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8/14/2019 • Name- Perumal Sex: M • Age
http://slidepdf.com/reader/full/-name-perumal-sex-m-age 1/21
ARDSARDS
8/14/2019 • Name- Perumal Sex: M • Age
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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
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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
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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 +
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PROVISIONAL DIAGNOSISPROVISIONAL DIAGNOSIS
• ? Pneumonia with ARDS? Pneumonia with ARDS
• ? Pancreatitis / perforation with? Pancreatitis / perforation with
sepsissepsis
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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
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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
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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+
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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
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ACUTE RESPIRATORYACUTE RESPIRATORY
DISTRESS SYNDROMEDISTRESS SYNDROME
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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