Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content ++ Acute onset and progression within hoursRespiratory: Not cardiogenic clinically or by echo. PA occlusion pressure (wedge) <18 cm H2ODistress: Decreased oxygenation: PaO2/FiO2 <200 mm Hg<300 for ALI regardless of PEEPSyndrome: Mortality with current management still 25–50%Survivors suffer from significant morbidity and reduced quality of life because of respiratory sequelae such as chronic infections and tracheostomyPulmonary HTN and RV failure may be present: Acute RV failure on echo: RV dilation and paradoxical septum motion ++ Sepsis (30%)Aspiration (36%)Trauma (11%)TRALI and others (burns and toxic fumes, drug overdose, drowning, acute pancreatitis) ++ Treat underlying cause if possible (especially sepsis)Sedate as little as possibleRespiratory management: First goal: Avoid secondary lung injury with hyperinflation: Low tidal volume ventilation (6 mL/kg IBW): VC and PCV same efficacy. Watch TV and maintain plateau pressure (Ppl) <30 cm H2O (add 0.2 second inspiratory pause to measure Ppl)Absolute mortality risk reduction from 40% to 31% with NNT = 11Second goal: Optimize oxygenation and V/Q matching: Place arterial line and titrate to PaO2 >60 with incremental PEEP up to 12 first and then increasing FiO2Third goal: Permissive hypercapnia (accept PacO2 up to 60 mm Hg): RR up to 30 if needed, but watch auto-PEEP with risk of breath stackingNo indication to NaHCO3 with respiratory acidosisTroubleshooting: when the goals are difficult to achieve: Recruitment maneuver to reopen atelectatic areas of lungs: Set APL valve to 40, squeeze bag to achieve peak airway pressures of 40 cm H2O, hold for 30 seconds (8–12 seconds probably sufficient), and repeat a few timesMay transiently improve oxygenation by opening collapsed alveoli (but also by reducing pulmonary shunt by decreasing cardiac output)Watch for hypotension (usually brief, due to decrease in venous return) and pneumothoraxContraindicated if elevated ICPConservative fluid strategy (ARDSNet trial in ICU setting): Guided strictly by CVP, PAOP, urine output, MAP, cardiac output, and capillary refillElaborate treatment algorithm using fluid boluses, KVO fluid, dopamine, or furosemideConservative strategy improved lung function and shortened mechanical ventilation without increasing nonpulmonary organ failuresNo proven mortality benefit but can be considered: Prone position: Improves oxygenation, but does not reduce mortalitySteroids: May shorten course and decrease fibrosis if given <7 days (methylprednisolone 2 mg/kg per day), but may worsen mortality if given >2 weeks into ARDS. Avoid combining with NMB (risk of critical illness myo/neuropathy)Inhaled nitric oxide: Improves oxygenation but not survival. May be useful with refractory hypoxemia, severe pulmonary hypertension, or RV failureInhaled surfactant/prostaglandins, ECMO for intractable hypoxemiaNutritional support: Avoid hypophosphatemia; reduce CO2 with increased lipid proportion in dietPA catheter not useful ++ Use pressure-controlled-volume-guaranteed (PCVG) mode if available to optimize Vt to 6–8 mL/kg IBW while limiting Paw to ... Your Access profile is currently affiliated with [InstitutionA] and is in the process of switching affiliations to [InstitutionB]. Please select how you would like to proceed. Keep the current affiliation with [InstitutionA] and continue with the Access profile sign in process Switch affiliation to [InstitutionB] and continue with the Access profile sign in process Get Free Access Through Your Institution Learn how to see if your library subscribes to McGraw Hill Medical products. Subscribe: Institutional or Individual Sign In Error: Incorrect UserName or Password Username Error: Please enter User Name Password Error: Please enter Password Sign in Forgot Password? Forgot Username? Sign in via OpenAthens Sign in via Shibboleth You already have access! Please proceed to your institution's subscription. Create a free profile for additional features.