to set in, in about 8 days after the onset of initial COVID-19 symptoms.21
For COVID‐19 ARDS, mortality rates for patients in critical care settings range from 26-61%, whereas patients who received mechanical ventilation range from 65.7% - 94%. The ventilation strategy for treating COVID-19 ARDS is essential for breathing support. However, the following points are key elements:
Oxygen therapy is the main treatment for ARDS as it improves the oxygen level in the blood and promotes organ functionality. Measuring the level of EtCO2, capnography waveform and respiratory rate are essential to help assess the level of respiratory distress and the efficacy of a treatment.
The OxyMask™* EtCO2 with microstream™ connector is engineered to deliver a wide range of O2 levels (up to 15 lpm, and 65% FiO2) and captures EtCO2 sampling. Microstream is a low flow, plug & play leading capnography monitoring technology that does not require individual patient calibration and is not affected by the presence of other gases.
These therapies allow for early application of optimal oxygen.
Compared to conventional mechanical ventilation, The Puritan Bennett™ 980 ventilator helps enable patients to breathe more naturally through some of the most innovative breath delivery technology available.24 Ventilation treatment is recommended for patients suffering from ARDS and COVID-19 according to their pathology stage levels, in critical and intensive care units.24
The Puritan Bennett™ 980 ventilator includes advanced synchrony tools like HFO2T Software, PAV+™ , Leak sync and P-Drive that help clinicians to better tailor to patients' needs providing the appropriate level of support throughout the single breath. In patients with acute hypoxia respiratory failure, HFO2T has been shown to improve oxygenation and comfort while decreasing mortality rates.1,25
The automated functions available on the Puritan Bennett™ 840 and 980 ventilators, such as the Leak compensation and PAV+™ software, has clinically shown to reduce the asynchrony rate by 81%, increase the weaning success rate by 23%, and decrease the ICU admission time by five days.26
Puritan Bennett™ PAV+™ software can help clinicians address patient-ventilator asynchrony. It considers how a patient is breathing and enables the patient to determine each breath's rate, depth, and timing.27
Engineered with key clinical features, the Nellcor™ pulse oximeters measurements are tied to true arterial oxygen saturation and cardiac induced pulse. It offers advanced digital signal processing technology for reliable operation even during low perfusion and signal interference, including patient motion. And LoSat™ expanded the accuracy range of 60% to 100% SpO2 when used with Nellcor™ pulse oximetry adhesive sensors with OxiMax™ technology.
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2. Beitler JR, Schoenfeld DA, Thompson BT. Preventing ARDS: progress, promise, and pitfalls. Chest. 2014;146(4):1102-1113.
3. Diamond M, Peniston HL, Sanghavi D, et al. Acute Respiratory Distress Syndrome. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available at: https://www.ncbi.nlm.nih.gov/books/NBK436002
4. Siuba MT, Sadana D, Gadre S, Bruckman D, Duggal A. Acute respiratory distress syndrome readmissions: A nationwide cross-sectional analysis of epidemiology and costs of care. PLoS One. 2022 Jan 25;17(1):e0263000
5. Nhlbi.nih.gov. 2021. Acute Respiratory Distress Syndrome NHLBI, NIH. [online] Available at: https://www.nhlbi.nih.gov/health-topics/acute-respiratory-distress-syndrome [Accessed 23 July 2021].
6. Mayo Clinic. June 13, 2020. ARDS, [online - Accessed 03 Dec 2021] Available at: https://www.mayoclinic.org/diseases-conditions/ards/symptoms-causes/syc-20355576
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10. Arrivé F, Coudroy R, Thille AW. Early Identification and Diagnostic Approach in Acute Respiratory Distress Syndrome (ARDS). Diagnostics (Basel). 2021;11(12):2307. Published 2021 Dec 8.
11. Matthay MA, Zemans RL, Zimmerman GA, et al. Acute respiratory distress syndrome. Nat Rev Dis Prim. 2018;5:18.
12. Ohshimo, S. Oxygen administration for patients with ARDS. j intensive care 9, 17 (2021).
13. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(21):1965-1975.
14. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-2533.
15. Matthay MA, Zemans RL, Zimmerman GA, et al. Acute respiratory distress syndrome. Nat Rev Dis Primers. 2019;5(1):18. Published 2019 Mar 14. doi:10.1038/s41572-019-0069-0
16. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.
17. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-755.
18. Pelosi, P., Ball, L., Barbas, C.S.V. et al. Personalized mechanical ventilation in acute respiratory distress syndrome. Crit Care 25, 250 (2021).
19. Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress Syndrome. Pediatr Allergy Immunol Pulmonol. 2019;32(2):35-44.
20. Gibson PG, Qin L, Puah SH. COVID-19 acute respiratory distress syndrome (ARDS): clinical features and differences from typical pre-COVID-19 ARDS. Med J Aust. 2020;213(2):54-56.e1. doi:10.5694/mja2.50674
21. Acute Respiratory Distress Syndrome (ARDS). (2022, June 6). Yale Medicine. https://www.yalemedicine.org/conditions/ards
22. Mina B, Newton A, Hadda V. Noninvasive Ventilation in Treatment of Respiratory Failure-Related COVID-19 Infection: Review of the Literature. Can Respir J. 2022;2022:9914081. Published 2022 Aug 31.
23. Sodhi K, Chanchalani G. Awake Proning: Current Evidence and Practical Considerations. Indian J Crit Care Med. 2020;24(12):1236-1241
24. Oto J., Chenelle T.C. at al, A Comparison of Leak compensation in CUTE Care Ventilators During Noninvasive and Invasive Ventilation: A Lung Model Study, Respir Care. 2013 Dec;58(12):2027-37. doi: 10.4187/respcare.02466. Epub 2013 May 21. PMID: 23696688.
25. Biselli PJ, Kirkness JP, Grote L, et al. Nasal high flow therapy reduces work of breathing compared with oxygen during sleep in COPD and smoking controls: a prospective observational study. J Appl Physiol (1985). 2017;122(1):82–88
26. Loss SH, De Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, et al. The reality of patients requiring prolonged mechanical ventilation: a multicenter study. Rev Bras Ter Intensiv. 2015;27:26–35
27. Itagaki T. Chenelle T et all, Effects of Leak Compensation on Patient-Ventilator Synchrony During Premature/Neonatal Invasive and Noninvasive Ventilation: A Lung Model Study, Respir Care. 2017; 62(1): 22-23 Daedalus Enterprises