• Name- Perumal Sex: M • Age

8/14/2019 • Name- Perumal Sex: M • Age

http://slidepdf.com/reader/full/-name-perumal-sex-m-age 1/21

ARDSARDS



HISTORYHISTORY

• Name- PerumalName- Perumal

• Age- 48 sex: MAge- 48 sex: M

•DOA- 3/12/2004DOA- 3/12/2004

• Chief complaints- fever 4 daysChief complaints- fever 4 days

cough & expectoration 4dayscough & expectoration 4days

seizure 1 episode with alteredseizure 1 episode with altered

sensorium 4hrs prior to admsensorium 4hrs prior to adm



HISTORYHISTORY

• H/O continuous fever of high grade assH/O continuous fever of high grade asswith chillswith chills

• Associated with cough &expectorationAssociated with cough &expectoration• Difficulty in breathingDifficulty in breathing

• H/o generalised tonic seizure associatedH/o generalised tonic seizure associatedwith urinary incontinencewith urinary incontinence

• Jaundice 3 yrs back Jaundice 3 yrs back• Chronic smoker & alcoholicChronic smoker & alcoholic



EXAMINATIONEXAMINATION

• Conscious, restless,obeying commandsConscious, restless,obeying commands

• No pallor,icterus,cyanosis,clubbingNo pallor,icterus,cyanosis,clubbing

• Mild pedel edema +Mild pedel edema +

• Afebrile, tachypnea+Afebrile, tachypnea+

PR- 110/min,regular BP- 80 systolicPR- 110/min,regular BP- 80 systolic

CVS-S1,S2 not heard clearlyCVS-S1,S2 not heard clearly

RS- Bil crepts + ,occ rhonchi +RS- Bil crepts + ,occ rhonchi +

P/A-diffuse tenderness/guarding +P/A-diffuse tenderness/guarding +



PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS

• ? Pneumonia with ARDS? Pneumonia with ARDS

• ? Pancreatitis / perforation with? Pancreatitis / perforation with

sepsissepsis



MANAGEMENTMANAGEMENT

• 44thth hrly PTR/ IO chart/ npo/ RThrly PTR/ IO chart/ npo/ RT

drain/O2 by maskdrain/O2 by mask

• Antibiotics and bronchodilatorsAntibiotics and bronchodilators

• At 10.00 am on 4/12/04 pt wasAt 10.00 am on 4/12/04 pt was

intubated as the pt was gasping &intubated as the pt was gasping &

was shifted to ccu for ventilationwas shifted to ccu for ventilation



Course in ccuCourse in ccu

• Pt in grade 3 sensoriumPt in grade 3 sensorium

• PR-157/min BP-100/70 mmHgPR-157/min BP-100/70 mmHg

CVS – S1S2 +CVS – S1S2 +RS- bil crepts +, Rhonchi +, gasping &RS- bil crepts +, Rhonchi +, gasping &

chest indrawing +chest indrawing +

• Pt put on PB ventilator with SIMV PC PSPt put on PB ventilator with SIMV PC PSwith 50% FIO2with 50% FIO2



Contd….Contd….

• Pt weaned from ventilator and extubated onPt weaned from ventilator and extubated on77thth morningmorning

• Pt monitored with ECG,Spo2,HR,NIBPPt monitored with ECG,Spo2,HR,NIBP

• At present pt is conscious,oriented,obeyingAt present pt is conscious,oriented,obeyingcommands ,febrilecommands ,febrile

PR-98/min RR-26/min BP- 118/105mmHgPR-98/min RR-26/min BP- 118/105mmHg

Spo2- 98% in room airSpo2- 98% in room air

RS- clear, NVBS CVS-S1S2 +RS- clear, NVBS CVS-S1S2 +

P/A-soft distension+P/A-soft distension+



workupworkup

• WBC-13,200cells/cu mmWBC-13,200cells/cu mm Hb-10gms%Hb-10gms%

• N-77% E-7% L-16%N-77% E-7% L-16%

• BU-114mg%BU-114mg% BS- 189mg%BS- 189mg% SC-3.4mg%SC-3.4mg%

• Na 144 K-5.3 se amylase-113 iu/lNa 144 K-5.3 se amylase-113 iu/l• STP-4.6, Alb-2.4, bil-0.6,STP-4.6, Alb-2.4, bil-0.6,AST-109,ALT-73AST-109,ALT-73

