Acute Respiratory Distress Syndrome (ARDS)

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Treatment

Treatment for ARDS is initiated as soon as possible to reduce the risk for death and to help prevent additional damage to the lungs and other organs. The goal is to treat the underlying condition and keep the patient alive and breathing.

Mechanical Ventilation
In most cases, keeping the patient alive requires mechanical ventilation. With ARDS, the breathing muscles (i.e., diaphragm and other muscles in the chest) become fatigued very quickly and can stop working in their effort to get oxygen into the body. The level of oxygen in the blood drops rapidly to dangerously low levels, causing damage to vital organs and body processes. If the oxygen level is not improved quickly and maintained at adequate levels, damage (including severe brain damage) can be irreversible. Mechanical ventilation keeps the level of oxygen at life-sustaining levels.

Once breathing is stabilized and blood is reoxygenated, the underlying condition is treated. For example, if the condition is pneumonia or a septic infection, the patient is treated with antibiotics.

Positive Pressure Ventilation
Mechanical ventilators deliver oxygen-rich air to the lungs and remove carbon dioxide from the body. The technique, also known as positive pressure ventilation, usually involves inserting an endotracheal tube into the trachea through the mouth or nose. The endotracheal tube passes through the upper airways, between the vocal cords, and into the trachea.

An inflatable balloon attached to the tube at the tracheal end prevents air from escaping through the upper airways and out of the body. The end of the tube outside of the body the is connected to a ventilator (machine that forces air into the lungs by providing positive pressure).

Normally, people breathe spontaneously by contracting the large dome-shaped muscle underneath the lungs (diaphragm). When the diaphragm contracts during inhalation, the dome deflates, the volume of the chest cavity increases, and negative pressure, or a partial vacuum, is created, bringing air into the lungs. When the diaphragm relaxes during exhalation, the dome rises, the volume of the chest cavity decreases, and air is pushed out of the lungs.

Positive pressure ventilation does two things:

• It pushes air into the lungs, relieving fatigued, nonfunctioning breathing muscles.
• It creates positive pressure in the alveoli, keeping them from collapsing and pushing fluid out of the alveolar spaces.

How long does a patient with ARDS need mechanical ventilation support?
Positive pressure ventilation is maintained until the patient can breathe independently at a normal rhythm. Some patients need support for only a few days and others may require it for months.

Health care practitioners often refer to taking a person off mechanical support as "weaning" them from the ventilator. Patients without a history of lung disease are usually weaned fairly smoothly. Difficult weaning may indicate complications, such as poor nutritional status, or an untreated or new infection.

Noninvasive positive pressure ventilation (NIPPV)
Positive pressure ventilation is sometimes accomplished with a facemask that forms a tight seal around the mouth and nose or just the nose. Since ventilation via an endotracheal tube is more efficient, NIPPV is usually used on a temporary basis and for milder cases.

Continous positive airway pressure (CPAP)
CPAP may be used temporarily in patients who can maintain breathing but cannot oxygenate adequately. CPAP is applied through a mask, in this instance usually over both the nose and mouth, that forms a tight seal. Positive pressure is applied by a machine with inspiration and expiration, causing fluid to be pushed out of the alveolar space and opening alveoli or preventing them from collapsing.

Techniques for patients who are difficult to oxygenate
Sometimes, putting a patient into the prone position (on their stomach) helps positive pressure get oxygen into the bloodstream easier. Lying on the stomach increases gas exchange in the alveoli.

Inverse ratio ventilation and muscle-paralyzing drugs
Inverse ratio ventilation is reserved for severe cases when it is impossible to oxygenate the patient adequately. Treatment involves increasing the amount of time that the ventilator is inspiring versus expiring. Patients normally spend more time exhaling than inhaling, at a ratio of about 3:1. Increasing the amount of time spent inhaling re-expands more collapsed alveoli than positive pressure alone. This is an uncomfortable technique and usually requires sedation and a muscle-paralyzing drug that keeps the respiratory muscles from resisting the unnatural inverse ratio ventilation.

Complications of mechanical ventilation
Volutrauma, over expansion of the alveoli, can contribute to lung injury and is one of the most common complications of mechanical ventilation. Recent studies have shown that decreasing the amount of air pushed into the lungs can reduce the risk for volutrauma.

Pneumothorax, air in the pleural cavity (the normally empty space between the lungs and the ultra thin membranes that surround the lungs [pleura]), occurs when lung tissue ruptures. Weakened lungs, high pressures from the ventilator, and the high volume of air increase the risk for pneumothorax.

Medication
Most medications prescribed during an ARDS episode treat the underlying condition. Although corticosteroids have no proven benefit for early ARDS, they may be beneficial 7 to 10 days following mechanical ventilation. Sedating or muscle-paralyzing drugs are used during mechanical ventilation to prevent resistance to the forced movement of air.

Other Treatments
Other techniques have been used to restore breathing in patients with ARDS (e.g., inhalation of nitric oxide), but they do not prolong survival or prevent further lung damage. For example, inhaled nitric oxide can significantly improve pulmonary hypertension, a complication of ARDS, but its toxic byproducts can be damaging. Initial studies of an aerosolized synthetic surfactant designed to keep the alveoli from collapsing have been disappointing.

Resources for patients and families
The ARDS Support Center, Inc. is an excellent source of information, support, and education resources for patients and families.

For information on clinical trials for the treatment of ARDS, visit the National Heart, Lung, and Blood Institute's ARDS Clinical Network FAQs site.

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