Defne Neriman ALTINTAŞ, Topeli Arzu İSKİT

Akut solunum sıkıntısı sendromu tanısı ve tedavisinde güncel yaklaşımlar

Akut solunum sıkıntısı sendromu yoğun bakımlarda sık karşılaşılan, patogeneziyle ilgili geniş bilgi birikimine rağmen hala etkin tedavisi gösterilememiş mortalitesi yüksek bir durumdur. Ayırıcı tanısında kardiyojenik pulmoner ödemin dışlanması önemlidir. Tedavisinde farklı mekanik ventilasyon uygulamaları ve inflamasyonun kontrolünü sağlayacak değişik ajanlar denenmektedir. Bugün için düşük tidal volüm ve 30 cmH2O’nun altında plato basınçları ile yapılan ventilasyonun, sağkalımı anlamlı olarak artırdığı gösterilmiş tek yaklaşımdır. Düşük doz steroid verilmesi, nitrik oksit inhalasyonu, sürfaktan uygulanması, çeşitli antioksidanlar, β2 adrenerjik ajanlar, HMG-CoA redüktaz inhibitörleri etkin olabileceği düşünülen ajanlardır. Bu hastaları izlerken sıvı kısıtlaması uygulanması ve immünnütrisyonun dikkate alınması önerilmektedir.

Current strategies for the diagnosis and treatment of acute respiratory distress syndrome

Acute respiratory distress syndrome is a frequently encountered condition in the intensive care units, with high mortality rates despite cumulating knowledge on its pathogenesis. It is important that cardiac pulmonary edema should be ruled out for diagnosis. Different mechanical ventilation strategies, as well as agents for the control of inflammation are being tested. Currently, low tidal volume ventilation with high PEEP and plateau pressures below 30 cmH2O is the only intervention that has been shown to improve survival significantly. Low dose steroids, nitric oxide inhalation, surfactant, antioxidants, β2 adrenergic agents, HMG-CoA reductase inhibitors are promising agents. Fluid restriction and immunonutrition should be considered when these patients are being cared for.

