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Acute Respiratory Distress Syndrome (Respiratory Management (Intubation…
Acute Respiratory Distress Syndrome
Etiology
Rapid progression of acute respiratory failure characterized by noncardiogenic pulmonary edema causing severe hypoxemia that is refractory to usual oxygen thereapy
Pathophysiology
increase in the permeability of alveolar-capillary membrane due to a variety of injuries
Decreased aerated lung tissue
Impaired gas exchange
Decreased lung compliance
Increased pulmonary vascular resistance
Pulmonary arterial pressures
Clinical signs and symptoms
Acute onset (within 1 week of known clinical upset)
Bilateral infiltrates consistent with pulmonary edema
Pulmonary edema not due to cardiac failure or fluid overload - no clear cause
Refractory hypoxemia
Differential Diagnostics
cardiogenic pulmonary edema
BNP to rule out CHF
CVP to rule out overhydration
Lab data to rule out sepsis: CBC, blood and urine cultures, blood lactate
Diagnostics
New and/or worsening respiratory symptoms
Signs and symptoms of respiratory distress
Diffuse crackles on auscultation
Signs and symptoms of hypoxemia
ABGs: P/F ratio < 100
CXR or CT findings of diffuse bilateral infiltrates showing a "ground glass" appearance
Respiratory Management
Intubation and mechanical ventilation: Vt 6 - 4 mL/Kg IBW
Goal of plateau pressures at or below < 30 cmH2O
I:E ratio 1:2 or 1:3
Set minute ventilation with rate to achieve ~ 7 - 9 L/min
Titrate PEEP and FiO2 to maintain PaO2 55 - 80 mmHg and SaO2 88 - 95%
Maintain pH at or above 7.20 and PaCO2 allowed to rise (permissive hypercapnia)
Medications: inhaled nitric oxide (iNO) and Flolan