ARDS

HISTORY
• Name- Perumal
• Age- 48 sex: M
• DOA- 3/12/2004
• Chief complaints- fever 4 days
cough & expectoration 4days
seizure 1 episode with altered
sensorium 4hrs prior to adm
HISTORY
• H/O continuous fever of high grade ass
with chills
• Associated with cough &expectoration
• Difficulty in breathing
• H/o generalised tonic seizure associated
with urinary incontinence
• Jaundice 3 yrs back
• Chronic smoker & alcoholic
EXAMINATION
• Conscious, restless,obeying commands
• No pallor,icterus,cyanosis,clubbing
• Mild pedel edema +
• Afebrile, tachypnea+
PR- 110/min,regular BP- 80 systolic
CVS-S1,S2 not heard clearly
RS- Bil crepts + ,occ rhonchi +
P/A-diffuse tenderness/guarding +
PROVISIONAL DIAGNOSIS

• ? Pneumonia with ARDS

• ? Pancreatitis / perforation with
sepsis
MANAGEMENT

• 4th hrly PTR/ IO chart/ npo/ RT

drain/O2 by mask
• Antibiotics and bronchodilators
• At 10.00 am on 4/12/04 pt was
intubated as the pt was gasping &
was shifted to ccu for ventilation
Course in ccu

• Pt in grade 3 sensorium
• PR-157/min BP-100/70 mmHg
CVS – S1S2 +
RS- bil crepts +, Rhonchi +, gasping &
chest indrawing +
• Pt put on PB ventilator with SIMV PC PS
with 50% FIO2
Contd….
• Pt weaned from ventilator and extubated on
7th morning
• Pt monitored with ECG,Spo2,HR,NIBP
• At present pt is conscious,oriented,obeying
commands ,febrile
PR-98/min RR-26/min BP- 118/105mmHg
Spo2- 98% in room air
RS- clear, NVBS CVS-S1S2 +
P/A-soft distension+
workup
• WBC-13,200cells/cu mm Hb-10gms%
• N-77% E-7% L-16%
• BU-114mg% BS- 189mg% SC-3.4mg%
• Na 144 K-5.3 se amylase-113 iu/l
• STP-4.6, Alb-2.4, bil-0.6,AST-109,ALT-73
ALP-413
• CSF-protein-100mg% sugar-71mg%
• MP/MF- negative
• Tracheal aspirate- pseudomonas sens to
cipro,amikacin,ceftazidime
ACUTE RESPIRATORY
DISTRESS SYNDROME
DEFINITION

condition characterized by acute

hypoxemic respiratory failure due to
pulmonary edema caused by
increased permiability of the alveolar
capillary barrier
 CAUSES
Direct lung injury Indirect lung injury
Common- pnemonia, Common-sepsis,severe
aspiration of gastric trauma with shock &
contents multiple transfusion
Less common –pul Less common- CPB
contusion Drug overdose
Fat emboli Acute pancreatitis
Near drowning Transfusion of blood
Inhalational injury products
Reperfusion pul edema
Common cause in tropics
• Severe pneumonia
• Pul tuberculosis
• Enteric fever
• Malaria
• Strongyloidiasis
• Leptospirosis
• OP poisoning,paraquat poisoning
• Scorpion bite, heat stroke
DIAGNOSTIC CRITERIA

• Acute onset
• Bil infilterates on chest radiograph
• PAWP-<18mmHg or absence of
clinical evidence of lt atrial
hypertension
• ALI-Pao2/Fio2<= 300mmHg
• ARDS-Pao2/Fio2<= 200mmHg
Pathophysiology
• Hallmark-increased vascular
permeability to proteins
• Three stages-initiation
ampilification
injury
• Interstitial and alveolar edema
• Alveolar collapse and decreased
compliance
Pathology

• Necrosis of type 1 pnemocytes &

denuded BM
• Endothelial swelling with widened IC
junction
• Hyaline membrane-fibrin & matrix
protein in airspace
• Neutrophilic inflammation
Clinical features
• Occurs within 5 days of initial at-risk diagnosis
• 50% in first 24 hrs
• Increased RR,dyspnea
• CXR-initial clear
-diffuse bil interstitial & alveolar edema
-difficult to diff from cardiogenic pul edema
 CXR
Criterion Acute pul edema ARDS

1.Cardiomegaly common uncommon

2.Alveolar +++ +++
edema Patchy more in More patchy
3.Appearance of midlung
parenchymal “butterfly
shadow shadow”
Less likely
4.Perivascular,p More often seen
eribronchial
cuffing No
Yes
5.Gravitational
distribution unlikely
Treatment
• No specific therapy
• Mechanical ventilation-to achieve
adequate oxygenation
airway pressure: 30-35mmHg
low tidal volumes appro 6ml/Kg
permissive hypercapnia
adequate PEEP-lung protective
strategy
Contd....

• Fluid and hemodynamic management

• Surfactant therapy
• Inhaled nitricoxide and other vasodilators
• Glucocorticoids
• Acceleration of resolution-beta agonists
THANK U