Acute Respiratory Distress Syndrome:

Update for the New Millennium

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One (1) contact hour.
This course expires on November 16, 2010.

Copyright © 2004 by RN.com.

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First Published: November 16, 2004 Revised: November 16, 2007

Acknowledgements
RN.com acknowledges the valuable contributions of…

…Karen Siroky, RN, MSN, course coordinator for Acute Respiratory Distress Syndrome: Update for
the New Millennium. Karen is the Director of Education for RN.com. Karen received her B.S.N. from
the University of Arizona and her MSN from San Diego State University. Her nursing experience
includes ICU, transplant coordination, recruitment, quality improvement, information, and education.
She has previously published articles on Quality Improvement and Cardiac Transplantation.

…National Heart, Lung and Blood Institute (NHLBI), part of the National Institutes of Health,
provider of the information for this course. The National Heart, Lung, and Blood Institute (NHLBI)
provides leadership for a national program in diseases of the heart, blood vessels, lung, and blood;
blood resources; and sleep disorders. Since October 1997, the NHLBI has also had administrative
responsibility for the NIH Woman's Health Initiative. The Institute plans, conducts, fosters, and
supports an integrated and coordinated program of basic research, clinical investigations and trials,
observational studies, and demonstration and education projects. Research is related to the causes,
prevention, diagnosis, and treatment of heart, blood vessel, lung, and blood diseases; and sleep
disorders. The NHLBI plans and directs research in development and evaluation of interventions and
devices related to prevention, treatment, and rehabilitation of patients suffering from such diseases
and disorders. It also supports research on clinical use of blood and all aspects of the management of
blood resources. Research is conducted in the Institute's own laboratories and by scientific institutions
and individuals supported by research grants and contracts.

...Robin Varela, RN, BSN, for updating and editing this revised course. Robin has over 20 years
experience in critical care and emergency department nursing. During her years as a staff nurse and
nurse preceptor she has been certified as CCRN, TNCC, BLS, ACLS, ACLS Instructor, PALS and

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MICN. As an emergency department Clinical Nurse Manager, Varela took an active role in numerous
multi-disciplinary committees and partnered with local EMS to co-ordinate emergency preparedness
within the community. She has worked for American Mobile Healthcare as a Clinical Services Clinical
Liaison RN and works per diem as a critical care transport nurse. Varela completed her BSN in 2003
and plans to begin graduate school the summer of 2007.

Purpose and Objectives

The purpose of Acute Respiratory Distress: Update for the New Millennium is to educate
healthcare providers on ARDS, the course of the disease, its treatment and complications.

After successful completion of this course, you will be able to:

1. Describe the pathophysiology associated with ARDS.
2. Describe the treatment modalities used for patients with ARDS.
3. Identify which groups are at risk for ARDS.
4. Identify the role of family/significant others in relation to patients
diagnosed with ARDS.

Introduction
Acute Respiratory Distress Syndrome, also known as ARDS, is a type of breathing failure
that can occur in critically ill persons with underlying illnesses. It is not considered to be a
specific disease; however, it is a life-threatening condition that occurs when there is severe
fluid buildup in both lungs. The fluid buildup prevents the lungs from allowing the transfer of
oxygen from inspired air into the body and the elimination of carbon dioxide out of the body.

Overview of ARDS
In ARDS, the tiny blood vessels (capillaries) in the lungs or the air sacs (alveoli) are damaged
because of an infection, blood loss, inhalation injury or trauma. Damage causes fluid to leak
from the blood vessels into the alveoli of the lungs. While some alveoli fill with fluid, others
sometimes collapse. When this occurs, the lungs can no longer fill adequately with air and
the lungs lose elasticity and become stiff. Without adequate amounts of air entering the
lungs, the amount of oxygen in the blood becomes depleted. When this happens, the patient
develops the syndrome called ARDS. Key initial treatment includes oxygen and in most
cases, mechanical ventilation.

Respiratory failure can occur very quickly after the condition begins. It may take only a day or
two for fluid to build up. The process that causes ARDS may continue for weeks and cause
scarring in the lungs. If scarring occurs, the lungs (and your patient) have to work harder to
take in oxygen and eliminate of carbon dioxide.

In the past, only about four out of ten individuals who developed ARDS survived. Today,
many people (about seven out of ten) with ARDS survive. Although most people who survive
ARDS make a full recovery, some survivors sustain lasting damage to their lungs.

A Quick Review
To understand ARDS, it is helpful to understand how the lungs work. A quick review of lung
physiology can be helpful to understanding ARDS.

