Adult Respiratory Distress Syndrome
Adult Respiratory Distress Syndrome
Adult respiratory distress syndrome (ARDS), also called acute respiratory distress syndrome, is a type of lung (pulmonary) failure that may result from any disease that causes large amounts of fluid to collect in the lungs. ARDS is not itself a specific disease, but a syndrome, a group of symptoms and signs that make up one of the most important forms of lung or respiratory failure. It can develop quite suddenly in persons whose lungs have been perfectly normal. Very often ARDS is a true medical emergency. The basic fault is a breakdown of the barrier, or membrane, that normally keeps fluid from leaking out of the small blood vessels of the lung into the breathing sacs (the alveoli).
Another name for ARDS is shock lung. Its formal name is misleading, because children, as well as adults, may be affected. In the lungs the smallest blood vessels, or capillaries, make contact with the alveoli, tiny air sacs at the tips of the smallest breathing tubes (the bronchi). This is the all-important site where oxygen passes from air that is inhaled to the blood, which carries it to all parts of the body. Any form of lung injury that damages this point of contact, called the alveolo-capillary junction, will allow blood and tissue fluid to leak into the alveoli, eventually filling them so that air cannot enter. The result is the type of breathing distress called ARDS. ARDS is one of the major causes of excess fluid in the lungs, the other being heart failure.
Along with fluid there is a marked increase in inflamed cells in the lungs. There also is debris left over from damaged lung cells, and fibrin, a semisolid material derived from blood in the tissues. Typically these materials join together with large molecules in the blood (proteins), to form hyaline membranes. (These membranes are very prominent in premature infants who develop respiratory distress syndrome; it is often called hyaline membrane disease.) If ARDS is very severe or lasts a long time, the lungs do not heal, but rather become scarred, a process known as fibrosis. The lack of a normal amount of oxygen causes the blood vessels of the lung to become narrower, and in time they, too, may become scarred and filled with clotted blood. The lungs as a whole become very "stiff," and it becomes much harder for the patient to breathe.
Alveoli— The tiny air sacs at the ends of the breathing tubes of the lung where oxygen normally is taken up by the capillaries to enter the circulation.
Aspiration— The process in which solid food, liquids, or secretions that normally are swallowed are, instead, breathed into the lungs.
Capillaries— The smallest arteries which, in the lung, are located next to the alveoli so that they can pick up oxygen from inhaled air.
Face mask— The simplest way of delivering a high level of oxygen to patients with ARDS or other low-oxygen conditions.
Steroids— A class of drugs resembling normal body substances that often help control inflammation in the body tissues.
Ventilator— A mechanical device that can take over the work of breathing for a patient whose lungs are injured or are starting to heal.
Causes and symptoms
A very wide range of diseases or toxic substances, including some drugs, can cause ARDS. They include:
- Breathing in (aspiration) of the stomach contents when regurgitated, or salt water or fresh water from nearly drowning.
- Inhaling smoke, as in a fire; toxic materials in the air, such as ammonia or hydrocarbons; or too much oxygen, which itself can injure the lungs.
- Infection by a virus or bacterium, or sepsis, a widespread infection that gets into the blood.
- Massive trauma, with severe injury to any part of the body.
- Shock with persistently low blood pressure may not in itself cause ARDS, but it can be an important factor.
- A blood clotting disorder called disseminated intravascular coagulation, in which blood clots form in vessels throughout the body, including the lungs.
- A large amount of fat entering the circulation and traveling to the lungs, where it lodges in small blood vessels, injuring the cells lining the vessel walls.
- An overdose of a narcotic drug, a sedative, or, rarely, aspirin.
- Inflammation of the pancreas (pancreatitis ), when blood proteins, called enzymes, pass to the lungs and injure lung cells.
- Severe burn injury.
- Injury of the brain, or bleeding into the brain, from any cause may be a factor in ARDS for reasons that are not clear. Convulsions also may cause some cases.
Usually ARDS develops within one to two days of the original illness or injury. The person begins to take rapid but shallow breaths. The doctor who listens to the patient's chest with a stethoscope may hear "crackling" or wheezing sounds. The low blood oxygen content may cause the skin to appear mottled or even blue. As fluid continues to fill the breathing sacs, the patient may have great trouble breathing, take very rapid breaths, and gasp for air.
A simple test using a device applied to the ear will show whether the blood is carrying too little oxygen, and this can be confirmed by analyzing blood taken from an artery. The chest x ray may be normal in the early stages, but, in a short time, fluid will be seen where it does not belong. The two lungs are about equally affected. A heart of normal size indicates that the problem actually is ARDS and not heart failure. Another way a physician can distinguish between these two possibilities is to place a catheter into a vein and advance it into the main artery of the lung. In this way, the pressure within the pulmonary capillaries can be measured. Pressure within the pulmonary capillaries is elevated in heart failure, but normal in ARDS.
The three main goals in treating patients with ARDS are:
- To treat whatever injury or disease has caused ARDS. Examples are: to treat septic infection with the proper antibiotics, and to reduce the level of oxygen therapy if ARDS has resulted from a toxic level of oxygen.
- To control the process in the lungs that allows fluid to leak out of the blood vessels. At present there is no certain way to achieve this. Certain steroid hormones have been tried because they can combat inflammation, but the actual results have been disappointing.
- To make sure the patient gets enough oxygen until the lung injury has had time to heal. If oxygen delivered by a face mask is not enough, the patient is placed on a ventilator, which takes over breathing, and, through a tube placed in the nose or mouth (or an incision in the windpipe), forces oxygen into the lungs. This treatment must be closely supervised, and the pressure adjusted so that too much oxygen is not delivered.
Patients with ARDS should be cared for in an intensive care unit, where experienced staff and all needed equipment are available. Enough fluid must be provided, by vein if necessary, to prevent dehydration. Also, the patient's nutritional state must be maintained, again by vein, if oral intake is not sufficient.
If the patient's lung injury does not soon begin to heal, the lack of sufficient oxygen can injure other organs, such as the kidneys. There always is a risk that bacterial pneumonia will develop at some point. Without prompt treatment, as many as 90% of patients with ARDS can be expected to die. With modern treatment, however, about half of all patients will survive. Those who do live usually recover completely, with little or no long-term breathing difficulty. Lung scarring is a risk after a long period on a ventilator, but it may improve in the months after the patient is taken off ventilation. Whether a particular patient will recover depends to a great extent on whether the primary disease that caused ARDS to develop in the first place can be effectively treated.
The only way to prevent ARDS is to avoid those diseases and harmful conditions that damage the lung. For instance, the danger of aspirating stomach contents into the lungs can be avoided by making sure a patient does not eat shortly before receiving general anesthesia. If a patient needs oxygen therapy, as low a level as possible should be given. Any form of lung infection, or infection anywhere in the body that gets into the blood, must be treated promptly to avoid the lung injury that causes ARDS.
Smolley, Lawrence A., and Debra F. Bryse. Breathe RightNow: A Comprehensive Guide to Understanding and Treating the Most Common Breathing Disorders. New York: W. W. Norton & Co., 1998.
National Heart, Lung and Blood Institute. P.O. Box 30105, Bethesda, MD 20824-0105. (301) 251-1222. 〈http://www.nhlbi.nih.gov〉.
National Respiratory Distress Syndrome Foundation. P.O. Box 723, Montgomeryville, PA 18936.