Elsevier

Journal of Critical Care

Volume 29, Issue 5, October 2014, Pages 883.e1-883.e5
Journal of Critical Care

Electronic Article
Act fast and ventilate soft: The Düsseldorf hands-on translation of the acute respiratory distress syndrome Berlin definition

https://doi.org/10.1016/j.jcrc.2014.03.024Get rights and content

Abstract

Early identification of acute respiratory distress syndrome (ARDS) and forceful implementation of standardized therapy algorithms are the mandatory basis of an effective therapy to improve patient outcome. Recently, a new definition of ARDS was implemented, which simplified the diagnostic criteria for ARDS. Evidence-based therapies are rare, but some cornerstone interventions can be recommended. Lung-protective ventilation with high positive end-expiratory pressure and low tidal volume and early prone positioning in severe cases improve survival rate. We here present an integrated “Düsseldorf hands-on translation” in the form of a “one-page” standard operating procedure in order to fasten and standardize both diagnosis and therapeutic algorithms on an intensive care unit.

Introduction

Acute respiratory distress syndrome (ARDS) is characterized by an acute onset of lung injury as a consequence of a variety of pulmonary or extrapulmonary diseases. Subsequent development of noncardiac lung edema causes hypoxemia [1], which may lead to multiorgan failure and death. In recent years, it has been demonstrated that early diagnosis and application of standardized therapy algorithms improve prognosis [2]. The key element of an effective therapy of ARDS is early treatment of the underlying disease and a ventilator therapy that minimizes iatrogenic ventilator-induced lung injury [3]. In order to cope with the increasing body of knowledge and to overcome delayed diagnosis of ARDS, the definition was redefined in 2012 and named “Berlin definition” referring to the site of the consensus conference [4]. The major novelty of the Berlin definition of ARDS was the implementation of ventilation parameters (mandatory application of positive end-expiratory pressure [PEEP]), the definition of 3 distinct severity grades, and the withdrawal of invasive hemodynamic parameters to establish the diagnosis [4].

Today, ARDS is still associated with a high mortality, and the clinical picture constitutes a major challenge for the intensive care physician [2]. In order to standardize and to accelerate the diagnosis and to fasten the implementation of evidence-based therapeutic interventions, we summarized the current ARDS diagnosis criteria and evidence-based therapies to offer a standard operation procedure (SOP) for the physicians on the intensive care unit (ICU). Strict adherence to the therapy guidelines constitutes the basis of the ARDS-SOP described here [5]. The following tutorial will guide the clinician through the SOP (Fig. 1), summarizing the current state-of-the-art evidence on ARDS.

Section snippets

Blood gas analysis

After detection of a relevant hypoxemia in a patient presenting with dyspnea, the Pao2/fraction of inspired oxygen (Fio2) ratio should be determined.

Kinetics

Diagnosis of ARDS requires a rapid onset of symptoms within 7 days, in line with the label “acute.”

X-ray

Evidence of bilateral infiltrates (x-ray or computer tomography of the chest) with an acute onset within 7 days (acute) is mandatory for the diagnosis of ARDS. Importantly, these infiltrations must not be a consequence of pleural effusions,

Therapy of ARDS

Until now, only a few therapeutic procedures fulfill the criteria of an evidence-based therapy. In the following, we summarize the therapeutic options and the existing body of evidence.

Ventilation: small tidal volume and low peak pressure decrease mortality

Cornerstones of mechanical ventilation in patients with ARDS are application of PEEP to keep open and to recruit collapsed alveoli, use of low tidal volume to reduce shear force to the lung parenchyma, and maintaining a low inspiratory pressure plateau [3], [6]. Ventilator-delivered tidal volumes should not exceed 4 to 6 mL/kg of predicted body weight, and the plateau airway pressures should be (Pinsp) less than 30 cm H2O. In contrast to these clear recommendations, it is still under debate

Position: turn your patient! Early prone positioning decreases mortality

In supine position, hydrostatic pressure compresses dorsobasal lung areas with subsequent development of atelectasis and a reduction of aeration area causing an increased right-left shunt and a decreased oxygenation [12]. Consequently, in a recent multicenter trial, it was investigated whether intermittent prone positioning in patients presenting with ARDS can improve oxygenation and survival [8]. The authors of the “Prone Positioning in Severe Acute Respiratory Distress Syndrome” trial showed

Nutrition and volume management: keep your patient dry and hungry!