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Normal Lung Function
A slice of normal lung looks like a pink sponge—filled with tiny bubbles or holes. Around each
bubble is a fine network of tiny blood vessels. These bubbles surrounded by blood vessels
give the lungs a large surface to exchange oxygen (into the blood where it is carried
throughout the body) and carbon dioxide (out of the blood) through the process of gas
exchange. Healthy lungs perform gas exchange (respiration) effectively.

A Quick Review
Normal Breathing
Oxygenation of the cells occurs via air entering the body through the respiratory tract as you
breathe in air through your nose and mouth. The air travels down through your trachea
through large and small tubes in your lungs called bronchial tubes. The larger tubes are
bronchi, and the smaller tubes are bronchioles. One way to explain this to patients is to
describe the airways of the lungs as something like an upside-down tree with many branches.

At the ends of the small bronchial tubes, there are groups of air sacs or alveoli. The alveoli
have very thin walls adjacent to the alveoli small blood vessels called capillaries are present.
Oxygen passes from the alveoli into the blood in these small blood vessels. At the same time,
carbon dioxide passes from the blood following through the capillaries into the alveoli.

Effects of ARDS
In ARDS, damaged capillaries leak too much fluid into the lung. The leakage results from
toxins that the body produces in response to the underlying illness or injury. The lungs
become like a wet sponge, heavy and stiffer than normal. They no longer provide an effective
surface for gas exchange, and the level of oxygen in the blood falls. If ARDS is severe and
goes on for some time, scar tissue called fibrosis may form in the lungs. The scar tissue
(fibrosis) decreases the amount of functional surface area, thereby limiting the number of
alveoli available for gas exchange.

As noted earlier, patients with ARDS need extra oxygen and may need ventilatory support
while the lungs attempt to heal. If the patient survives, full recovery is possible; however,
recovery may take weeks or months. Some ARDS survivors take a year or longer to recover,
and some never completely recover from having ARDS.

There is a similar condition in infants called Infant Respiratory Distress Syndrome (IRDS,
RDS, and hyaline membrane disease). It mainly affects premature infants whose lungs are
not well developed when they are born.

What Causes ARDS

The causes of ARDS are not well understood. It can occur in individuals with or without lung
disease.

There are two ways that lung injury leading to ARDS can occur: through a direct injury to the
lungs, or indirectly when a patient is critically ill or has a serious injury not directly related to
the respiratory tract. Not all seriously ill or badly injured patients will develop ARDS.

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Direct Lung Injury
A direct injury to the lungs may be the result of inhaling toxic substances or a pulmonary
infection.

Some direct lung injuries that can lead to ARDS include:

• Severe pneumonia
• Aspiration
• Breathing in harmful fumes or smoke
• A severe blow to the chest or other accident that bruises the lungs

Indirect Lung Injury

Most cases of ARDS happen in people who are very ill or who have been in a major accident.
This is sometimes called an "indirect lung injury." Less is known about how indirect injuries
lead to ARDS than about how direct injuries to the lungs cause ARDS. Indirect lung injury
leading to ARDS sometimes occurs in cases of:
• Sepsis
• Severe injury with shock
• Severe blood loss and subsequent transfusions
• Drug overdose
• Pancreatitis

It is not clear why some very sick or seriously injured people develop ARDS, and others do
not. Researchers are trying to find out why ARDS develops and how to prevent it.

Who Does ARDS Affect?

ARDS usually affects people who are being treated for another serious illness or those who
have had major injuries. It affects about 150,000 people each year in the United States.
ARDS can occur in people with or without a previous lung disease. People who have a
serious accident with a large blood loss are more likely to develop ARDS. However, only a
small portion of people who have problems that can lead to ARDS actually develops it.

In most cases, a person who develops ARDS is already in the hospital being treated for other
medical problems.

Some illnesses or injuries that can lead to ARDS include:

• Serious, widespread infection in the body (sepsis)
• Severe injury (trauma) and shock from a car crash, fire, or other cause
• Severe bleeding that requires blood transfusions
• Severe pneumonia (infection of the lungs)
• Breathing in vomited stomach contents
• Breathing in smoke or harmful gases and fumes
• Injury to the chest from trauma (such as rib fractures) that causes bruising of the lungs
• Nearly drowning
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 • Some drug overdoses

Signs and Symptoms of ARDS

Physicians and other healthcare professionals must watch for these signs and symptoms in
patients who have conditions that might lead to ARDS. Patients who develop ARDS are often
too sick to complain about having trouble breathing or other related symptoms. If a patient
begins to show signs of developing ARDS, healthcare professionals should inform the
healthcare provider that the tests to confirm ARDS can be performed.

