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Signa Vitae

Journal of Intensive Care and Emergency Medicine

The management of ARDS: what is really evidence-based? 

Introduction

Acute respiratory distress syndrome (ARDS) is the result of a diffuse inflammatory lung injury, which leads to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue. (1) The causes of ARDS are multiple and include sepsis –the most common–, pneumonia, aspiration, and severe trauma. The Berlin criteria (1) define ARDS according to four key features: timing (within 1 week of a known clinical insult or new or worsening respiratory symptoms); chest imaging (presence of bilateral opacities that cannot be fully explained by effusions, lobar/lung collapse, or nodules); edema due to primary respiratory failure and not cardiac failure or fluid overload; the PaO2/FIO2 ratio. This latter feature is used to define the severity of ARDS as mild, moderate or severe. In a large observational study of 29,144 patients admitted to 459 intensive care units (ICUs) in 50 countries, 10% had ARDS. The overall mortality rate was 40%, increasing from 35% in patients with mild ARDS, to 40% in moderate and 46% in severe ARDS. (2) Although several studies have suggested a trend towards lower mortality rates over time (3-7), hospital mortality rates remain high (1, 2) and long-term morbidity is considerable. (8-10)

Many potential pharmacological agents, both inhaled (11) and systemic, have been assessed for use in patients with ARDS (table 1), but none has consistently been shown to improve mortality. As such, management essentially relies on treatment of the underlying cause, especially sepsis and limiting further lung injury by providing appropriate protective lung ventilation and avoiding highly positive fluid balances. (12) Here we will briefly consider the evidence base (or lack of) for these approaches and for some of the other therapeutic approaches that have been proposed.

Dr Vincent has no conflicts of interest to declare regarding this manuscript

Key words: acute respiratory distress syndrome

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Bronchoscopy during non-invasive ventilation in a patient with acute respiratory distress syndrome

Abstract

A 72-year-old man was transferred to our hospital for refractory severe acute respiratory syndrome. On arrival, he was intubated and mechanically ventilated. Furthermore, he required veno-venous extracorporeal membrane oxygenation. Two days later, he was extubated and supported with periods of non-invasive ventilation (NIV), with a new mask. Because of large amounts of bronchial secretions that he was not able to expectorate, flexible fiberoptic bronchoscopy (FFB) was performed to remove the secretions, without interrupting NIV support. During the procedure, the patient remained hemodynamically stable, breathing spontaneously and with just a mild reduction in oxygen saturation (SpO2) (97.9% vs. 96.8%). This case report highlights the possibility of performing upper endoscopic procedures, such as FFB, during non-invasive ventilation in patients in whom this respiratory support is required and its interruption may be harmful.

Key words: non-invasive ventilation, acute respiratory distress syndrome, flexible fiberoptic bronchoscopy, intensive care unit

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Serum levels of nitric oxide as a predictor of survival in acute respiratory distress syndrome caused by H1N1 pneumonia?

Abstract

A large number of studies show elevated levels of nitric oxide (NO) in infective syndromes, but there is an insufficient number of studies which have investigated serum levels of NO in patients with acute respiratory distress syndrome (ARDS), especially in relation to survival. Hence, we created a study with the aim of determining the NO levels in relation to ARDS survival.

Serum levels of NO were measured by Griess reaction in 29 patients [16 men (55%), mean age years 52.72±18]. All data were statistically analyzed using one way ANOVA.

Our results show significantly higher serum NO levels in ARDS survivors compared to ARDS non-survivors, (p < 0.05). We conclude that higher serum levels of NO are strongly associated with better clinical outcomes, including increased survival.

Key words: acute respiratory distress syndrome, nitrogen oxide species, outcome

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Advantage of spontaneous breathing in patients with respiratory failure

Abstract

The fact that different modalities of mechanical ventilation are associated with a number of serious side effects and risks and can influence the clinical outcome of patients, the various modes of mechanical ventilation have, over the past ten years, been the subject of a wide variety of scientific studies. Many of these modalities are designed for partial ventilatory support, which might reflect the complexity of the issue of patient’s ventilator interactions when spontaneous breathing activity is present, compared to controlled mechanical ventilation. Spontaneous breathing modes during mechanical ventilation may integrate intrinsic feedback mechanisms that should help prevent ventilator- induced lung injury and improve synchrony between the ventilator and the patient’s demand. The improvements in pulmonary gas exchange, systemic blood flow, and oxygen supply to the tissue that have been observed when spontaneous breathing has been maintained during mechanical ventilation are reflected in the clinical improvement in the patient’ s condition. It is the aim of this article to review the effects of preserved spontaneous breathing activity during mechanical ventilation in patients with acute respiratory failure.

Key words: mechanical ventilation, acute respiratory distress syndrome, ventilation mode, spontaneous breathing

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