8/25/2023 0 Comments Shunt vs dead space on abgBeta-D-glucan (if fungal infection or PJP is possible).Urinary antigens (legionella, pneumococcus) if pneumonia suspected.Sputum culture & staining for bacteria +/- fungi.Nasopharyngeal PCR for influenza, COVID-19, other viral pathogens.? Infectious or rheumatologic prodrome.? Malignancy (considerations include chemotherapy, checkpoint inhibitors, radiotherapy, opportunistic infections).In some cases, the cause of ARDS may be obvious, so extensive evaluation is unnecessary. The extent of evaluation should be tailored to the clinical context. Fat emboli syndrome (traumatic or following orthopedic surgery).High-risk surgeries (e.g., lung resection, esophagectomy).Pulmonary contusion, patients with multiple trauma.E-cigarette or Vaping Associated Lung Injury (EVALI).TRALI (transfusion-related acute lung injury), especially following massive transfusion.Acute hypersensitivity pneumonitis (HP).Most often: exacerbation of IPF (idiopathic pulmonary fibrosis) or NSIP (nonspecific interstitial pneumonitis).Exacerbation of pre-existing interstitial lung disease.Diffuse alveolar hemorrhage (often due to ANCA vasculitis).Fungal (e.g., aspergillosis) is less common.Pneumocystis jirovecii pneumonia is possible.Infection is the most common cause of ARDS ( 34217425) One advantage of ultrasonography and chest CT is that they are capable of diagnosing features of both processes simultaneously. In reality, it is possible to have both ARDS plus pulmonary edema (they aren't mutually exclusive).ARDS: patchy areas with B-lines intermixed with areas with A-lines (normal lung), areas of dense sub-pulmonic consolidation (small patches of severely diseased lung in contact with the pleura), pleural line may appear thick/ragged.Cardiogenic pulmonary edema: B-lines distributed throughout the lung, pleural effusions, pleural line is normal (thin).ARDS: patchy edema, often areas of dense consolidation interspersed with normal-appearing lung.Cardiogenic pulmonary edema: diffuse edema, septal thickening, pleural effusions, evidence of heart failure (e.g., dilated left atrium).Chest CT scan (similar findings are sometimes suggested by CXR, but X-ray is less specific):.The best ways to make this distinction are lung ultrasonography and/or chest CT scan. noncardiogenic pulmonary edema was based on wedge pressure from pulmonary artery catheter, but currently the pulmonary artery catheter is rarely used. Historically differentiating cardiogenic vs.This includes what many authors would refer to as “ARDS mimics” as well as “true ARDS.” For the purposes of this chapter, ARDS will refer to the clinical syndrome as defined by the Berlin Definition (including a diversity of histological patterns – which in clinical practice is generally unknown). Many authors describe patients meeting the Berlin definition of ARDS who don't have diffuse alveolar damage as “ARDS mimics” (with the concept that only diseases causing diffuse alveolar damage are “true” ARDS).As discussed further below, patients should be optimized on the ventilator for >12 hours prior to proning, in order to sort out patients with pseudoARDS. PseudoARDS is clinically important to recognize because these patients generally respond well to high mean airway pressure, but do not benefit from interventions such as paralysis or proning.Acute onset (new or worsening respiratory symptoms within 300 mm (40 kPa) so patients no longer meet diagnostic criteria for ARDS.Start early enteral nutrition (even if proned and/or paralyzed).īerlin definition requires four criteria ( 22797452).Indicated if PaO2/FiO2 Consider after >12 hours of optimization on ventilator.Propofol and opioid will reduce respiratory drive and improve ventilator synchrony (but avoid prolonged high-dose exposure to these agents).Consider IV bicarbonate to increase the bicarbonate to ~30-35 mM (if needed to achieve adequate pH without lung-injurious ventilation).Consider if PaO2/FiO2 ~7.2 (unless elevated ICP or RV failure).□ Often the most important intervention!.Intubated ARDS patient: therapeutic package ✅ investigate & treat underlying cause ( more)
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