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1. Ware LB, Matthay MA. The acute respiratory distress syndrome. N Engl J Med 2000; 342: 1334-49.
2. Bernard GR, Artigas A, Brigham KL, et al. The American- European consensus conference on ARDS. Definitions, mechanisms, relevant outcomes, and clinical trial coordination. Am J Respir Crit Care Med 1994; 149: 818-24.
3. Piantadosi CA, Schwartz DA. The acute respiratory distress syndrome. Ann Intern Med 2004; 141: 460-70.
4. Connors AF Jr, Speroff T, Dawson NV, et al. The effectiveness of right heart catheterization in the initial care of critically ill patients. SUPPORT investigators. JAMA 1996; 276: 889-97.
5. Mueller C, Scholer A, Laule-Kilian K, et al. Use of B-type natriuretic peptide in the evaluation and management of acute dyspnea. N Engl J Med 2004; 350: 647-54.
6. Aybar M, Altıntaş ND, İskit AT. Kardiyojenik ve nonkardiyojenik pulmoner ödem ayırıcı tanısında BNP ve pro-BNP’nin rolü. 2. Ulusal Dahili ve Cerrahi Bilimler Yoğun Bakım Sempozyumu. Yoğun Bakım Dergisi 2005; 5(Ek 1): 28.
7. Türkoğlu M. Kardiyojenik ve nonkardiyojenik pulmoner ödemin ayırıcı tanısında beyin natriüretik peptid ve Nterminal pro-beyin natriüretik peptidin rolü (tez). Yoğun Bakım Uzmanlık Tezi, Ankara: 2007.
8. Jain R, DalNogare A. Pharmacological therapy for acute respiratory distress syndrome. Mayo Clin Proc 2006; 81: 205-12.
9. Ranieri VM, Suter PM, Tortorella C, et al. Effect of mechanical ventilation on inflammatory mediators in patients with acute respiratory distress syndrome: A randomized controlled trial. JAMA 1999; 282: 54-61.
10. Ricard JD, Dreyfuss D, Saumon G. Ventilator-induced lung injury. Curr Opin Crit Care 2002; 8: 12-20.
11. Belperio JA, Keane MP, Lynch JP 3rd, Strieter RM. The role of cytokines during the pathogenesis of ventilator-associated and ventilator-induced lung injury. Semin Respir Crit Care Med 2006; 27: 350-64.
12. Slutsky AS, Tremblay LN. Multiple system organ failure. Is mechanical ventilation a contributing factor? Am J Respir Crit Care Med 1998; 157: 1721-5.
13. Santos CC, Zhang H, Liu M, Slutsky AS. Bench-to-bedside review: Biotrauma and modulation of the innate immune response. Crit Care (London, England) 2005; 9: 280-6.
14. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med 2000; 342: 1301-8.
15. Hager DN, Krishnan JA, Hayden DL, et al. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med 2005; 172: 1241-5.
16. Marini JJ, Gattinoni L. Ventilatory management of acute respiratory distress syndrome: A consensus of two. Crit Care Med 2004; 32: 250-5.
17. Brower RG, Lanken PN, MacIntyre N, et al. Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome. N Engl J Med 2004; 351: 327-36.
18. Grasso S, Stripoli T, De Michele M, et al. Am J Respir Crit Care Med 2007; 176: 761-7.
19. Stahl CA, Moller K, Schumann S, et al. Dynamic versus static respiratory mechanics in acute lung injury and acute respiratory distress syndrome. Crit Care Med 2006; 34: 2090-8.
20. Carvalho CR, de Paula Pinto Schettino G, Maranhao B, Bethlem EP. Hyperoxia and lung disease. Curr Opin Pulm Med 1998; 4: 300-4.
21. Gunen H, Kizkin O. The principles of mechanical ventilation in ARDS. Tuberk Toraks 2004; 52: 199-206.
22. Marini JJ. How to recruit the injured lung. Minerva Anestesiol 2003; 69: 193-200.
23. Lapinsky SE, Mehta S. Bench-to-bedside review: Recruitment and recruiting maneuvers. Crit Care 2005; 9: 60-5.
24. Zavala E, Ferrer M, Polese G, et al. Effect of inverse I: E ratio ventilation on pulmonary gas exchange in acute respiratory distress syndrome. Anesthesiology 1998; 88: 35-42.
25. Gattinoni L, Tognoni G, Pesenti A, et al. Effect of prone positioning on the survival of patients with acute respiratory failure. N Engl J Med 2001; 345: 568-73.
26. Rocco PR, Zin WA. Pulmonary and extrapulmonary acute respiratory distress syndrome: Are they different? Curr Opin Crit Care 2005; 11: 10-7.
27. Pelosi P, Caironi P, Gattinoni L. Pulmonary and extrapulmonary forms of acute respiratory distress syndrome. Semin Respir Crit Care Med 2001; 22: 259-68.
28. Gattinoni L, Pelosi P, Suter PM, et al. Acute respiratory distress syndrome caused by pulmonary and extrapulmonary disease: Different syndromes? Am J Respir Crit Care Med 1998; 158: 3-11.
29. Puybasset L, Gusman P, Muller JC, et al. Regional distribution of gas and tissue in acute respiratory distress syndrome: Consequences for the effects of positive end-expiratory pressure. Intensive Care Med 2000; 26: 1215-27.
30. Agarwal R, Srinivas R, Nath A, Jindal SK. Is the mortality higher in the pulmonary versus extrapulmonary ARDS? A meta-analysis. Chest 2007 Nov 7; [Epub] )
31. Meduri GU, Headley AS, Golden E, et al. Effect of prolonged methylprednisolone therapy in unresolving acute respiratory distress syndrome: A randomized controlled trial. JAMA 1998; 280: 159-65.
32. Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of corticosteroids for persistent acute resiratory distress syndrome. N Engl J Med 2006; 354: 1671-84.
33. Meduri GU, Golden E, Freire AX, et al. Methylprednisolone infusion in early severe ARDS: Results of a randomized controlled trial. Chest 2007; 131: 954-63.
34. Hsu CW, Lee DL, Lin SL, et al. The initial response to inhaled nitric oxide treatment for intensive care unit patients with acute respiratory distress syndrome. Respiration 2008; 75: 288-95.