ALP-413ALP-413

• CSF-protein-100mg%CSF-protein-100mg% sugar-71mg%sugar-71mg%

• MP/MF- negativeMP/MF- negative• Tracheal aspirate- pseudomonas sens to Tracheal aspirate- pseudomonas sens to

cipro,amikacin,ceftazidimecipro,amikacin,ceftazidime



ACUTE RESPIRATORYACUTE RESPIRATORY

DISTRESS SYNDROMEDISTRESS SYNDROME



DEFINITIONDEFINITION

condition characterized by acutecondition characterized by acute

hypoxemic respiratory failure due tohypoxemic respiratory failure due to

pulmonary edema caused bypulmonary edema caused byincreased permiability of the alveolarincreased permiability of the alveolar

capillary barriercapillary barrier



CAUSESCAUSES

Direct lung injury Indirect lung injury

Common- pnemonia,aspiration of gastric

contentsLess common –pulcontusion

Fat emboli

Near drowning

Inhalational injury

Reperfusion pul edema

Common-sepsis,severetrauma with shock &

multiple transfusionLess common- CPB

Drug overdose

Acute pancreatitis

Transfusion of bloodproducts



Common cause in tropicsCommon cause in tropics

• Severe pneumoniaSevere pneumonia

• Pul tuberculosisPul tuberculosis

•Enteric feverEnteric fever

• MalariaMalaria

• StrongyloidiasisStrongyloidiasis

• LeptospirosisLeptospirosis

• OP poisoning,paraquat poisoningOP poisoning,paraquat poisoning• Scorpion bite, heat strokeScorpion bite, heat stroke



DIAGNOSTIC CRITERIADIAGNOSTIC CRITERIA

• Acute onsetAcute onset

• Bil infilterates on chest radiographBil infilterates on chest radiograph

• PAWP-<18mmHg or absence of PAWP-<18mmHg or absence of

clinical evidence of lt atrialclinical evidence of lt atrial

hypertensionhypertension

• ALI-Pao2/Fio2<= 300mmHgALI-Pao2/Fio2<= 300mmHg

• ARDS-Pao2/Fio2<= 200mmHgARDS-Pao2/Fio2<= 200mmHg



PathophysiologyPathophysiology

• Hallmark-increased vascularHallmark-increased vascularpermeability to proteinspermeability to proteins

• Three stages-initiation Three stages-initiationampilificationampilification

injuryinjury

• Interstitial and alveolar edemaInterstitial and alveolar edema• Alveolar collapse and decreasedAlveolar collapse and decreased

compliancecompliance



PathologyPathology

• Necrosis of type 1 pnemocytes &Necrosis of type 1 pnemocytes &

denuded BMdenuded BM

• Endothelial swelling with widened ICEndothelial swelling with widened IC junction junction

• Hyaline membrane-fibrin & matrixHyaline membrane-fibrin & matrix

protein in airspaceprotein in airspace• Neutrophilic inflammationNeutrophilic inflammation



Clinical featuresClinical features

• Occurs within 5 days of initial at-risk diagnosisOccurs within 5 days of initial at-risk diagnosis

• 50% in first 24 hrs50% in first 24 hrs

•Increased RR,dyspneaIncreased RR,dyspnea

• CXR-initial clearCXR-initial clear

-diffuse bil interstitial & alveolar edema-diffuse bil interstitial & alveolar edema

-difficult to diff from cardiogenic pul edema-difficult to diff from cardiogenic pul edema



CXRCXRCriterion Acute pul edema ARDS

1.Cardiomegaly

2.Alveolaredema

3.Appearance of parenchymalshadow

4.Perivascular,peribronchialcuffing

5.Gravitational

distribution

common

+++

Patchy more inmidlung“butterflyshadow”

More often seen

Yes

uncommon

+++

More patchy

Less likely

No

unlikely



Treatment Treatment

• No specific therapyNo specific therapy

• Mechanical ventilation-to achieveMechanical ventilation-to achieveadequate oxygenationadequate oxygenation

airway pressure: 30-35mmHgairway pressure: 30-35mmHg

low tidal volumes appro 6ml/Kglow tidal volumes appro 6ml/Kg

permissive hypercapniapermissive hypercapnia

adequate PEEP-lung protectiveadequate PEEP-lung protectivestrategystrategy



Contd....Contd....

• Fluid and hemodynamic managementFluid and hemodynamic management

• Surfactant therapySurfactant therapy

• Inhaled nitricoxide and other vasodilatorsInhaled nitricoxide and other vasodilators• GlucocorticoidsGlucocorticoids

• Acceleration of resolution-beta agonistsAcceleration of resolution-beta agonists



THANK U THANK U

• Name- Perumal Sex: M • Age

Documents

Transcript of • Name- Perumal Sex: M • Age