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Sepsis pp 138-151 | Cite as

ARDS: Current Concepts

  • Elisa Estenssoro
  • Arnaldo Dubin
  • Fernando Pálizas

Summary

As in other critical care fields, the past 5 years have been rich with good news about adult respiratory distress syndrome (ARDS). New epidemiologic data concerning incidence and outcome in different countries have been published. Components of the ARDS definition are being clarified. The influence of genetics is beginning to be studied. Risk factors are grouped according to pathophysiologic characteristics. Techniques such as computed tomography (CT) not only give data about lung morphology in different stages of ARDS, but also provide information about response to therapy. Mechanisms of repair continue to be clarified. And, above all, there are new insights about essential supportive therapy, mechanical ventilation. Limitation of tidal volumes has been associated with an improved outcome, possibly because of protecting from overdistention and subsequent ventilator-induced lung injury. New methods to titrate positive end-expiratory pressure (PEEP) have been proposed, but none has shown a clear advantage over the others. PEEP has been associated with a protective effect against ventilator-induced lung injury (VILI), well demonstrated in experimental studies but still uncertain in clinical trials. Of the new adjunctive measures for mechanical ventilation, prone positioning and recruitment maneuvers have been most extensively studied, especially with regard to their mechanisms of action, and are physiologically appealing. Prone positioning is an inexpensive and effective method for reversing hypoxemia, but effects on mortality have not been demonstrated, possibly because the timing and duration of this adjuvant have not been established yet. Recruitment maneuvers are starting to be used in the clinical arena; data about optimal frequency, duration, magnitude, and impact on outcome are still lacking.

Keywords

Acute Lung Injury Acute Respiratory Distress Syndrome Respir Crit Adult Respiratory Distress Syndrome Recruitment Maneuver 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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References

