Pulmonary and Extrapulmonary Forms of Acute Respiratory Distress Syndrome

 

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ABSTRACT

Acute respiratory distress syndrome (ARDS) is usually viewed as the functional and morphological expression of a similar underlying lung injury caused by a variety of insults. However, the distinction between ARDS due to a direct (ARDSp) versus an indirect (ARDSexp) lung injury is gaining more attention as a means of better comprehending the pathophysiology of ARDS and for modifying ventilatory management. From the few published studies, we can summarize that: (1) the prevalent damage in early stages of a direct insult is intra-alveolar, whereas in indirect injury it is the interstitial edema. It is possible that the two insults may coexist (i.e., one lung with direct injury (as in pneumonia) and the other with indirect injury, through mediator release from the contralateral pneumonia); (2) the radiological pattern, by chest x-ray or computed tomography (CT), is different in ARDSp (characterized by prominent consolidation) and ARDSexp (characterized by prominent ground-glass opacification); (3) in ARDSp lung elastance is more markedly increased than in ARDSexp, where the main abnormality is the increase in chest wall elastance, due to abnormally high intra-abdominal pressure; (4) positive end-expiratory pressure (PEEP), inspiratory recruitment, and prone position are more effective to improve respiratory mechanics, alveolar recruitment, and gas-exchange in ARDSexp. Further studies are warranted to better define if the distinction between ARDS of different origins can improve clinical management and survival.

