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Your treatment guide to save patient's lives

Acute respiratory distress syndrome (ARDS)

Globally, ARDS affects more than 3 million people a year, accounting for 10% of intensive care unit admissions.1 Learn how you can identify and treat ARDS.

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What is ARDS?

Acute respiratory distress syndrome is a serious lung condition that is rapidly progressive and commonly leads to lung failure. It occurs when the capillary membrane leaks fluid into the alveoli sac due to widespread inflammation or severe lung injury.2

What causes ARDS?

ARDS can occur to anyone at any age including children.3 Despite advances in critical care, ARDS carries a high mortality rate of 43% and, even those who survive, have poorer quality of life with long morbidity and recovery periods leading many as 40%-52% of patients reporting re-hospitalization within one year.4

Conditions that increase the risk of ARDS are Sepsis, Pneumonia, Coronavirus disease, traumatic brain injuries, organ failure and alcohol and smoking abuse. Patients often experience severe shortness of breath leading to low oxygen in the blood (Hypoxia), followed by low blood pressure, confusion and dizziness.3,5

Preventing ARDS

There is no way to completely prevent ARDS, however there are several safety measures to take to lessen the risks that lead to the development of ARDS.

  1. Routine vaccinations against influenza and pneumonia are predicted to lessen a substantial amount of ARDS, since it is incited by pneumonia in most cases.6
  2. Studies have shown aspirations of gastric content have contributed to a large percentage of causing ARDS.2,7 In addition, nosocomial pneumonia occurs four times more often in patients assigned to supine positioning than in those assigned to semi-recumbent (head of bed 45°) positioning.2
  3. Preventing iatrogenic injuries, which eventually leads to increased risks for ARDS development. Although sporadically preventing ARDS from progressing is inevitable, the majority of the ARDS population are exposed to one or more hazardous risk factors while hospitalized.7 According to a large study that spanned over the course of eight years, that compared hospital acquired ARDS communities with low rates vs high rates and based on these studies, a proposed checklist of hospital best practices preventing lung injuries has been developed. See below.2

Watch the recording of our #ARDStalk live discussion

The Checklist for Lung Injury Prevention (CLIP)

Clip Elements Definition
Lung protective ventilation Limit tidal volumes & pressure swings, recruitment (body position/PEEP)
Aspiration precautions Intubation supervised by experienced providers, elevaed head of the bed, oral care
Adequate antimicrobials & source control According to site of infection, health care exposure, and immune suppression
Limiting fluid overload Limit IV fluid, use diuretics
Restrictive transfusion Hemoglobin target >7g/dL; minimize platelet transufions in the absence of active bleeding, male donor plasma
Prevention of new infections Rapid weaning from ventilators (use noninvasive), devices and medications

Diagnosing ARDS

Acute respiratory distress syndrome is acknowledged to be a complex problem to solve in respiratory medicine. ARDS is under-diagnosed and results in a strikingly high mortality rate, and even those who survive still face complications.3

Early diagnosis and recognition of the symptoms are crucial to treat effectively and help your patients survive the highly dangerous disorder.8 It is important to note that ARDS is a rapidly progressive disorder that first appears as dyspnea, tachypnea, and hypoxemia and quickly evolves to respiratory failure.9

Diagnosing ARDS entails defining the partial pressure of arterial oxygen to fraction of inspired oxygen (PaO2/FiO2) of 300 or less.10 In addition, performing frontal chest radiography where bilateral infiltrates are seen; an applied PEEP of at least 5, and pulmonary artery wedge pressure of 18 mm Hg or less when measured.10

Treating & managing ARDS

Treatment for ARDS mainly focuses on oxygen and fluid therapy to deliver enough oxygen in the blood and to prevent organs from failing.11 Depending on the level of severity, treatment for ARDS should vary. For mild ARDS, oxygen therapy via a mask or high flow nasal cannulae can be used; however, mechanical ventilation and even extracorporeal membrane oxygenation (ECMO) may be required for patients classified with moderate and severe ARDS.12,13

The Berlin criteria for ARDS have three levels of severity: mild, moderate, and severe:14

  • 200 mm Hg < PaO2 /FiO2 ≤ 300 mm Hg with PEEP or CPAP ≥ 5 cm H2O (mild ARDS);
  • 100 mm Hg < PaO2 /FiO2 ≤ 200 mm Hg with PEEP ≥ 5 cm H2 O (moderate ARDS);
  • PaO2 /FiO2 ≤ 100 mm Hg with PEEP ≥ 5 cm H2O (severe ARDS).
  • When PaO2 is not available, an SpO2 /FiO2 ratio ≤ 315 suggests ARDS.