  1. 1.
    Ashbaugh DG, Bigelow DB, Petty TL, et al. Acute respiratory distress in adults. Lancet 1967; 12: 319–23.CrossRefGoogle Scholar
  2. 2.
    Bernard GR, Artigas A, Brigham KL, et al. The American-European Consensus Conference on ARDS: Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818–24.PubMedGoogle Scholar
  3. 3.
    Rubenfeld GD, Caldwell E, Granton J, et al. Interobserver variability in applying a radiographic definition of ARDS. Chest 1999; 116: 1347–53.PubMedCrossRefGoogle Scholar
  4. 4.
    Meade MO, Cook RJ, Guyatt GH, et al. Interobserver variation in interpreting chest radiographs for the diagnosis of acute respiratory distress syndrome. Am J Respir Crit Care Med 2000; 161: 85–90.PubMedGoogle Scholar
  5. 5.
    Murray JF, Matthay MA, Luce JM, et al. An expanded definition of the adult respiratory distress syndrome. Am Rev Respir Dis 1988; 138: 720–3.PubMedGoogle Scholar
  6. 6.
    Meade MO, Guyatt GH, Cook RJ, et al. Agreement between alternative classifications of acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 163: 490–3.PubMedGoogle Scholar
  7. 7.
    Bersten A, Edibam C, Hunt H, et al. Incidence and mortality of acute lung injury and the acute respiratory distress syndrome in three Australian states. Am J Respir Crit Care Med 2002; 165: 443–8.PubMedGoogle Scholar
  8. 8.
    Moss M, Goodman PL, Heinig M, et al. Establishing the relative accuracy of three new definitions of the adult respiratory distress syndrome. Crit Care Med 1995; 23: 16 2937.Google Scholar
  9. 9.
    Luhr OR, Antonsen K, Karlsson M, et al. Incidence and mortality after acute respiratory failure and acute respiratory distress syndrome in Sweden, Denmark, and Iceland. Am J Respir Crit Care Med 1999; 159: 1849–61.PubMedGoogle Scholar
  10. 10.
    Esteban A., Anzueto A, Alfa I, et al. How is mechanical ventilation employed in the intensive care unit? An international utilization review. Am J Respir Crit Care Med 2000; 161: 1450–8.PubMedGoogle Scholar
  11. 11.
    Estenssoro E, Dubin A, Laffaire E, et al. Incidence, clinical course and outcome in 217 patients with acute respiratory distress syndrome. Crit Care Med 2002; 30: 2450–6.PubMedCrossRefGoogle Scholar
  12. 12.
    Roupie E, Lepage E, Wysocki M, et al. Prevalence, etiologies and outcome of the acute respiratory distress syndrome among hypoxemic ventilated patients. Intensive Care Med 1999; 25: 920–9.PubMedCrossRefGoogle Scholar
  13. 13.
    Esteban A, Anzueto A, Frutos F, et al. Characteristics and outcomes in adult patients receiving mechanical ventilation. A 28-day international study. JAMA 2002; 287: 345–5.PubMedCrossRefGoogle Scholar
  14. 14.
    Gattinoni L, Pelosi P, Suter PM, et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary diseases. Different syndromes? Am J Respir Crit Care Med 1998; 158: 3–11.PubMedGoogle Scholar
  15. 15.
    Pelosi P, Gattinoni L. Acute respiratory distress syndrome of pulmonary and extrapulmonary origin: fancy or reality? Int Care Med 2001; 27: 457–60.CrossRefGoogle Scholar
  16. 16.
    Hail JB. Respiratory system mechanics in adult respiratory distress syndrome: Stretching our understanding. Am J Respir Crit Care Med 1998; 158: 1–2.Google Scholar
  17. 17.
    Van der Kloot TE, Blanch Ll, Youngblood AM, et al. Recruitment maneuvers in three experimental models of acute lung injury. Effect on lung volume and gas exchange. Am J Respir Crit Care Med 2000; 16: 1485–94.Google Scholar
  18. 18.
    Lim C, Kim EK, Lee JS, et al. Comparison of the response to prone position between pulmonary and extrapulmonary ARDS. Intensive Care Med 2001; 27: 47785.CrossRefGoogle Scholar
  19. 19.
    Puybasset L, Gusman P, Muller JC, et al. Regional distribution of gas and tissue in acute respiratory distress syndrome. III. Consequences for the effects of positive end-expiratory pressure. Intensive Care Med 2000; 26: 1215–27.PubMedCrossRefGoogle Scholar
