Acute Respiratory Failure

Acute respiratory distress syndrome (ARDS) is

a rapidly developing, life-threatening
condition in which the lung is injured to the
point where it can't properly do its job of
moving air in and out of the blood.

Doctors first recognized the syndrome in 1967,
when they came across 12 people who
developed sudden breathing problems and
rapid lung failure. All of them had similar
patchy spots on their chest X-rays.

ARDS may also be called acute lung injury,
noncardiac pulmonary edema, and increased-
permeability pulmonary edema. In the past it
was also called stiff lung, wet lung, and shock
lung.

What Causes ARDS?
ARDS can occur when a major injury or
extreme inflammation somewhere in the body
damages the small blood vessels, including
those in the lungs. As a result, the lungs are
unable to fill with air and can't move enough
oxygen into the bloodstream.
The lung damage can be direct or indirect.

Conditions that can directly injure the lungs and
possibly lead to ARDS include:

Breathing in smoke or poisonous chemicals
Breathing in stomach contents while throwing
up (aspiration)
Near drowning
Pneumonia
Severe acute respiratory syndrome (SARS), a
lung infection

Conditions that can indirectly injure the lungs
and possibly lead to ARDS include:
Bacterial blood infection (sepsis)
Drug overdose
Having many blood transfusions
Heart-lung bypass
Infection or irritation of
the pancreas(pancreatitis)
Severe bleeding from a traumatic injury (such
as a car accident)
Severe hit to the chest or head
Classification:


Type 1 (Hypoxemic ) - PO
2
< 50 mmHg on room air. Usually seen in
patients with acute pulmonary edema or acute lung injury. These
disorders interfere with the lung's ability to oxygenate blood as it
flows through the pulmonary vasculature.
Type 2 (Hypercapnic/ Ventilatory ) - PCO
2
> 50 mmHg (if not a
chronic CO
2
retainer). This is usually seen in patients with an
increased work of breathing due to airflow obstruction or
decreased respiratory system compliance, with decreased
respiratory muscle power due to neuromuscular disease, or with
central respiratory failure and decreased respiratory drive.
Type 3 (Peri-operative). This is generally a subset of type 1 failure
but is sometimes considered separately because it is so common.
Type 4 (Shock) - secondary to cardiovascular instability.

ARDS is defined by three main signs and
symptoms:

Rapid breathing
Feeling like you can't get enough air in your
lungs
Low oxygen levels in your blood, which can
lead to organ failure and symptoms such as
rapid heart rate, abnormal heart rhythms,
confusion, and extreme tiredness.

DIAGNOSING ARDS

Early findings on the chest radiograph include
normal or diffuse alveolar opacities
(consolidation), which are often bilateral and
which obscure the pulmonary vascular markings.
Later, these opacities progress to more extensive
consolidation that is diffuse, and they are often
asymmetrical. Again, effusions and septal lines
are not usually seen on chest radiographs of
patients affected by ARDS, although these
findings are commonly seen in patients with
congestive heart failure (CHF). Radiographic
findings tend to stabilize (part of the clinical
definition of ARDS); if further radiographic
worsening occurs after 5-7 days, another disease
process should be considered.

Chest radiograph correlation with the
pulmonary pathologic findings is useful because
steroids may be helpful at the beginning of the
fibrotic process in ARDS.

In the early exudative
phase, chest radiographs show 3 general
findings:

(1) a bilateral, whiteout appearance;
(2) asymmetric consolidations; and
(3) a central bat-wing, consolidative
appearance.


Mechanical ventilation with positive end-expiratory pressure
(PEEP) is another common therapy in ARDS. Chest radiograph
findings when PEEP is applied vary from no change to
apparent hyperinflation. Higher levels of PEEP may result in
barotraumatic changes, which include vesicular refactions,
pulmonary interstitial emphysema radiolucent halos around
vessels, pneumatocele formation, subpleural emphysema as
manifested by blebs or lucent lines on the chest radiograph,
pneumothorax, mediastinal emphysema, and extrathoracic
gas collection.


Management of Acute Respiratory Failure

The management of acute respiratory failure
can be divided into an urgent resuscitation
phase followed by a phase of ongoing care.
The goal of the urgent resuscitation phase is
to stabilize the patient as much as possible
and to prevent any further life-threatening
deterioration
Urgent resuscitation
Oxygenation
Airway control
Ventilator management
Stabilization of the circulation
Bronchodilators/ Steroids
Ongoing care
Differential diagnosis and investigations
Therapeutic plan tailored to diagnosis


Oxygenation
Almost all patients with ARF require supplemental oxygen. All
should be placed on a pulse oximeter and oxygen saturation
should generally be maintained above 90%. Oxygen diffuses
from the alveolus across the alveolar membrane into capillary
blood. The rate of diffusion is driven by the oxygen partial-
pressure gradient. Therefore increasing the PAO
2
with
supplementary oxygen should improve the transfer of oxygen
into the pulmonary capillary blood.

Oxygen Delivery Devices:
Nasal cannula
Venturi masks.
Reservoir Face Masks.
Resuscitation Bag-Mask-Valve Unit.
Non-Invasive Positive Pressure Ventilation
(NPPV).NPPV provides ventilatory
Introduction to Mechanical Ventilation