Acute respiratory distress in adults.
TL;DR: Positive end-expiratory pressure was most helpful in combating atelectasis and hypoxaemia and Corticosteroids appeared to have value in the treatment of patients with fat-embolism and possibly viral pneumonia.
About: This article is published in The Lancet.The article was published on 1967-08-12. It has received 3706 citations till now. The article focuses on the topics: Respiratory distress & Atelectasis.
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TL;DR: The updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition and may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.
Abstract: The acute respiratory distress syndrome (ARDS) was defined in 1994 by the American-European Consensus Conference (AECC); since then, issues regarding the reliability and validity of this definition have emerged. Using a consensus process, a panel of experts convened in 2011 (an initiative of the European Society of Intensive Care Medicine endorsed by the American Thoracic Society and the Society of Critical Care Medicine) developed the Berlin Definition, focusing on feasibility, reliability, validity, and objective evaluation of its performance. A draft definition proposed 3 mutually exclusive categories of ARDS based on degree of hypoxemia: mild (200 mm Hg < PaO2/FIO2 ≤ 300 mm Hg), moderate (100 mm Hg < PaO2/FIO2 ≤ 200 mm Hg), and severe (PaO2/FIO2 ≤ 100 mm Hg) and 4 ancillary variables for severe ARDS: radiographic severity, respiratory system compliance (≤40 mL/cm H2O), positive end-expiratory pressure (≥10 cm H2O), and corrected expired volume per minute (≥10 L/min). The draft Berlin Definition was empirically evaluated using patient-level meta-analysis of 4188 patients with ARDS from 4 multicenter clinical data sets and 269 patients with ARDS from 3 single-center data sets containing physiologic information. The 4 ancillary variables did not contribute to the predictive validity of severe ARDS for mortality and were removed from the definition. Using the Berlin Definition, stages of mild, moderate, and severe ARDS were associated with increased mortality (27%; 95% CI, 24%-30%; 32%; 95% CI, 29%-34%; and 45%; 95% CI, 42%-48%, respectively; P < .001) and increased median duration of mechanical ventilation in survivors (5 days; interquartile [IQR], 2-11; 7 days; IQR, 4-14; and 9 days; IQR, 5-17, respectively; P < .001). Compared with the AECC definition, the final Berlin Definition had better predictive validity for mortality, with an area under the receiver operating curve of 0.577 (95% CI, 0.561-0.593) vs 0.536 (95% CI, 0.520-0.553; P < .001). This updated and revised Berlin Definition for ARDS addresses a number of the limitations of the AECC definition. The approach of combining consensus discussions with empirical evaluation may serve as a model to create more accurate, evidence-based, critical illness syndrome definitions and to better inform clinical care, research, and health services planning.
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Cites background from "Acute respiratory distress in adult..."
...Median (IQR) ventilatorfree days declined with stages of ARDS from mild (20 [1-25] days) to moderate (16 [0-23] days) to severe (1 [020] day)....
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...Median (IQR) duration of mechanical ventilation in survivors increased with stages of ARDS from mild (5 [2-11] days) to moderate (7 [414] days) to severe (9 [5-17] days)....
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TL;DR: The acute respiratory distress syndrome (ARDS), a process of nonhydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies, carries a high morbidity, mortality, and financial cost.
Abstract: The acute respiratory distress syndrome (ARDS), a process of nonhydrostatic pulmonary edema and hypoxemia associated with a variety of etiologies, carries a high morbidity, mortality (10 to 90%), and financial cost. The reported annual incidence in the United States is 150,000 cases, but this figure has been challenged, and it may be different in Europe. Part of the reason for these uncertainties are the heterogeneity of diseases underlying ARDS and the lack of uniform definitions for ARDS. Thus, those who wish to know the true incidence and outcome of this clinical syndrome are stymied. The American-European Consensus Committee on ARDS was formed to focus on these issues and on the pathophysiologic mechanisms of the process. It was felt that international coordination between North America and Europe in clinical studies of ARDS was becoming increasingly important in order to address the recent plethora of potential therapeutic agents for the prevention and treatment of ARDS.