Mechanical-ventilation strategies that use lower end-inspiratory (plateau) airway pressures and lower tidal volumes (VT) are the two most important variable that can improve the survival of patients on mechanical ventilators. 16 The modern standard of practice suggests the initiation of oxygen therapy with low tidal volumes of 6 mL per kg, rather than starting with traditional tidal volumes of 10 to 15 mL per kg.9 In addition, to maintain oxygenation, higher PEEP values (12 cm H2O or more) are associated with decreased mortality compared with lower values of 5 to 12 cm H2O.9 According to multilevel mediation analysis to analyze individual data from 3562 patients with ARDS, among ventilation variables, Driving pressure (ΔP) was most strongly associated with survival17. Individual changes in tidal volumes VT or PEEP after randomization were not independently associated with survival; they were associated only if they were among the changes that led to reductions in ΔP. 17

In addition, even though studies have showed thatlower tidal volumes’results in decreased mortality and increases the number of days without ventilator use, 16,17 it’s always wise to not generalize this approach as the standard practice of care as it can sometimes cause respiratory acidosis and decrease arterial oxygenation. An individualized approach to the management of the ARDS patient, where oxygenation, CO2, driving pressure, and haemodynamic targets are adjusted regularly at the bedside may be the best approach.18

Lastly and importantly, conservative fluid therapy (titrated to lower central pressures) and prone positioning (at least 12 hours per day) are recommended as adjunct treatments.9

Paediatric ARDS

Paediatric acute respiratory distress syndrome (PARDS) accounts for up to 10% of admissions to the paediatric intensive care unit (PICU) and the most common cause of death to children admitted to PICU. A large PARDS study found that neurologic failure and multi-system organ failure are the primary cause of death compared to the deaths attributed to hypoxemia. Overall, the PARDS mortality rate has decreased over the past few decades, and its mortality rate is still lower than the Adult ARDS mortality rate.19

Clinical evidence and recommendations for Paediatric acute respiratory distress syndrome Therapies are as follows:19 

  • Initiate oxygen therapy with low tidal volumes 3–6 mL/kg if poor compliance 5–8 mL/kg
  • if preserved compliance plateau ≤28 cm H2O
  • Permissive hypoxemia
  • Mild PARDS: Saturation target 92%–97%

In Severe PARDS: 

  • Saturation target 88%–92% and PEEP >10 cm H2O
  • Permissive hypercapnia (in Moderate/severe PARDS, tolerate a pH 7.15–7.30, with exceptions for specific populations such as brain injury)

Other recommendations include:

  • After initial resuscitation, use a goal-directed fluid management protocol to maintain intravascular volume while minimizing fluid overload.19
  • Consider prone positioning as an option in cases of severe PARDS. It is not recommended to apply as a routine therapy given current paediatric data.19
  • Apply sedation to ensure patients can tolerate MV to optimize oxygen delivery/consumption. Pain and sedation scales should be titrated.19 (Check out our NOL monitor, an objective measure of the patient's nociceptive (pain) state.)
  • Consider HFOV in patients with moderate to severe PARDS and Plateau >28 cm H2O.19 

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Covid-19 ARDS

ARDS develops within 42% of patients diagnosed with COVID-19 Pneumonia. Respiratory rate and SpO2 are two measures to indicate the early onset of ARDS. A patient whose measures fall within the following rates may have severely progressed with the COVID-19 ARDS disease: respiratory rate ≥ 30 breaths/min; SpO2 ≤ 92%; and PaO2/FiO2 ≤ 300 mm Hg.20

When COVID-19 enters the body, it often attaches to cells in the upper airway, and 42% of the time, the virus goes through beyond the upper airway and ends up in the alveolii of the lungs, causing both vascular and alveolar damage. You can expect COVID-19 ARDS to set in, in about 8 days after the onset of initial COVID-19 symptoms.21

For COVID‐19 ARDS, mortality rates for patients in critical care settings range from 26-61%, whereas patients who received mechanical ventilation range from 65.7% - 94%. The ventilation strategy for treating COVID-19 ARDS is essential for breathing support. However, the following points are key elements:

  • use oxygen by nasal cannulas to achieve SpO2 > 92%20
  • use of high flow nasal oxygen is controversial and highly dependent on the treatment location20
  • Non-invasive ventilation may be beneficial22
  • Awake prone ventilation appears to be beneficialto improve oxygenation23
  • Once mechanically ventilated, prone ventilation is beneficial when applied for >12 hours a day20
  • and consider extracorporeal membrane oxygenation for rescue.20

Recommended products to help you fight ARDS

Capnography monitoring

OxyMask™* EtCO2 with microstream™ connector

Oxygen therapy is the main treatment for ARDS as it improves the oxygen level in the blood and promotes organ functionality. Measuring the level of EtCO2, capnography waveform and respiratory rate are essential to help assess the level of respiratory distress and the efficacy of a treatment.

The OxyMask™* EtCO2 with microstream™ connector is engineered to deliver a wide range of O2 levels (up to 15 lpm, and 65% FiO2) and captures EtCO2 sampling. Microstream is a low flow, plug & play leading capnography monitoring technology that does not require individual patient calibration and is not affected by the presence of other gases.

These therapies allow for early application of optimal oxygen. 

Learn more

Pulse oximetry

Nellcor™ bedside SpO₂ patient monitoring system, PM100N

Engineered with key clinical features, the Nellcor™ pulse oximeters measurements are tied to true arterial oxygen saturation and cardiac induced pulse. It offers advanced digital signal processing technology for reliable operation even during low perfusion and signal interference, including patient motion. And LoSat™ expanded the accuracy range of 60% to 100% SpO2 when used with Nellcor™ pulse oximetry adhesive sensors with OxiMax™ technology.

