# Acute Respiratory Distress Syndrome

# *** Acute Respiratory Distress Syndrome

Severity by P:F Ratio:
-- Mild - 200-300
-- Moderate - 100-200
-- Severe - <100
‍
Checklist
-- ABCs: will most commonly be treated in the ICU; intubate early if needed
-- Diagnosis: Berlin Definition - onset within 1 week of insult, not due to cardiogenic pulm edema, imaging shows bilateral opacities on CXR, PaO2:FiO2 (P:F) <300 with PEEP >5
‍-- Chart Check: *** h/o heart disease
-- HPI Intake: ***
-- Can't Miss: ***
-- Admission Orders: *** CBC (infection), infectious workup, lipase, trop, NT-proBNP,
-- Initial Treatment to Consider: *** can trial non-invasive ventilation if P:F >200, otherwise intubate

Assessment:
-- History: ***fever, medications, recent blood product, malignancy (chemo, checkpoint inhibitors, radiation, infection)
-- Clinical: ***
-- Exam: *** volume exam, crackles, localizing infectious
-- Data: *** P:F ratio, ABG, CXR, POCUS vs formal echo to prove not cardiogenic etiology
-- Etiology/DDx: *** Etiology: pneumonia/sepsis, pancreatitis, drugs, TRALI, inhalation injury, DAH 2/2 ANCA vasculitis, ILD exacerbation, COP, pneumonitis, ontusion, near drowning; Others - cardiogenic pulm edema, atelectasis, TACO

The patient's HPI is notable for ***. Exam showed ***. Labwork and data were notable for ***. Taken together, the patient's presentation is most concerning for ***, with a differential including ***.

Plan:
Workup
-- f/u Echo
-- f/u CT chest for further characterization of infiltrates
-- consider bronch for BAL if c/f DAH or opportunistic infection (PJP, aspergillus)
-- trend ABG for P:F ratio calculations

Treatment
-- Ventilation:  *** goal to maintain PaO2 55-80 or SpO2 88-94% with pH >7.2 to 7.25 (permissive hypercapnia) via: tidal volume 4-6cc/kg of predicted body weight; Pplat <30 - if higher, decrease Vt; Driving pressure <15
-- Volume: *** diurese with *** for goal of euvolemia
-- Etiology: ** treat underyling sepsis/PNA, pancreatitis, etc.
-- Steroids: *** methylpred 1mg/kg IV daily (early only; not after 14 days) vs dex for COVID
-- Proning: goal for *** 16+ hours (P:F <150 with optimal PEEP should prone within 12-24h unless HD unstable, can’t turn neck, pregnant, recent sternotomy)
-- Pulmonary Vasodilators: *** (iNO trial → inhaled epoprostenol)
-- Neuromuscular Blockade: *** (if c/f dysynchrony)
-- ECMO: *** candidacy (consider if P:F <100, chance of recovery or bridge to transplant)