Acute respiratory distress syndromeBMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j5055 (Published 16 November 2017) Cite this as: BMJ 2017;359:j5055
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Ambulatory monitoring by ultrasonography and clinical manifestation may be helpful for managing ARDS.
Acute respiratory distress syndrome (ARDS) is one of the most critical clinical syndromes, resulting in higher mortality, morbidity, and financial cost. We are fully consistent with the view that early and accurate diagnosis by chest radiograph and arterial blood gas is the key. However, applying these two strategies may not be enough. We would like to highlight some effective measures to manage ARDS.
Firstly, we, as clinical doctors, should pay more attention to ambulatory monitoring patient’s condition after admission to hospital, including consciousness, respiratory rate, cyanosis, chest examination, associated with various underlying diseases and inducement. In addition, ambulatory monitoring APACHEII and SOFA score, an effective tool for predicting mortality, may be useful for earlier distinguishing different degrees of severity and prognosis prediction at different points, which may attract clinician’s attention to prevent or focus more on possible complications in a timely fashion. Moreover, from shift change in the bedside, clinician may be well aware of the patients who need to be focused on more, what complications may occur and how to identify and respond immediately. It may be a second insurance.
Undoubtedly, chest X-ray and computerized tomography is one of the most significant cores for diagnosing ARDS. But there do exist some limitations in clinical practice for chest radiograph, such as radioactive damage and poor portability. Ultrasonography, a noninvasive, radiation-free and bedside technique, has been a great influence for identifying various diseases, such as pneumothorax, pleural effusion, lung consolidation and circulation managing, and so on[3 4]. International consensus conference on lung ultrasound suggests following performances for the presence of ARDS: anterior subpleural consolidations, absence or reduction of lung sliding, ‘‘spared areas’’ of normal parenchyma, pleural line abnormalities (irregular thickened fragmented pleural line) and nonhomogeneous distribution of B-lines. Moreover, according to the Berlin guidelines for ARDS, the reason for pulmonary edema of patients who are suspected to have ARDS should be rapidly identified . Thus, bedside ultrasonography is a good choice. In addition to diagnosis, for managing ARDS, PEEP-induced lung recruitment can be adequately assessed and ambulatory monitored with bedside lung ultrasound. Ultrasound combined cardiac with lung may help in the weaning process, for identifying pulmonary-derived, cardiac-derived and diaphragmatic-derived factors. Complications of mechanical ventilation for ARDS can also be diagnosed quickly by lung ultrasound. Then, supported by bedside ultrasonography, clinicians could ambulatory monitor disease change and guide intervention in real time. Nowadays, bedside ultrasonography has been promoted to be applied in ICU according to the Chinese experts' opinions on ultrasonography in critical patients. In emergency department and ICU department, ultrasonography has been widely used in an effort to establish the diagnosis and ambulatory monitoring in clinical practice in China. Thus, to push the pulmonary and cardiac bedside ultrasound as the “first-line” clinical routine practice for the patients with high risk factor for ARDS is urgent and essential.
Apart from early use of muscle relaxation and prone positioning, some articles indicate that altered microbiota is associated with ARDS[12-14]. So, microbiome may be a good view for in-depth understanding ARDS and as a target for further treatment.
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Competing interests: No competing interests
Competing interests: No competing interests
I read with interest the review article by Laffey et al. on Acute Respiratory Distress Syndrome (ARDS). As stated, one of the main differential diagnoses is of acute (cardiogenic) pulmonary oedema. Updated guidelines from the European Society of Cardiology recommend measuring plasma natriuretic peptides (NP’s) in all patients with acute dyspnoea to help in the differentiation of acute heart failure (AHF) from non-cardiac causes. NP’s have high sensitivity, and normal levels in patients with suspected AHF make the diagnosis unlikely (1). This should then alert the clinician to other causes of bilateral air space opacification on a chest x-ray such as ARDS. Likewise if AHF is suspected then prompt intravenous diuretic should be given (2).
(1) Ponikowski P, Voors AA, Anker SD et al. 2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure: The Task Force for the diagnosis and treatment of acute and chronic heart failure of the European Society of Cardiology (ESC). Eur J Heart Fail. 2016 (8):891-975.
(2) Matsue Y, Damman K, Voors AA et al. Time-to-Furosemide Treatment and Mortality in Patients Hospitalized With Acute Heart Failure. J Am Coll Cardiol. 2017;69(25):3042-3051
Competing interests: No competing interests
Motivated by reading the article published in The BMJ on 16 November 2017, by John G Laffey and Brian P Kavanagh: Acute Respiratory Distress Syndrome, as Professors of Intensive Care Medicine and Emergencies, we wish to make some comments that alert all medical professionals to improve the prognosis of patients affected by this syndrome.
As recognized in the article, it was recognized as an individual clinical entity from the original description of Ashbaug, Petty and collaborators in 1967.
It is associated with high mortality and morbidity. It has a high cost, both economically and in human lives.
The Acute Respiratory Distress Syndrome is a condition that involves the pulmonary parenchyma, where there is a rapid and progressive alteration in the permeability of the alveolar-capillary set with progressive increase of hypoxemia and hypercapnia is produced and the formation of a hyaline membrane is added. Finally it evolves to a respiratory failure of difficult reversal.
Whatever the cause that leads a patient to suffer from Acute Respiratory Distress Syndrome, the Goal-Standard of treatment is the use of optimal and punctual ventilatory parameters.
We wish to emphasize that its timely diagnosis in emergency services may favor its prognosis, since it does not develop as an isolated process in the course of a well-defined illness. This implies that the best way to prevent its development is to diagnose it opportunely, to control the causes that trigger it, if possible, adequate and early control of sepsis, hemorrhages and other frequent causes.
We must not forget that to prevent pulmonary complications an adequate technique of respiratory support is essential, the correct humidification of the inspired mixture, together with physical thoracic therapy, will avoid the retention of secretions and will facilitate a correct distribution of ventilation in relation with perfusion.
Unfortunately, about 40 percent of people with Acute Respiratory Distress Syndrome die due to organ failure. However, the risk of death is not the same for all patients with Acute Respiratory Distress Syndrome. The mortality rate is linked both to the cause of the Acute Respiratory Distress Syndrome and to the general health of the patient. Many people who survive the Acute Respiratory Distress Syndrome recover completely within a few months. However, in some people the lung damage is sustained for life. Other side effects may include muscle weakness, fatigue, reduced quality of life and mental health commitment.
The characteristic of the natural evolution of the Acute Respiratory Distress Syndrome requires early identification of patients at risk, an early diagnosis, a multidisciplinary study with imaging support and prompt and effective treatment with particular emphasis on the optimization of respiratory parameters during mechanical ventilation
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Competing interests: No competing interests