REFERENCES

• 1 Ashbaugh D G, Bigelow D B, Petty T L, Levine B E. Acute respiratory distress in adults.  Lancet . 1967;  2 319-323
  PubMedGoogle Scholar
• 2 Fauci A S, Braunwald E, Isselbacher K J. The practice medicine. In: Fauci AS, Braunwald E, Isselbacher KJ, et al, eds. Harrison's Principles of Internal Medicine New York: McGraw-Hill 1998: 1-6
  Google Scholar
• 3 Bernard G R, Artigas A, Brigham K L, the Consensus Committee. The American-European Consensus Conference on ARDS: definitions, mechanisms, relevant outcomes, and clinical trial coordination.  Am J Respir Crit Care Med . 1994;  149 818-824
  CrossrefPubMedGoogle Scholar
• 4 Gattinoni L, Pelosi P, Suter P M, Pedoto A, Vercesi P, Lissoni A. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease: different syndromes?.  Am J Respir Crit Care Med . 1998;  158 3-11
  CrossrefPubMedGoogle Scholar
• 5 Pelosi P, Brazzi L, Gattinoni L. Diagnostic imaging in acute respiratory distress syndrome.  Current Opinion in Critical Care . 1999;  5 9-16
  PubMedGoogle Scholar
• 6 Goodman L R, Fumagalli R, Tagliabue P. Adult respiratory distress syndrome due to pulmonary and extrapulmonary causes: CT, clinical, and functional correlations.  Radiology . 1999;  213 545-552
  PubMedGoogle Scholar
• 7 Pelosi P, Cadringher P, Bottino N. Sigh in acute respiratory distress syndrome.  Am J Respir Crit Care Med . 1999;  159 872-880
  PubMedGoogle Scholar
• 8 Puybasset L, Gusman P, Muller J C, Cluzel P, Coriat P, Rouby J J, and the CT Scan ARDS Study Group. Regional distribution of gas and tissue in acute respiratory distress syndrome. III: Consequences for the effects of positive end-expiratory pressure.  Intensive Care Med . 2000;  26 1215-1227
  CrossrefPubMedGoogle Scholar
• 9 Hudson L D, Milberg J A, Anardi D, Maunder R J. Clinical risks for development of the acute respiratory distress syndrome.  Am J Respir Crit Care Med . 1995;  151 293-301
  CrossrefPubMedGoogle Scholar
• 10 Villar J, Perez-Mendez L, Kacmarek R M. Current definitions of acute respiratory distress syndrome do not reflect their true severity and outcome.  Intensive Care Med . 1999;  25 930-935
  CrossrefPubMedGoogle Scholar
• 11 Jardin F, Fellahi J L, Beauchet A, Vieillard-Baron A, Loubieres Y, Page B. Improved prognosis of acute respiratory distress syndrome 15 years on.  Intensive Care Med . 1999;  25 936-941
  CrossrefPubMedGoogle Scholar
• 12 Pelosi P, Brazzi L, Gattinoni L. Prone position in acute respiratory distress syndrome.  Eur Respir J (in press). 2001; 
  PubMedGoogle Scholar
• 13 Squara P, Dhainout J F, Artigas A, Carlet J. Hemodynamic profile in severe ARDS: results of the European Collaborative ARDS study.  Intensive Care Med . 1998;  24 1018-1028
  CrossrefPubMedGoogle Scholar
• 14 Suchyta M, Clemmer T, Elliot C, Orme J, Weaver L. The adult respiratory distress syndrome: a report of survival and modifyng factors.  Chest . 1992;  101 1074-1079
  PubMedGoogle Scholar
• 15 Arigas A, Le Gall K J, Chastang C L, Carlet J, Blanch L, Fernandez R. Clinical presentation, prognostic factors, and outcome of ARDS in the European Collaborative study: a preliminary report. In: Zapol WM, Lemaire F, eds. Adult Respiratory Distress Syndrome New York: Marcel Dekker 1991: 37-63
  Google Scholar
• 16 Montgomery B, Stager M, Carrico C, Hudson L. Cause of mortality in patients with the adult respiratory distress syndrome.  Am Rev Respir Dis . 1985;  32 485-489
  PubMedGoogle Scholar
• 17 Pugin J, Verghese G, Widmer M C, Matthay M A. The alveolar space is the site of intense inflammatory and profibrotic reactions in the early phase of acute respiratory distress syndrome.  Crit Care Med . 1999;  27 304-312
  CrossrefPubMedGoogle Scholar
• 18 Terashima T, Kanazawa M, Sayama K. Granulocyte colony-stimulating factor exacerbates acute lung injury induced by intratracheal endotoxin in guinea pigs.  Am J Respir Crit Care Med . 1994;  149 1295-1303
  PubMedGoogle Scholar
• 19 Shaw J O, Henson P M, Henson J, Webster R O. Lung inflammation induced by complement derived chemotatic fragments in the alveolus.  Lab Invest . 1980;  42 547-558
  PubMedGoogle Scholar
• 20 Tutor J D, Mason C M, Dobard E, Beckerman C, Summer W R, Nelson S. Loss of compartimentalization of alveolar tumor necrosis factor after lung injury.  Am J Respir Crit Care Med . 1994;  149 1107-1111
  PubMedGoogle Scholar
• 21 Johanson W G, Higuchi J H, Woods D E, Gomez P, Coalson J J. Dissemination of Pseudomonas aeruginosa during lung infection in hamsters.  Am Rev Respir Dis . 1985;  132 358-361
  PubMedGoogle Scholar
• 22 Muller-Leisse C, Klosterhalfen B, Hauptmann S. Computed tomography and histologic results in the early stages of endotoxin-injury lungs as a model for adult respiratory distress syndrome.  Invest Radio . 1993;  28 39-45
  PubMedGoogle Scholar
