0.3 CME

ARDS: Diagnosis dan Penatalaksanaan Klinis

Pembicara: Dr. Dharanindra Moturu

Alumni - Bharati Vidyapeeth

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Keterangan

Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by rapid onset of severe respiratory failure, often resulting from underlying illnesses like pneumonia, sepsis, or trauma. Clinical diagnosis of ARDS is based on criteria including acute onset of respiratory distress, bilateral lung infiltrates on chest imaging, and impaired oxygenation not fully explained by cardiac failure. Early recognition and management are essential in ARDS to prevent further lung damage and improve patient outcomes. Oxygen therapy and mechanical ventilation are typically necessary to provide adequate oxygen levels while minimizing the risk of ventilator-induced lung injury. Positive End-Expiratory Pressure (PEEP) is commonly used to maintain lung recruitment and improve oxygenation. Management strategies focus on treating the underlying cause, such as antibiotics for infections or addressing fluid balance issues. Prone positioning, a technique where the patient lies face down, can improve oxygenation in some cases. Low tidal volume ventilation, which involves using smaller breath volumes, is a recommended ventilatory strategy to prevent further lung injury.

Ringkasan

  • Acute Respiratory Distress Syndrome (ARDS) presents as hypoxic respiratory failure resulting from direct or indirect lung insults, initially termed by Ashbaugh and colleagues. Direct injuries include pneumonia, trauma, aspiration, and near-drowning. Indirect injuries stem from pancreatitis, sepsis, or cellulitis. The Berlin definition defines ARDS based on acute onset, bilateral ground-glass opacities, hypoxemia, and an insult within the past 7 days, distinguishing it from cardiac pulmonary edema.
  • The pathophysiology of ARDS progresses through exudative, proliferative, and fibrotic phases. The exudative phase involves an exaggerated immune response, causing increased permeability and edema. The proliferative phase sees proliferation of type II pneumocytes, impairing gas exchange. The fibrotic phase involves replacement of inflammatory cells with fibrocytes, reducing lung compliance. Management focuses on preventing the fibrotic phase.
  • Severity of ARDS is classified as mild (PaO2/FiO2 200-300), moderate (100-200), or severe (less than 100). Oxygen therapy is crucial, starting with non-invasive methods like high-flow nasal oxygen for mild ARDS. Moderate to severe cases require endotracheal intubation and low tidal volume ventilation (4-6 ml/kg of ideal body weight). Sedation and neuromuscular blockade may be necessary.
  • Positive end-expiratory pressure (PEEP) is essential, guided by FiO2 settings using the ARDSnet protocol. Refractory ARDS necessitates prone ventilation, reducing mortality. As per the PROSEVA trial, prone ventilation reduces mortality. For persistent hypoxemia, veno-venous ECMO (VV-ECMO) can be considered to rest the lungs.
  • VV-ECMO involves extracting blood, oxygenating it extracorporeally, and returning it to the patient. Early VV-ECMO consideration is crucial, especially with PF ratios less than 100, extensive ground-glass opacities, and reduced compliance. Long-term consequences of ARDS include pulmonary and extrapulmonary complications, infections, critical illness neuropathy/myopathy, and psychological issues like PTSD.

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