title: [Acute respiratory distress syndrome].
abstract: Acute respiratory distress syndrome (ARDS) is an acute respiratory failure produced by an inflammatory edema secondary to increased lung capillary permeability. This causes alveolar flooding and subsequently deep hypoxemia, with intrapulmonary shunt as its most important underlying mechanism. Characteristically, this alteration is unresponsive to high FIO2 and only reverses with end-expiratory positive pressure (PEEP). Pulmonary infiltrates on CXR and CT are the hallmark, together with decreased lung compliance. ARDS always occurs within a week of exposition to a precipitating factor; most frequently pneumonia, shock, aspiration of gastric contents, sepsis, and trauma. In CT scan, the disease is frequently inhomogeneous, with gravitational infiltrates coexisting with normal-density areas and also with hyperaerated parenchyma. Mortality is high (30-60%) especially in ARDS associated with septic shock and neurocritical diseases. The cornerstone of therapy lies in the treatment of the underlying cause and in the use mechanical ventilation which, if inappropriately administered, can lead to ventilator-induced lung injury. Tidal volume = 6 ml/kg of ideal body weight to maintain an end-inspiratory (plateau) pressure = 30 cm H2O ("protective ventilation") is the only variable consistently associated with decreased mortality. Moderate-to-high PEEP levels are frequently required to treat hypoxemia, yet no specific level or titration strategy has improved outcomes. Recently, the use of early prone positioning in patients with PaO2/FIO2 = 150 was associated with increased survival. In severely hypoxemic patients, it may be necessary to use adjuvants of mechanical ventilation as recruitment maneuvers, pressure-controlled modes, neuromuscular blocking agents, and extracorporeal-membrane oxygenation. Fluid restriction appears beneficial.
authors: Servicio de Terapia Intensiva, Hospital Interzonal de Agudos General San Martín, Argentina.
authors: Elisa
authors: E
authors: Estenssoro
authors: Cátedra de Farmacología Aplicada, Facultad de Ciencias Médicas, Universidad Nacional de La Plata, Buenos Aires, Argentina. E-mail: arnaldodubin@gmail.com.
authors: Arnaldo
authors: A
authors: Dubin
mesh_terms: D000305:Adrenal Cortex Hormones / Q000627:therapeutic use; D015199:Extracorporeal Membrane Oxygenation; D006801:Humans; D009466:Neuromuscular Blocking Agents / Q000627:therapeutic use; D056888:Patient Positioning / Q000379:methods; D011175:Positive-Pressure Respiration / Q000379:methods; D011379:Prognosis; D016684:Prone Position; D012121:Respiration, Artificial / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012307:Risk Factors; D014057:Tomography, X-Ray Computed
chemical_list: D000305:Adrenal Cortex Hormones; D009466:Neuromuscular Blocking Agents
keywords: ARDS; PEEP; mechanical ventilation; prone positioning; protective ventilation