Happy 50th birthday ARDS!
ARDS in China
focus on ventilated
patients
Berlin Definition
New ARDS Definition was imperative
Evolving definition of ARDS
If a"Better"Definition Is the Answer, What Is the Question?
最早是ESICM，也就是欧洲的重症学会要更新概念和ARDS的guideline。然后，一些美国研究者认为不能在ESICM框架上做definition，要做global。
ARDS VS
Conceptual model
Key point 1
·ARDS is an acute diffuse, inflammatory lung injury precipitated by a predisposing risk factor such as pneumonia, non-pulmonary infection, trauma, transfusion, burn,aspiration, or shock
·The resulting injury leads to increased pulmonary vascular and epithelial permeability, lung edema, and gravity dependent atelectasis, all of which contribute to loss of aerated lung tissue
-increased lung weight"is no longer included because of limited feasibility of measurement"
·The clinical hallmarks are arterial hypoxemia and diffuse radiographic opacities associated with increased shunting , increased alveolar dead space, and decreased lung compliance
-the concept of venous admixture is replaced by increased shunting and increased ratio of physiologic to alveolar dead space
·The clinical presentation is influenced by medical management (position, sedation,paralysis, and fluid balance)
·Histological findings vary and may include intra-alveolar edema, inflammation, hyaline membrane formation, and alveolar hemorrhage
-Not all patients with clinical ARDS have histological findings of diffuse alveolar damage
-it is rare to obtain lung biopsies in patients with ARDS
HFNO ≥30L/min
Key point 2
Timing of Intubation and Clinical Outcomes in Adults With Acute Respiratory Distress Syndrome
·Intubated and non-intubated patients with ARDS defined by Acute hypoxemia (P/F≤300 or S/F≤315)
·Bilateral radiographic opacities not explained by cardiac failure
·In 457 patients, 106 (23%) were not intubated at the time of meeting all other ARDS criteria
·Late Intubation >1 day
HFNO generate PEEP for ARDS diagnosis
High flow nasal oxygen generates positive airway pressure in adult volunteers
Broadening the ARDS definition to include patients on HFNO with P/F≤300mmHg identify patients at earlier stages of disease
Do we really need PEEP for ARDS diagnosis?PEEP>=5cmH2O
S/F≤315mmHg
with SpO2≤97%
Key point 3
·S/F have been validated for diagnosis and management of ARDS
·Many evidences support the use of pulse oximetry-based measurements in the ARDS studies
·SpO2 is also a good predictor of PaO2 up to saturation values of 97%
·S/F correctly classify severity rather than exactly predict PaO2 from SpO2
lung ultrasound for the
detectionof bilateral
opacities Improve
the Radiographic
Diagnosis of ARDS
Key point 4
这样的结果可能告诉我们，超声会很快的帮助我们做诊断。
New definitions of ARDS LUS on the occurrence rate
Resource-limited setting
Key point 5
·Screen every adult patient for hypoxia at a public referral hospital in Rwanda for six weeks
·Using Berlin criteria, no patients would have met criteria for ARDS
·Objectives: To estimate the incidence and outcomes of ARDS at a Rwandan referral hospital using the Kigali modification of the Berlin definition
-Without requirement for PEEP
-Without ABG, hypoxia cutoff of SpO2 /FIO2< 315
-With bilateral opacities on lung ultrasound or chest radiograph
Modified ARDS criteria: Kagali criteria
The new criteria of ARDS reduced the severity of illness
ARDS vs. syndrome
·ARDS concenpt: it is time to change
·PEEP: Not only MV/NIV, but also HFNO >30L/min
·P/F: S/F when SpO2 <97%
·Pul infiltration: Not only chest X-ray or CT, but also Ultra-sound
·Resource-limited setting: PEEP and ABG--NOT necessary
Critical care and ICU
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参考文献
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