Part I: Introduction

What is Acute Respiratory Syndrome (ARDS)

Acute Respiratory Syndrome (ARDS) is a buildup of fluid in the tiny air sacs in your lungs called
alveoli. This means less oxygen can get to your organs, which is very dangerous. ARDS occurs
when there is significant trauma that either affects the lungs directly or indirectly. Fluid leaves
these small vessels and goes into the alveoli. The alveoli fill with this fluid making it difficult for
oxygen to get into the bloodstream. (CHEST Foundation, the philanthropic arm of the American
College of Chest Physicians.)

How Serious Is ARDS?

There are about 200,000 cases of ARDS each year in the United States. Most people who get
ARDS are already in the hospital in critical condition from some other health complication or
trauma. ARDS is a very serious disease and even with the best medical care between 30 and
50 percent of those diagnosed with ARDS die of it. Those surviving the disease will often have
long hospital stays. One of the biggest problems with this disease is that many patients develop
additional complications while they are in the intensive care unit. Some of these complications
include pneumonia, collapsed lungs, other infections, severe muscle weakness, confusion, and
kidney failure. (CHEST Foundation, the philanthropic arm of the American College of Chest
Physicians.)

What are the Risk Factors?

Most people who develop ARDS are already hospitalized for another condition, and many are
critically ill. You're especially at risk if you have a widespread infection in your bloodstream
(sepsis). People who have a history of chronic alcoholism are at higher risk of developing
ARDS. They're also more likely to die of ARDS. (Mayo Clinic)

What Are Symptoms of ARDS?

Patients with ARDS have shortness of breath, often severe. They also have a cough and many
have fever. Those with ARDS also have fast heart rates and rapid breathing. Occasionally, they
experience chest pain, especially during inhalation. Some patients who have very low oxygen
levels may have bluish coloring of nails and lips from the severely decreased oxygen levels in
the blood.

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Prevention
Although multiple risk factors for ARDS are known, no successful preventive measures have
been identified. Careful fluid management in high-risk patients may be helpful. Because
aspiration pneumonitis is a risk factor for ARDS, taking appropriate measures to prevent
aspiration (eg, elevating the head of the bed and evaluating swallowing mechanics before
feeding high-risk patients) may also prevent some ARDS cases. In patients without ARDS on
mechanical ventilation, the use of high tidal volumes appears to be a risk factor for the
development of ARDS, and, therefore, the use of lower tidal volumes in all patients on
mechanical ventilation may prevent some cases on ARDS. (emedicine)

Treatment
The first goal in treating ARDS is to improve the levels of oxygen in your blood. Without oxygen,
your organs can't function properly.
Oxygen
To get more oxygen into your bloodstream, your doctor will likely use: Supplemental
oxygen. For milder symptoms or as a temporary measure, oxygen may be delivered through a
mask that fits tightly over your nose and mouth.
-Mechanical ventilation. Most people with ARDS will need the help of a machine to breathe. A
mechanical ventilator pushes air into your lungs and forces some of the fluid out of the air sacs.

Fluids
Carefully managing the amount of intravenous fluids is crucial. Too much fluid can increase fluid
buildup in the lungs. Too little fluid can put a strain on your heart and other organs and lead to
shock.
Medication
People with ARDS usually are given medication to: Prevent and treat infections, Relieve pain
and discomfort, Prevent blood clots in the legs and lungs, Minimize gastric reflux, Sedate

Medical and Nursing Management

For all patients diagnosed with ARDS - Lower tidal volume mechanical ventilation (4-8 ml/kg
predicted body weight) and lower plateau pressures < 30cm H2O

-Prone positioning for > 12 hours/day in those with severe ARDS

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  Involves placing patient in prone position while on ventilator, shifts weight
of heart to ventral wall
 Potentially improves ventilation-perfusion, increasing end-expiratory lung
volume, and decreasing VILI by more uniform distribution of tidal volume
through lung recruitment and alterations in chest wall mechanics
(Gattinoni L, Pesenti A, Carlesso E, 2013).

For those with moderate to severe ARDS:

-Higher PEEP as opposed to lower PEEP

 In non-ARDS mechanical ventilation, typical initial PEEP is 5; however,

PEEP can often be as high as 24 in the treatment of ARDS; increasing
PEEP often allows for decreased FiO2
 higher PEEP may improve alveolar recruitment, reduce lung stress and
strain, and prevent atelectrauma (Fan et al. 2017)

-Recruitment maneuvers (RMs) - A transient, sustained increase in airway pressure with goal to
open collapsed alveoli. It also involves applying high PEEP for a specified time and evaluating
improvements in oxygenation. Both higher PEEP and RMs are thought to decrease atelectasis
by improving alveolar recruitment (increasing the number of alveoli participating in tidal
ventilation and improve end-expiratory lung volumes.

It was noted that further research is necessary on the use of Extra-corporeal Membrane
Oxygenation (ECMO) for treatment of refractory ARDS.

o Veno-venous ECMO works by pulling blood from the inferior vena-cava through a
circuit (outside of the body) which removes carbon dioxide and oxygenated blood
returning it to the venous system via internal jugular vein.
o
Pharmacologic treatment
No drug has proved beneficial in the prevention or management of acute respiratory distress
syndrome (ARDS). Early administration of corticosteroids to septic patients does not prevent the
development of ARDS. A study by Martin-Loeches et al concluded that the early use of
corticosteroids was also ineffective in patients with the pandemic H1N1 influenza A infection,
resulting in an increased risk of super infections. [23] This finding was also echoed in a study by

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Brun-Buisson et al, who found no evidence of benefit associated with corticosteroids in patients
with ARDS secondary to influenza pneumonia but did find that early corticosteroid therapy may
be harmful.

Complications
If you have ARDS, you can develop other medical problems while in the hospital. The most
common problems are:

Blood clots. Lying still in the hospital while you're on a ventilator can increase your risk of
developing blood clots, particularly in the deep veins in your legs. If a clot forms in your leg, a
portion of it can break off and travel to one or both of your lungs (pulmonary embolism) —
where it blocks blood flow.

Collapsed lung (pneumothorax). In most ARDS cases, a breathing machine called a ventilator
is used to increase oxygen in the body and force fluid out of the lungs. However, the pressure
and air volume of the ventilator can force gas to go through a small hole in the very outside of a
lung and cause that lung to collapse.

Infections. Because the ventilator is attached directly to a tube inserted in your windpipe, this
makes it much easier for germs to infect and further injure your lungs.

Scarring (pulmonary fibrosis). Scarring and thickening of the tissue between the air sacs can
occur within a few weeks of the onset of ARDS. This stiffens your lungs, making it even more
difficult for oxygen to flow from the air sacs into your bloodstream.