• 23 Seidenfeld J J, Curtix Mullins R, Fowler S R, Johanson W G. Bacterial infection and acute lung injury in hamsters.  Am Rev Respir Dis . 1986;  134 22-26
  PubMedGoogle Scholar
• 24 Terashima T, Matsubara M, Nakamura M. Local Pseudomonas instillation induces contralateral injury and plasma cytokines.  Am J Respir Crit Care Med . 1996;  153 1600-1605
  PubMedGoogle Scholar
• 25 D'Angelo E, Calderini E, Robatto F M, Puccio P, Milic-Emili J. Lung and chest wall mechanics in patients with acquired immunodeficiency syndrome and severe Pneumocystis carinii pneumonia.  Eur Respir J . 1997;  10 2343-2350
  CrossrefPubMedGoogle Scholar
• 26 Winer-Muran H T, Stainer R M, Gurney J W. Ventilator-associated pneumonia in patients with adult respiratory distress syndrome: CT evaluation.  Radiology . 1998;  208 193-199
  PubMedGoogle Scholar
• 27 Pelosi P, Colombo G, Gamberoni C. Effects of positive end-expiratory pressure on respiratory function in head-injured patients.  Intensive Care Med . 2000;  26 A450
  PubMedGoogle Scholar
• 28 Rodriguez J L, Gibbons K J, Bitzer L G, Dechert E, Steinberg S M, Flint M. Pneumonia: incidence, risk factors and outcome in head injured patients.  J Trauma . 1991;  31 907-914
  PubMedGoogle Scholar
• 29 Ewig S, Torres A, El-Ebiary M. Bacterial pattern in mechanically ventilated patients with traumatic and medical lung injury.  Am J Respir Crit Care Med . 1999;  159 188-198
  CrossrefPubMedGoogle Scholar
• 30 Torres A, El-Ebiary M, Gonzales J, Ferrer M, Puig de la Bellacasa J, Gene A, Martos A, Rodriguez-Roisin R. Gastric and pharyngeal flora in nosocomial pneumonia acquired during mechanical ventilation.  Am Rev Respir Dis . 1993;  148 352-357
  CrossrefPubMedGoogle Scholar
• 31 Ranieri V M, Suter P M, Tortorella C. Effects of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: a randomized controlled trial.  JAMA . 1999;  282 54-61
  CrossrefPubMedGoogle Scholar
• 32 Rouby J J, Puybasset L, Cluziel P, Richecoeur J, Lu Q, Grenier P. Regional distribution of gas and tissue in acute respiratory distress syndrome. II: Physiological correlations and definition of an ARDS severity score.  Intensive Care Med . 2000;  26 1046-1056
  CrossrefPubMedGoogle Scholar
• 33 Polese G, Rossi A, Appendini L, Brandi G, Bates J HT, Brandolese R. Partitioning of respiratory mechanics in mechanically ventilated patients.  J Appl Physiol . 1991;  71 2425-2433
  PubMedGoogle Scholar
• 34 Mergoni M, Martelli A, Volpi S, Primavera S, Zuccoli P, Rossi A. Impact of positive end-expiratory pressure on chest wall and lung pressure-volume curve in acute respiratory failure.  Am J Respir Crit Care Med . 1997;  156 846-854
  CrossrefPubMedGoogle Scholar
• 35 Ranieri V M, Brienza N, Santostasi S. Impairment of lung and chest wall mechanics in patients with acute respiratory distress syndrome: role of abdominal distension.  Am J Respir Crit Care Med . 1997;  156 1082-1091
  CrossrefPubMedGoogle Scholar
• 36 Lamy M, Fallat R J, Koeniger E. Pathologic features and mechanisms of hypoxemia in adult respiratory distress syndrome.  Am Rev Respir Dis . 1976;  114 267-284
  PubMedGoogle Scholar
• 37 Gattinoni L, Bombino M, Pelosi P, Lissoni L, Pesenti A, Fumagalli R, Tagliabue M. Lung structure and function in different stages of severe adult respiratory distress syndrome.  JAMA . 1994;  271 1772-1779
  CrossrefPubMedGoogle Scholar
• 38 Van der Kloot E T, Blanch L, Youngblood A M. Recruitment maneuvers in three experimental models of acute lung injury: effect on lung volume and gas exchange.  Am J Respir Crit Care Med . 2000;  161 1485-1494
  PubMedGoogle Scholar
• 39 Light R B, Mink S N, Wood D M. The effect of unilateral PEEP on gas exchange and pulmonary perfusion in canine lobar pneumonia.  Anesthesiology . 1981;  55 251-255
  PubMedGoogle Scholar
• 40 Pelosi P, Tubiolo D, Mascheroni D. Effects of the prone position on respiratory mechanics and gas exchange during acute lung injury.  Am J Respir Crit Care Med . 1998;  157 387-393
  PubMedGoogle Scholar
• 41 Lim C M, Kim E K, Lee J S. Comparison of the response to the prone position between pulmonary and extrapulmonary acute respiratory distress syndrome.  Intensive Care Med . 2001;  27 477-485
  CrossrefPubMedGoogle Scholar
• 42 Pelosi P, Ravagnan I, Giurati G. Positive end-expiratory pressure improves respiratory function in obese but not in normal subjects during anesthesia and paralysis.  Anesthesiology . 1999;  91 1221-1231
  CrossrefPubMedGoogle Scholar
• 43 Gattinoni L, Pelosi P, Vitale G, Pesenti P, D'Andrea L, Mascheroni D. Body position changes redistribute lung computed tomographic density in patients with respiratory failure.  Anesthesiology . 1991;  74 15-23
  PubMedGoogle Scholar
• 44 Mure M, Glenny R W, Domino K B, Hlastala M P. Pulmonary gas exchange improves in the prone position with abdominal distension.  Am J Respir Crit Care Med . 1998;  157 1785-1790
  PubMedGoogle Scholar