  20. 20.
    Marshall RP, Webb S, Bellingan GJ, et al. Angiotensin enzyme insertion/deletion polymorphism is associated with susceptibility and outcome in acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 166: 646–50.PubMedCrossRefGoogle Scholar
  21. 21.
    Milberg JD, Davis DR, Steinberg KP, et al. Improved survival of patients with acute respiratory distress syndrome. JAMA 1995; 273: 306–9.PubMedCrossRefGoogle Scholar
  22. 22.
    Monchi M, Bellenfant F, Cariou A, et al. Early predictive factors of survival in the acute respiratory distress syndrome. A multivariate analysis. Am J Respir Crit Care Med 1998; 158: 1076–81.PubMedGoogle Scholar
  23. 23.
    Zilberberg M, Epstein SK. Acute lung injury in the medical ICU. Comorbid conditions, age, etiology, and hospital outcome. Am J Respir Crit Care Med 1998; 157: 1159–64.PubMedGoogle Scholar
  24. 24.
    Doyle RL, Szaflarski N, Modin GW, et al. Identification of patients with acute lung injury. Predictors of mortality. Am J Respir Crit Care Med 1995; 152: 1818–24.PubMedGoogle Scholar
  25. 25.
    Run-Buisson C, Minnelli C, Brazzi L, et al. The European Survey (ALIVE) of acute lung injury and ARDS. Am J Respir Crit Care Med 2001; 163: A957.Google Scholar
  26. 26.
    Suchyta M, Morris AH, Thompson T. Attributes and outcomes of randomized vs. excluded patients in ALI/ARDS clinical trials. Am J Respir Crit Care Med 2000; 161: A210.Google Scholar
  27. 27.
    Villar J, Pérez Méndez M, Kacmarek RM. Current definitions of acute lung injury and the acute respiratory distress syndrome do not reflect their true severity and outcome. Intensive Care Med 1999; 25; 930–5.PubMedCrossRefGoogle Scholar
  28. 28.
    Nuckton TJ, Alonso JA, Kallet RH, et al. Pulmonary dead-space fraction as a risk factor for death in the acute respiratory distress syndrome. N Engl J Med 2002; 346: 1281–6.PubMedCrossRefGoogle Scholar
  29. 29.
    Davidson TA, Rubenfeld GD, Caldwell ES, et al. The effect of acute respiratory distress syndrome on long-term survival. Am J Respir Crit Care Med 1999; 160: 1838–42.PubMedGoogle Scholar
  30. 30.
    Angus DC, Musthafa AA, Clermont G, et al. Quality-adjusted survival in the first year after the acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 163: 1989–94.Google Scholar
  31. 31.
    Schelling G, Stoll C, Haller M, et al. Health-related quality of life and posttraumatic stress disorder in survivors of ARDS. Crit Care Med 1998; 26: 651–9.PubMedCrossRefGoogle Scholar
  32. 32.
    Orme J, Romney JS, Hopkins RO, et al. Pulmonary function and health related quality of life in survivors of acute respiratory distress syndrome. Am J Respir Crit Care Med 2003; 167: 690–4.PubMedCrossRefGoogle Scholar
  33. 33.
    Herridge MS, Cheung A, Tansey CM, et al. One-year outcomes in survivors of the acute respiratory distress syndrome. N Engl J Med 2003; 348: 683–93.PubMedCrossRefGoogle Scholar
  34. 34.
    Hudson LD, Lee CM. Neuromuscular sequelae of critical illness. N Engl J Med 2003; 348: 683–93.CrossRefGoogle Scholar
  35. 35.
    Marini JJ. Ventilation in the acute respiratory distress syndrome. Looking for Mr. Goodmode. Anesthesiology. 1994; 80: 972–5.CrossRefGoogle Scholar
  36. 36.
    Gattinoni L, Pelosi P, Caironi P, et al. What has computed tomography taught us about acute respiratory distress syndrome? Am J Respir Crit Care Med 2001; 164: 1701–11.PubMedGoogle Scholar
  37. 37.
    Malbouisson LM, Busch CJ, Lu Qin, et al. Role of the heart in the loss of aeration characterizing lower lobes in acute respiratory distress syndrome. Am J Respir Crit Care Med 2001; 161: 2005–12.Google Scholar
  38. 38.
    Muscedere JG, Mullen JBM, Gan K, et al. Tidal ventilation at low lung volumes augments lung injury. Am J Respir Crit Care Med 1994; 149: 1327–34.PubMedGoogle Scholar
  39. 39.
    International Consensus Conferences in Intensive Care Medicine. Ventilator-associated lung injury in ARDS. Am J Respir Crit Care Med 1999; 160: 2118–24.Google Scholar
