Acute respiratory distress syndrome.
Several combination therapies have been described throughout this article: in all likelihood, it is combination therapy that will allow improved survival of ARDS patients. As medicine moves into the future, clinical trials evaluating the efficacy of therapies for ARDS will be performed. In human critical care medicine, a large forward step was taken when ALI and ARDS were clearly defined. Unfortunately. as good as the definition is, ALI and ARDS occur secondary to many different underlying pathologic processes,perhaps obscuring the benefits of certain therapies for ARDS based on the underlying condition, for example, trauma versus sepsis. Selection of patients entering any ARDS trial is crucial: not only must those patients meet the strict definition of ARDS but the underlying disease process should be clearly identified. Identification of patients suffering from different disease processes before the onset of ARDS will allow for stratification of outcomes according to the intervention and the underlying pathology--comparing apples to apples and not to oranges. We are in a unique position in veterinary medicine. Although frequently financially limited by our clients, we have the opportunity to achieve several goals. First, we need to clearly define what constitutes ALI and ARDS in veterinary medicine. Do we want to rely on the human definitions? Probably not; however, as a group, we need to determine what we will accept as definitions. For example, we may not be able perform right heart catheterizations on all our patients to meet the wedge pressure requirement of human beings of less than 18 mm Hg. Do we agree that a PAOP of less than 18 mmHg is appropriate for animals, and is it appropriate for all animals? Will we accept another measure, for example, pulmonary artery diameter increases with echocardiographic evidence of acceptable left heart function? What is acceptable left heart function? As veterinarians, what do we consider to be hypoxemia? Is it the same in all species that we work with? What do we define as acute onset? Most human ARDS cases occur while patients are in hospital being treated for other problems, whereas many of our patients present already in respiratory distress. If we are unable to ventilate patients for economic or practical reasons, what do we use as the equivalent of the Pao2/Flo, ratio'? Reliance on the pathologist is not reasonable, because many disease processes can look similar to ARDS under the microscope. If anything, ALI and ARDS are clinical diagnoses. It is time for veterinarians to reach a consensus on the definition for ALI and ARDS in our patients. Only when we have a consensus of definition can rational prospective clinical trials of therapies be designed.
Wilkins
Pamela A
PA
Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, New Bolton Center, 382 West Street Road, Kennett Square, PA 19348, USA. pwilkins@vet.upenn.edu
Seahorn
Thomas
T
D000818:Animals; D003131:Combined Modality Therapy / Q000662:veterinary; D016638:Critical Illness; D003937:Diagnosis, Differential; D006734:Horse Diseases / Q000209:etiology / Q000628:therapy*; D006736:Horses; D011379:Prognosis; D012128:Respiratory Distress Syndrome / Q000209:etiology / Q000628:therapy / Q000662:veterinary*