6,233 citations
TL;DR: An overview of the definitions, clinical features, and epidemiology of the acute respiratory distress syndrome is provided and advances in the areas of pathogenesis, resolution, and treatment are discussed.
Abstract: The acute respiratory distress syndrome is a common, devastating clinical syndrome of acute lung injury that affects both medical and surgical patients. Since the last review of this syndrome appeared in the Journal, 1 more uniform definitions have been devised and important advances have occurred in the understanding of the epidemiology, natural history, and pathogenesis of the disease, leading to the design and testing of new treatment strategies. This article provides an overview of the definitions, clinical features, and epidemiology of the acute respiratory distress syndrome and discusses advances in the areas of pathogenesis, resolution, and treatment. Historical Perspective and Definitions . . .
5,002 citations
01 Jan 1992
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References
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TL;DR: Evidence is presented that the material responsible for such a low surface tension is absent in the lungs of infants under 1,100-1,200 gm.
Abstract: Recent observations suggest that a low surface tension may be an important attribute of the lining of the air passages of the lung.1-4The purpose of this paper is to present evidence that the material responsible for such a low surface tension is absent in the lungs of infants under 1,100-1,200 gm. and in those dying with hyaline membrane disease. The role of this deficiency in the pathogenesis of the disease is considered. Surface tension operates so as to minimize the area of the surface. In the lungs, where the internal surface (the alveolar lining) is curved concave to the airway, the tendency of the surface to become smaller promotes collapse. Although the forces not only of surface tension but also of the elastic tissue tend to collapse the lungs, their behavior differs in one important respect. When the lung contains only a small volume of air, the elastic
1,524 citations
TL;DR: Saline-extractable surface-active material has been found in the lungs of rat and this material, probably mucoprotein, imparts large hysteresis and characteristic elasticity to the fluid surface.
Abstract: SummarySaline-extractable surface-active material has been found in the lungs of rat. cat. and dog. This material, probably mucoprotein. imparts large hysteresis and characteristic elasticity to the fluid surface. Its effect on lung mechanics has been studied. Its possible influence on diffusion across the alveolar barrier remains to be elucidated.
523 citations
TL;DR: Patients requiring mechanical artificial ventilation have increasing reduction in pulmonary compliance and vital capacity, with consequent hypoxia, are difficult to wean from the ventilator and often die of pulmonary insufficiency.
Abstract: CLINICIANS concerned with the care of patients requiring mechanical artificial ventilation have been impressed by the occasional development of gradually progressive deterioration of pulmonary function, apparently unrelated to the disease that necessitated the respiratory assistance. These patients have increasing reduction in pulmonary compliance and vital capacity, with consequent hypoxia, are difficult to wean from the ventilator and often die of pulmonary insufficiency.1 Many have had no respiratory or cardiac disease before the use of the ventilator. Clinicians have referred to this symptom complex as the "respirator lung syndrome." At autopsy in such cases the unusual gross and microscopical appearance of . . .
483 citations
TL;DR: The major outlines of the pulmonary pressure-volume diagram are quantitatively deduced, including opening pressures, hysteresis and residual volumes, and the role of surface compressibility in the structural stability of the lung is explored.
Abstract: An attempt is made to clarify the dependence of static pressure-volume characteristics of the lung on internal surface forces. The theoretical development is based on two premises: a) the lung is l...
238 citations
TL;DR: Findings supporting this hypothesis are the presence of strong surfactant uniquely in the washed mitochondrial fraction of mammalian lung, almost complete loss of mitochondrial lamellar forms accompanying loss of lung surface activity after vagotomy, and the absence of strong surface activity from the lung extracts of animals whose alveolar lining cells show no lameLLar forms.
Abstract: We propose that the surface-active lining of the mammalian lung is formed in the mitochondria of the alveolar epithelial cells. Findings supporting this hypothesis are the presence of strong surfactant uniquely in the washed mitochondrial fraction of mammalian lung, almost complete loss of mitochondrial lamellar forms accompanying loss of lung surface activity after vagotomy, and the absence of strong surface activity from the lung extracts of animals whose alveolar lining cells show no lamellar forms.
205 citations