Learn more
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References

1. Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018 Feb 20;319(7):698-710.

2. Beitler JR, Schoenfeld DA, Thompson BT. Preventing ARDS: progress, promise, and pitfalls. Chest. 2014;146(4):1102-1113.

3. Diamond M, Peniston HL, Sanghavi D, et al. Acute Respiratory Distress Syndrome. [Updated 2021 Jul 25]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2021 Jan-. Available at: https://www.ncbi.nlm.nih.gov/books/NBK436002

4. Siuba MT, Sadana D, Gadre S, Bruckman D, Duggal A. Acute respiratory distress syndrome readmissions: A nationwide cross-sectional analysis of epidemiology and costs of care. PLoS One. 2022 Jan 25;17(1):e0263000

5. Nhlbi.nih.gov. 2021. Acute Respiratory Distress Syndrome NHLBI, NIH. [online] Available at: https://www.nhlbi.nih.gov/health-topics/acute-respiratory-distress-syndrome [Accessed 23 July 2021].

6. Mayo Clinic. June 13, 2020. ARDS, [online - Accessed 03 Dec 2021] Available at: https://www.mayoclinic.org/diseases-conditions/ards/symptoms-causes/syc-20355576

7. Festic E, Kor DJ, Gajic O. Prevention of acute respiratory distress syndrome. Curr Opin Crit Care. 2015;21(1):82-90.

8. Bellani G, Pham T, Laffey JG. Missed or delayed diagnosis of ARDS: a common and serious problem. Intensive Care Med. 2020;46(6):1180-1183.

9. Saguil A, Fargo M. Acute respiratory distress syndrome: diagnosis and management. Am Fam Physician. 2012;85(4):352-358.

10. Arrivé F, Coudroy R, Thille AW. Early Identification and Diagnostic Approach in Acute Respiratory Distress Syndrome (ARDS). Diagnostics (Basel). 2021;11(12):2307. Published 2021 Dec 8.

11. Matthay MA, Zemans RL, Zimmerman GA, et al. Acute respiratory distress syndrome. Nat Rev Dis Prim. 2018;5:18.

12. Ohshimo, S. Oxygen administration for patients with ARDS. j intensive care 9, 17 (2021).

13. Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. N Engl J Med. 2018;378(21):1965-1975.

14. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012;307(23):2526-2533.

15. Matthay MA, Zemans RL, Zimmerman GA, et al. Acute respiratory distress syndrome. Nat Rev Dis Primers. 2019;5(1):18. Published 2019 Mar 14. doi:10.1038/s41572-019-0069-0

16. Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301-1308.

17. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-755.

18. Pelosi, P., Ball, L., Barbas, C.S.V. et al. Personalized mechanical ventilation in acute respiratory distress syndrome. Crit Care 25, 250 (2021).

19. Orloff KE, Turner DA, Rehder KJ. The Current State of Pediatric Acute Respiratory Distress Syndrome. Pediatr Allergy Immunol Pulmonol. 2019;32(2):35-44.

20. Gibson PG, Qin L, Puah SH. COVID-19 acute respiratory distress syndrome (ARDS): clinical features and differences from typical pre-COVID-19 ARDS. Med J Aust. 2020;213(2):54-56.e1. doi:10.5694/mja2.50674

21. Acute Respiratory Distress Syndrome (ARDS). (2022, June 6). Yale Medicine. https://www.yalemedicine.org/conditions/ards

22. Mina B, Newton A, Hadda V. Noninvasive Ventilation in Treatment of Respiratory Failure-Related COVID-19 Infection: Review of the Literature. Can Respir J. 2022;2022:9914081. Published 2022 Aug 31.

23. Sodhi K, Chanchalani G. Awake Proning: Current Evidence and Practical Considerations. Indian J Crit Care Med. 2020;24(12):1236-1241

24. Oto J., Chenelle T.C. at al, A Comparison of Leak compensation in CUTE Care Ventilators During Noninvasive and Invasive Ventilation: A Lung Model Study, Respir Care. 2013 Dec;58(12):2027-37. doi: 10.4187/respcare.02466. Epub 2013 May 21. PMID: 23696688.

25. Biselli PJ, Kirkness JP, Grote L, et al. Nasal high flow therapy reduces work of breathing compared with oxygen during sleep in COPD and smoking controls: a prospective observational study. J Appl Physiol (1985). 2017;122(1):82–88

26. Loss SH, De Oliveira RP, Maccari JG, Savi A, Boniatti MM, Hetzel MP, et al. The reality of patients requiring prolonged mechanical ventilation: a multicenter study. Rev Bras Ter Intensiv. 2015;27:26–35

27. Itagaki T. Chenelle T et all, Effects of Leak Compensation on Patient-Ventilator Synchrony During Premature/Neonatal Invasive and Noninvasive Ventilation: A Lung Model Study, Respir Care. 2017; 62(1): 22-23 Daedalus Enterprises