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Acute Respiratory Distress Syndrome: Follow-up

Author: Eloise M Harman, MD, Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida College of Medicine
Contributor Information and Disclosures

Updated: Nov 4, 2009

Follow-up

Further Inpatient Care

Once the acute phase of acute respiratory distress syndrome (ARDS) resolves, patients may require a prolonged period to wean from mechanical ventilation and to regain muscle strength lost after prolonged inactivity. This may necessitate transfer to a rehabilitation facility once the acute phase of the illness is resolved.

Transfer

  • Transfer to a tertiary care facility may be indicated in acute respiratory distress syndrome (ARDS) in some situations, if safe transport can be arranged.
    • Transfer may be indicated if inspired oxygen concentrations cannot be weaned to less than 0.65 within 48 hours.
    • Other patients who may potentially benefit from transfer include those who have experienced pneumothorax and have persistent air leaks, patients who cannot be weaned from mechanical ventilation, patients who have upper airway obstruction after prolonged intubation, or those with a progressive course in which an underlying cause cannot be identified.
    • If ARDS develops in a patient who previously has undergone organ or bone marrow transplantation, transfer to an experienced transplant center is essential for appropriate management.

Deterrence/Prevention

  • While multiple risk factors for acute respiratory distress syndrome (ARDS) are known, no successful preventative measure has been identified.
  • Careful fluid management in high-risk patients may be helpful.
  • Because aspiration pneumonitis is a risk factor for ARDS, taking appropriate measures to prevent aspiration, such as elevation of the head of the bed and evaluation of swallowing mechanics before feeding high-risk patients, may also prevent some ARDS cases.

Complications

  • Patients with acute respiratory distress syndrome (ARDS) often require high-intensity mechanical ventilation, including high levels of PEEP or CPAP and, possibly, high mean airway pressures; thus, barotrauma may occur. Patients present with pneumomediastinum and/or pneumothorax. Other potential complications that may occur in these mechanically ventilated patients include accidental extubation, right mainstem intubation, and ventilator-associated pneumonia. If prolonged mechanical ventilation is needed, patients may eventually require tracheostomy. With prolonged intubation and tracheostomy, upper airway complications may occur, most notably postextubation laryngeal edema and subglottic stenosis.
  • Nosocomial infections: As patients with ARDS often require prolonged mechanical ventilation and invasive hemodynamic monitoring, they are at risk for serious nosocomial infections including ventilator-associated pneumonia (VAP) and line sepsis. The incidence of VAP in ARDS may be as high as 55% and appears to be higher than in other populations requiring mechanical ventilation. Preventative strategies including elevation of head of the bed, use of subglottic suction endotracheal tubes, and oral decontamination.
  • Other potential infections include urinary tract infection related to the use of urinary catheters and sinusitis related to the use of nasal feeding and drainage tubes. Patients may also develop Clostridium difficile colitis as a complication of broad spectrum antibiotic therapy. Patients with ARDS, because of the duration of ICU stay and treatment with multiple antibiotics, may also develop infections with drug-resistant organisms such as methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococcus (VRE).
  • Muscle weakness: In a study of survivors of ARDS, significant functional impairment was noted at 1 year, primarily related to muscle wasting and weakness.6 Corticosteroid treatment and use of neuromuscular blockade are risk factors for muscle weakness and poor functional recovery.
  • Prolonged mechanical ventilation: Patients may have difficulty weaning from mechanical ventilation. Strategies to facilitate weaning, such as daily interruption of sedation, early institution of physical therapy, attention to maintaining nutrition, and use of weaning protocols, may decrease the duration of mechanical ventilation and facilitate recovery.
  • Renal failure is a frequent complication of ARDS, particularly in the context of sepsis. Renal failure may be related to hypotension, nephrotoxic drugs, or underlying illness. Fluid management is complicated in this context, especially if the patient is oliguric. Multisystem organ failure, rather than respiratory failure alone, is usually the cause of death in ARDS.
  • Other potential complications include ileus, stress gastritis, and anemia. Stress ulcer prophylaxis is indicated for these patients. Anemia may be prevented by the use of growth factors (epopoietin).