35. Adhikari NK, Burns KE, Friedrich JO, et al. Effect of nitric oxide on oxygenation and mortality in acute lung injury: Systematic review and meta-analysis. BMJ 2007; 334: 779.
36. Angus DC, Clermont G, Linde-Zwirble WT, et al. Healthcare costs and long-term outcomes after acute respiratory distress syndrome: A phase III trial of inhaled nitric oxide. Crit Care Med 2006; 34: 2883-90.
37. Johannigman JA, Davis K Jr, Miller SL, et al. Prone positioning and inhaled nitric oxide: Synergistic therapies for acute respiratory distress syndrome. J Trauma 2001; 50: 589-95.
38. Lewis JF, Veldhuizen RA. The future of surfactant therapy during ALI/ARDS. Semin Respir Crit Care Med 2006; 27: 377-88.
39. Schmidt R, Markart P, Ruppert C, et al. Time-dependent changes in pulmonary surfactant function and composition in acute respiratory distress syndrome due to pneumonia or aspiration. Respir Res 2007; 8: 55.
40. Stevens TP, Sinkin RA. Surfactant replacement therapy. Chest 2007; 131: 1577-82.
41. Markart P, Ruppert C, Wygrecka M, et al. Patients with ARDS show improvement but not normalisation of alveolar surface activity with surfactant treatment: Putative role of neutral lipids. Thorax 2007; 62: 588-94.
42. Moller JC, Schaible T, Roll C, et al. Treatment with bovine surfactant in severe acute respiratory distress syndrome in children: A randomized multicenter study. Intensive Care Med 2003; 29: 437-46.
43. Bautin A, Khubulava G, Kozlov I, et al. Surfactant therapy for patients with ARDS after cardiac surgery. J Liposome Res 2006; 16: 265-72.
44. Spragg RG, Lewis JF, Walmrath HD, et al. Effect of recombinant surfactant protein C-based surfactant on the acute respiratory distress syndrome. N Engl J Med 2004; 351: 884-92.
45. Yapicioglu H, Yildizdas D, Bayram I, et al. The use of surfactant in children with acute respiratory distress syndrome: Efficacy in terms of oxygenation, ventilation and mortality. Pulm Pharmacol Ther 2003; 16: 327-33.
46. Kozlov IA, Poptsov VN. Surfactant-BL and inhaled nitric oxide in acute respiratory distress syndrome in cardiac surgical patients. Anesteziol Reanimatol 2005; 6: 38-41.
47. Altıntaş ND, Atilla P, İskit AB, Topeli A. Uzun süreli HMGCoA redüktaz inhibitörü simvastatin kullanımının farelerde oleik asit ve endotoksin ile oluşturulmuş akut akciğer hasarına etkisi. 4. Ulusal Dahili ve Cerrahi Bilimler Yoğun Bakım Kongresi. Yoğun Bakım Dergisi 2007; 3: 408.
48. Altıntaş ND. Uzun süreli HMG-CoA redüktaz inhibitörü simvastatin kullanımının farelerde oleik asit ve endotoksin ile oluşturulmuş akut akciğer hasarına etkisi (tez). Ankara: Üni adı; Yoğun Bakım Uzmanlık Tezi, 2007.
49. Sadegh Soltan-Sharifi M, Mojtahedzadeh M, et al. Improvement by N-acetylcysteine of acute respiratory distress syndrome through increasing intracellular glutathione, and extracellular thiol molecules and anti-oxidant power: Evidence for underlying toxicological mechanisms. Hum Exp Toxicol 2007; 26: 697-703.
50. Bernard GR, Wheeler AP, Arons MM, et al. A trial of antioxidants N-acetylcysteine and procysteine in ARDS. The antioxidant in ARDS study group. Chest 1997; 112: 164-72.
51. Morina P, Herrera M, Venegas J, et al. Effects of nebulized salbutamol on respiratory mechanics in adult respiratory distress syndrome. Intensive Care Med 1997; 23: 58-64.
52. McAuley DF, Matthay MA. Is there a role for beta-adrenoceptor agonists in the management of acute lung injury and the acute respiratory distress syndrome? Treat Respir Med 2005; 4: 297-307.
53. Perkins GD, McAuley DF, Thickett DR, Gao F. The betaagonist lung injury trial (BALTI): A randomized placebocontrolled clinical trial. Am J Respir Crit Care Med 2006; 173: 281-7.
54. Calabro P, Yeh ET. The pleiotropic effects of statins. Curr Opin Cardiol 2005; 20: 541-6.
55. Blanco-Colio LM, Tunon J, Martin-Ventura JL, Egido J. Anti-inflammatory and immunomodulatory effects of statins. Kidney Int 2003; 63: 12-23.
56. Tesfamariam B. The effects of HMG-CoA reductase inhibitors on endothelial function. Am J Cardiovasc Drugs 2006; 6: 115-20.
57. Liappis AP, Kan VL, Rochester CG, Simon GL. The effect of statins on mortality in patients with bacteremia. Clin Infect Dis 2001; 33: 1352-7.
58. Kruger P, Fitzsimmons K, Cook D, et al. Statin therapy is associated with fewer deaths in patients with bacteraemia. Intensive Care Med 2006; 32: 75-9.
59. Pirat A, Zeyneloglu P, Aldemir D, et al. Pretreatment with simvastatin reduces lung injury related to intestinal ischemia- reperfusion in rats. Anesth Analg 2006; 102: 225-32.
60. Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006; 354: 2564-75.
61. Martin GS, Moss M, Wheeler AP, et al. A randomized, controlled trial of furosemide with or without albumin in hypoproteinemic patients with acute lung injury. Crit Care Med 2005; 33: 1681-7.
62. de Boisblanc BP, Girod-Espinoza A, Welsh DA, Taylor DE. Hemodynamic monitoring in acute lung injury and acute respiratory distress syndrome. Respir Care Clin N Am 2003; 9: 457-79.
63. Mancuso P, Whelan J, DeMichele SJ, et al. Dietary fish oil and fish and borage oil suppress intrapulmonary proinflammatory eicosanoid biosynthesis and attenuate pulmonary neutrophil accumulation in endotoxic rats. Crit Care Med 1997; 25: 1198-206.
64. Gadek JE, DeMichele SJ, Karlstad MD, et al. Effect of enteral feeding with eicosapentaenoic acid, gamma-linolenic acid, and antioxidants in patients with acute respiratory distress syndrome. Enteral nutrition in ARDS study group. Crit Care Med 1999; 27: 1409-20.