Abstract
The adult respiratory distress syndrome is the most severe pulmonary complication that can follow multiple trauma and critical illness. It is caused by an insult to the pulmonary circulation which results in an increased capillary permeability and subsequent interstitial edema. An increased venoarterial shunt occurs resulting in arterial hypoxemia. The mortality rate is at least 50% if treatment is not begun before profound hypoxemia occurs. Recognition of abnormal cardiopulmonary function before overt hypoxemia develops is important. This is best accomplished by attentive monitoring of arterial blood gases. Sequential arterial oxygen tensions obtained on 40% and 100% inspired oxygen concentration are the best guides to selecting patients who have a high probability of pulmonary deterioration. Aggressive cardiovascular monitoring and early treatment with low levels of positive-end expiratory pressure offer this group of patients an improved change of survival.
Résumé
Le syndrome de détresse respiratoire de l'adulte représente la complication la plus grave qui puisse survenir chez le polytraumatisé et le malade dont l'état est critique. Il est provoqué par une atteinte de la circulation pulmonaire qui résulte d'une augmentation de la perméabilité capillaire cause elle-même de l'oedème interstitiel. Un court-circuit artérioveineux accru en résulte qui est la source d'une hypoxie artérielle. Le taux de la mortalité atteint au moins 50% si le traitement n'est pas instauré rapidement avant que ne se développe une profonde hypoxie.
Le diagnostic de dysfonctionnement cardio-pulmonaire avant que l'hypoxie se développe est capital. Un monitorage attentif de la pression des gaz du sang artériel permet ce diagnostic. Les pressions séquentielles d'oxygène artériel mesurées lorsque les concentrations d'oxygène inspiré sont de 40% et de 100% sont les meilleurs éléments de sélection des malades qui présentent une haute probabilité d'atteinte pulmonaire. Le monitorage cardio-vasculaire très attentif et le traitement précoce qui a pour but de maintenir une pression positive résiduelle de fin d'expiration permet d'améliorer les chances de survie de ces malades.
Resumen
El síndrome de dificultad respiratoria del adulto es la complicación pulmonar más severa que puede presentarse como consecuencia del trauma o de enfermedad crítica. Es causado por una lesión de la circulación pulmonar que resulta en permeabilidad capilar aumentada y subsecuente edema intersticial. Hay incremento en el “shunt” venoarterial, lo cual resulta en hipoxemia. La mortalidad es no menor de 50% si no se instituye tratamiento adecuado antes del desarrollo de hipoxemia profunda.
Es importante el reconocimiento de la alteración de la función cardiopulmonar antes de la aparición de clara hipoxemia, lo cual se logra en forma óptima mediante cuidadosa monitoría de los gases sanguíneos arteriales. Las determinaciones secuenciales de la tension del oxígeno arterial bajo concentraciones de oxígeno inspirado al 40% y el 100% constituyen las mejores guías para seleccionar a aquellos patientes que poseen una elevada probabilidad de deterioro pulmonar. Una agresiva monitoría cardiovascular y el tratamiento precoz con bajos niveles de PEEP (presión positiva al final de la espiración) ofrecen a este grupo de pacientes una mejor posibilidad de supervivencia. En nuestra experiencia los esteroides fueron ineficaces en cuanto a mejoría de la función pulmonar y estuvieron asociados con un aumento en la tasa de infección. Nosotros creemos que la terapia pulmonar intensiva y el soporte general siguen siendo la forma preferencial de terapia en el síndrome de dificultad respiratoria del adulto.
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Weigelt, J.A. Current concepts in the management of the adult respiratory distress syndrome. World J. Surg. 11, 161–166 (1987). https://doi.org/10.1007/BF01656398
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DOI: https://doi.org/10.1007/BF01656398