Prognosis

  • As previously noted, the prognosis of acute respiratory distress syndrome (ARDS) has improved over the last 20 years. Sixty to 70% of patients survive.
  • Patients with poor prognostic factors include those older than 65 years and those with sepsis as the underlying cause. The adverse effect of age may be related to underlying health status.
  • The severity of hypoxemia at the time of diagnosis does not correlate well with survival rates.
  • Survivors of ARDS frequently have significant functional impairment even 1 year after discharge. In a study of 109 survivors, spirometry and lung volumes were normal at 6 months, but diffusing capacity remained mildly diminished (72%) at 1 year.6 ARDS survivors had abnormal 6-minute walking distances at 1 year and only 49% had returned to work. Their health-related quality of life was significantly below normal. However, no patient remained oxygen dependent at 12 months.
  • Radiographic abnormalities also completely resolve within a year of recovery.
  • Severe disease and prolonged duration of mechanical ventilation are predictors of persistent abnormalities in pulmonary function.

Patient Education

For excellent patient education resources, visit eMedicine's Lung and Airway Center, Procedures Center, and Bacterial and Viral Infections Center. Also, see eMedicine's patient education articles Acute Respiratory Distress Syndrome, Bronchoscopy, and Severe Acute Respiratory Syndrome (SARS).

Miscellaneous

Medicolegal Pitfalls

  • The main concerns are missing a potentially treatable underlying cause or complication of acute respiratory distress syndrome (ARDS), such as a drainable infection or a pneumothorax. In these critically ill patients, pay careful attention to early recognition of potential complications in the intensive care unit, including pneumothorax, intravenous line infections, skin breakdown, inadequate nutrition, arterial occlusion at the site of intra-arterial monitoring devices, deep venous thrombophlebitis and pulmonary embolism, retroperitoneal hemorrhage, gastrointestinal hemorrhage, erroneous placement of lines and tubes, and the development of muscle weakness.
  • In situations in which the patient requires the use of paralyzing agents to allow certain modes of mechanical ventilation, take meticulous care to ensure that an adequate alarm system is in place to alert staff to mechanical ventilator disconnection or malfunction. In addition, adequate sedation is important in most patients on ventilators and is essential when paralytic agents are in use.
  • As in all situations in which patients are critically ill, the family and friends are very concerned and experience stress. Keep them informed and let them come to the patient's bedside as much as possible if they desire. Even if the patient is sedated, assume that he or she is capable of hearing and understanding all conversations in the room and is treated with respect and care. The sedated patient may experience pain and should receive appropriate local anesthesia and pain medication for procedures.
 
Acknowledgments

The authors and editors of eMedicine gratefully acknowledge the contributions of previous author Rajat Walia, MD to the development and writing of this article.



More on Acute Respiratory Distress Syndrome

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Differential Diagnoses & Workup: Acute Respiratory Distress Syndrome
Treatment & Medication: Acute Respiratory Distress Syndrome
Follow-up: Acute Respiratory Distress Syndrome
Multimedia: Acute Respiratory Distress Syndrome
References
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Further Reading

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Keywords

acute respiratory distress syndrome, ARDS, adult respiratory distress syndrome, acute lung injury, ALI, diffuse alveolar damage, noncardiogenic pulmonary edema, diffuse alveolar injury, bilateral pulmonary infiltrates

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Contributor Information and Disclosures

Author

Eloise M Harman, MD, Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida College of Medicine
Eloise M Harman, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Chest Physicians, American Medical Women's Association, American Thoracic Society, Phi Beta Kappa, and Sigma Xi
Disclosure: Nothing to disclose.

Medical Editor

Cory Franklin, MD, Professor, Department of Medicine, Rosalind Franklin University of Medicine and Science; Director, Division of Critical Care Medicine, Cook County Hospital
Cory Franklin, MD is a member of the following medical societies: New York Academy of Sciences and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Michael R Pinsky, MD, CM, FCCP, FCCM, Professor of Critical Care Medicine, Bioengineering, Cardiovascular Disease and Anesthesiology, Vice-Chair, Academic Affairs, University of Pittsburgh School of Medicine, University of Pittsburgh Medical Center
Michael R Pinsky, MD, CM, FCCP, FCCM is a member of the following medical societies: American College of Chest Physicians, American College of Critical Care Medicine, American Heart Association, American Thoracic Society, Association of University Anesthetists, Shock Society, and Society of Critical Care Medicine
Disclosure: LiDCO Ltd Honoraria Consulting; iNTELOMED Intellectual property rights Board membership; Edwards Lifesciences Honoraria Consulting; Applied Physiology, Ltd Honoraria Consulting; Cheetah Medical Consulting fee Consulting

 
 
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