  40. 40.
    Hubmayr RD. Perspective on lung injury and recruitment. A skeptical look at the opening and collapse story. Am J Respir Crit Care Med 2002; 165: 1647–53.PubMedCrossRefGoogle Scholar
  41. 41.
    Ware LB, Matthay MA. Alveolar fluid clearance is impaired in the majority of patients with ALI and ARDS. Am J Respir Crit Care Med 2001; 163: 1376–83.PubMedGoogle Scholar
  42. 42.
    International Consensus Conferences in Intensive Care Medicine. Ventilator-associated lung injury in ARDS. Am J Respir Crit Care Med 1999; 160: 2118–24.Google Scholar
  43. 43.
    Amato MR, Barbas C, Medeiros DM, et al. Effect of a protective-ventilation strategy on mortality in the acute respiratory distress syndrome. N Engl J Med 1998; 338: 347–54.PubMedCrossRefGoogle Scholar
  44. 44.
    The Acute Respiratory Distress Syndrome Network. 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;342:1301–8.Google Scholar
  45. 45.
    Stewart TE, Meade MO, Cook DJ, et al. Evaluation of a ventilation strategy to prevent barotrauma in patients at high-risk for acute respiratory distress syndrome. N Engl J Med 1998; 338: 355–61.PubMedCrossRefGoogle Scholar
  46. 46.
    Brochard L, Roudot-Thoraval F, Roupie E, et al. Tidal volume reduction for prevention of ventilator-induced lung injury in acute respiratory distress syndrome. Am J Respir Crit Care Med 1998; 158: 1831–8.PubMedGoogle Scholar
  47. 47.
    Brower RG, Shanholtz CB, Fessier HE, et al. Prospective, randomized, controlled clinical trial comparing traditional versus reduced tidal volume ventilation in acute respiratory distress syndrome in patients. Crit Care Med 1999; 27: 1492–8.PubMedCrossRefGoogle Scholar
  48. 48.
    Tobin M. Culmination of an era in research on the acute respiratory distress syndrome. N Engl J Med 2000; 342: 1360–1.PubMedCrossRefGoogle Scholar
  49. 49.
    de Durante G, del Turco M, Rustichini L, et al. ARDSNet lower tidal volume strategy may generate intrinsic PEEP in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 165: 1271–4.PubMedCrossRefGoogle Scholar
  50. 50.
    Eichacker PQ, Gesrtenberger EP, Banks SM, et al. Meta-analysis of acute lung injury and acute respiratory distress syndrome trials testing. Low tidal volumes. Am J Respir Crit Care Med 2002; 166: 1510–4.PubMedCrossRefGoogle Scholar
  51. 51.
    Brower RG, Matthay M, Schoenfeld D. Correspondence: Meta-analysis of acute lung injury and acute respiratory distress syndrome trials. Am J Respir Crit Care Med 2002; 166: 1515–7.PubMedGoogle Scholar
  52. 52.
    Stewart TE. Controversies around lung protective mechanical ventilation. Am J Respir Crit Care Med 2002; 166: 1421–2.PubMedCrossRefGoogle Scholar
  53. 53.
    Suter P, Fairley B, Isenberg MD. Optimum end-expiratory airway pressure in patients with acute pulmonary failure. N Engl J Med 1975; 292: 284–9.PubMedCrossRefGoogle Scholar
  54. 54.
    Lachmann B. Open up the lung and keep the lung open. Intensive Care Med 2000; 18: 319–21.CrossRefGoogle Scholar
  55. 55.
    Pare PD, Warriner B, Baffle EM et al. Redistribution of extravascular water with positive end-expiratory pressure in canine pulmonary edema. Am Rev Respir Dis 1983; 127: 590–3.PubMedGoogle Scholar
  56. 56.
    Vlahakis NE, Schroeder MA, Limper AH, et al. Stretch induces cytokine release by alveolar cells in vitro. Am J Physiol 1999; 277: L167–73.PubMedGoogle Scholar
  57. 57.
    Ranieri M, Suter PM, Tortorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome. A randomized controlled trial. JAMA. 1999; 282: 54–61.PubMedCrossRefGoogle Scholar
  58. 58.
    Ricard JD, Dreyfuss D, Saumon G. Production of proinflammatory cytokines in ventilator-induced lung injury: a reappraisal. Am J Respir Crit Care Med 2001; 163: 1176–80.PubMedGoogle Scholar
  59. 59.