With regard to nutrition or fluid supplementation in patients with ARDS, some evidence to guide recommendations is available, but the ideal nutrition of patients with ARDS is still not clearly defined [13]. In ARDS and in general ICU patients alike, and in line with current guidelines, we aim to start enteral nutrition as early as possible after ruling out of potential contraindications [14], [15], [16]. The energy supply should be adjusted stepwise to the dynamic and kinetic of the disease

No pill for the ARDS patient? Evidence for pharmacologic approach is missing

Effective and straightforward therapy of the primary disease is the fundamental cornerstone of pharmacologic therapy in patients with ARDS. Because pneumonia and septic shock constitute the major cause of ARDS, the identification of the underlying septic focus followed by a hard and early antibiotic therapy is mandatory and the only causal therapy in these patients. Referring to the sepsis guidelines, we recommend an early and comprehensive sample collection of blood, urine, and bronchoalveolar

Extracorporeal membrane oxygenation: when and what and for which patient?

In case of refractory hypoxemia despite optimal supportive and pharmacologic therapy, extracorporeal membrane oxygenation (ECMO) constitutes a treatment option for patients with severe ARDS and a Pao2/Fio2 ratio lower than 100.

Despite disappointing early studies, a recent multicenter trial confirmed that ECMO therapy in an experienced center can decrease mortality in patients with ARDS [26]. The challenge for the ICU physician is to identify the ideal patient and the correct timing. Most

Take-home message for the ICU physician: act fast and ventilate soft

We here summarized an overview of the current status of the literature considering the cornerstones of ARDS therapy. It is of importance that ARDS is diagnosed early and that the adequate therapy is applied as fast as possible [5]. In order to warrant guideline-oriented fast and standardized application of diagnostic and therapeutic algorithms, we developed an ARDS pocket card that covers the key features of this disease. Fig. 1 shows the condensed content of this summary as a single-page SOP

References (27)

  • A. Krzak et al.

    Nutrition therapy for ALI and ARDS

    Crit Care Clin

    (2011)
  • K.G. Kreymann et al.

    ESPEN guidelines on enteral nutrition: intensive care

    Clin Nutr

    (2006)
  • G.J. Peek et al.

    Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial

    Lancet

    (2009)
  • G.R. Bernard et al.

    The American-European Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination

    Am J Respir Crit Care Med

    (1994)
  • J. Phua et al.

    Has mortality from acute respiratory distress syndrome decreased over time? A systematic review

    Am J Respir Crit Care Med

    (2009)
  • Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network

    N Engl J Med

    (2000)
  • V.M. Ranieri et al.

    Acute respiratory distress syndrome: the Berlin definition

    JAMA

    (2012)
  • R.P. Dellinger et al.

    Surviving sepsis campaign: international guidelines for management of severe sepsis and septic shock: 2012

    Crit Care Med

    (2013)
  • D.M. Needham et al.

    Lung protective mechanical ventilation and two year survival in patients with acute lung injury: prospective cohort study

    BMJ

    (2012)
  • M. Briel et al.

    Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis

    JAMA

    (2010)
  • C. Guerin et al.

    Prone positioning in severe acute respiratory distress syndrome

    N Engl J Med

    (2013)
  • B.D. Medoff et al.

    Use of recruitment maneuvers and high-positive end-expiratory pressure in a patient with acute respiratory distress syndrome

    Crit Care Med

    (2000)
  • S. Grasso et al.

    Effects of recruiting maneuvers in patients with acute respiratory distress syndrome ventilated with protective ventilatory strategy

    Anesthesiology

    (2002)
  • Cited by (0)

    P.L. and M.T. are funded by the Research Committee of the medical faculty of the University of Düsseldorf. T.R. is a Heisenberg professor funded by the DFG (Ra969/7-2).

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