    Rouby JJ, Lu Q, Goldstein I. Selecting the right level of positive end-expiratory pressure in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2002; 165: 1182–6.PubMedGoogle Scholar
  60. 60.
    Jonson B, Richard JC, Starus C. Pressure-volume curves and compliance in acute lung injury: evidence of recruitment above the lower inflection point. Am J Respir Crit Care Med 1999; 159: 1172–8.PubMedGoogle Scholar
  61. 61.
    Malbouisson LM, Muller JC, Constantin JM, et al. Computed tomography assessment of positive end-expiratory pressure-induced alveolar recruitment in patients with acute respiratory distress syndrome. Am J Respir Crit Care Med 2001;163: PM 50.Google Scholar
  62. 62.
    Hickling K. Recruitment greatly alters the pressure-volume curve: a mathematical model of ARDS lungs. Am J Respir Crit Care Med 1998; 158: 194–202.PubMedGoogle Scholar
  63. 63.
    ALVEOLI Study. ARDS Network web site. Accessed on March 4, 2003.Google Scholar
  64. 64.
    Meade MO, Guyatt GH, Cook DJ, et al. Physiologic randomized study of a lung recruitment maneuver in acute lung injury. Am J Respi Crit Care Med 2002; 165: A883.Google Scholar
  65. 65.
    Gattinoni L, Rothen HU, Sporre B, et al. Reexpansion of atelectasis following general anesthesia: a computed tomographic study. Br J Anaesth 1993; 71: 788–95.CrossRefGoogle Scholar
  66. 66.
    Richard JC, Maggiore SM, Jonson B, et al. Influence of tidal volume on alveolar recruitment. Respective role of PEEP and of a recruitment maneuver. Am J Respir Crit Care Med 2001; 163: 1609–13.PubMedGoogle Scholar
  67. 67.
    Grasso S, Mascia L, del Turco M. Effects of recruiting maneuvers in patients in acute respiratory distress syndrome ventilated with protective ventilatory strategy. Anesthesiology 2002; 96: 795–802.PubMedCrossRefGoogle Scholar
  68. 68.
    Richard JC, Maggiore S, Mercat A. Where are we with recruitment maneuvers in patients with acute lung injury and acute respiratory distress syndrome? Curr Opinion Cr Care 2003; 9: 22–7.CrossRefGoogle Scholar
  69. 69.
    Lapinsky SE, Aubin M, Mehta S, et al. Safety and efficacy of a sustained inflation for alveolar recruitment in adults with respiratory failure. Intensive Care Med 1999; 25: 1297–1301.PubMedCrossRefGoogle Scholar
  70. 70.
    Pelosi P, Cadringher P, Bottino N, et al. Sighs in acute respiratory distress syndrome. Am J Respir Crit Care Med 1999; 159: 872–80.PubMedGoogle Scholar
  71. 71.
    Messerole E, Peine P, Wittkopp Sue, et al. The pragmatics of prone positioning. Am J Respir Crit Care Med 2002; 165: 1359–63.PubMedCrossRefGoogle Scholar
  72. 72.
    Douglas WW, Rehder K, Beynen FM, et al. Improved oxygenation in patients with acute respiratory failure: the prone position. Am Rev Respir Dis 1977; 115: 559–66.PubMedGoogle Scholar
  73. 73.
    Broccard A, Shapiro R, Schmitz L, et al. Prone positioning attenuates and redistributes ventilatory-induced lung injury in dogs. Crit Care Med 2000; 28: 295–303.PubMedCrossRefGoogle Scholar
  74. 74.
    Gattinoni L, Pelosi, P, Vitale G. Body position changes redistribute lung computed tomographic density in patients with acute respiratory failure. Anesthesiology 1991; 74: 15–23.PubMedCrossRefGoogle Scholar
  75. 75.
    Glenny RW, Lamm WJE, Albert RK, et al. Gravity is a minor determinant in pulmonary blood flow distribution. J Appl Physiol 1991; 71: 620–9.PubMedGoogle Scholar
  76. 76.
    Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone positioning on survival of patients with acute respiratory failure. N Engl J Med 2001; 345: 568–71.PubMedCrossRefGoogle Scholar
  77. 77.
    Slutsky A. The acute respiratory distress syndrome, mechanical ventilation and the prone position. N Engl J Med 2001; 345: 610–2.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2004

Authors and Affiliations

  • Elisa Estenssoro
  • Arnaldo Dubin
  • Fernando Pálizas

There are no affiliations available

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