ARDS is often associated with the failure of other organs and body systems, including the
liver, kidneys, and the immune system. Multiple organ failure often leads to death.

The major signs and symptoms of ARDS are:

• Shortness of breath
• Rapid, labored breathing
• Cyanosis
• Decreased oxygen level in the blood

Diagnosis of ARDS
Healthcare providers diagnose ARDS when:
• A person suffering from severe infection or injury develops breathing problems.
• A chest x-ray shows fluid in the alveoli of both lungs.
• Arterial blood gases show a low level of oxygen in the blood
• Other conditions that could cause breathing problems have been ruled out.

ARDS can be confused with other illnesses that have similar symptoms. The most significant
is congestive heart failure. In congestive heart failure, fluid backs up into the lungs because
the heart is not pumping effectively. There is no injury to the lungs in congestive heart failure.
Since a chest x-ray is abnormal for both ARDS and congestive heart failure, it can be difficult
to differentiate between them.

Treatment of ARDS
Patients with ARDS are usually treated in the intensive or critical care unit of a hospital. The
primary focus for treating ARDS is to provide enough oxygen into the blood until the lungs
heal enough to function effectively on their own again. The following are the most common
and the most important treatments for an ARDS patient.

Due to the nature of the disease, there is no specific treatment for ARDS. Treatment and
therapy is supportive in the hope that the patient will spontaneously recover. Since there is
sometimes disagreement about what constitutes the best support, the National Heart, Lung,
and Blood Institute (NHLBI) of the National Institutes of Health developed and maintains an
ARDS clinical web site. The goal of the network is to test promising agents, devices and
patient management strategies to improve the care of patients with ARDS (See appendix to
view an example of a NHLBI test synopsis).

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Treatment of ARDS
Oxygen
The main treatment is providing a higher concentration of oxygen, enough to raise blood
levels of oxygen to nourish the cells. This can sometimes be accomplished with a face mask.
A face mask can deliver oxygen at a concentration of 40-60 percent (room air is
approximately 21%). As the ARDS progresses over hours or days, the patient may require a
higher level of oxygen than a face mask can provide.

As the patient becomes tired from the work of breathing so hard, it may become necessary to
mechanically ventilate the patient. If basic mechanical ventilation does not raise the blood
oxygen level to adequately perfuse the cells, positive end expiratory pressure (PEEP) may be
added to support the alveolar surface needed for adequate gas exchange.

Treatment of ARDS
Medication
Many different types of medications can be used to treat ARDS patients.
Common medications for a patient with ARDS include:
• Antibiotics to fight infection
• Pain relievers
• Drugs to relieve anxiety and keep the patient calm and from "fighting" the ventilator
• Drugs to maintain blood pressure or heart rate
• Muscle relaxants to reduce movement and reduce the body's demand for oxygen

Other Treatment
A patient that requires mechanical ventilation must receive fluids and nutrition via IVs and in
the case of long term ventilation, tube feedings. A pressurized air bed can help prevent
complications such as skin breakdown.

Results of Treatment
• Some patients recover quickly and can breathe on their own within a week or so. These
individuals have the best chance of a full recovery.
• Patients whose underlying illness is more severe may die within the first week of
treatment.
• Those who survive the first week but cannot breathe on their own may face many weeks
of mechanical ventilation and possible tracheotomy. They are more likely to have
complications and a slow recovery if they survive.

Complications of ARDS
Anyone who stays in the hospital for a long period of time is at greater risk for complications.
Common complications in ARDS patients are infections with hospital-acquired infections such
as ventilator acquired pneumonia (VAP) and pneumothorax.

Infections

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The lungs or other systems of the body may succumb to infection. Infections are treated
aggressively to prevent sepsis from developing. If signs and symptoms of an infection are
detected, the healthcare provider will usually request various types of cultures such as blood,
IV line, or urine to help determine the appropriate type of antibiotic therapy.

Complications of ARDS
Pneumothorax
Air-leaks through holes in the lungs can be caused by pressure from a mechanical ventilator
and from noncompliant or the very stiff lungs. Air from the injured lungs may enter the space
between the lungs and the lining around the lungs (the pleura) and cause a pneumothorax
(collapsed lung). This can be related to the patient’s relatively “stiff” lungs and the amount of
pressure needed for the ventilator to adequately manage the patient’s oxygen saturation.
Treatment involves placing a chest tube to remove the air and help the lungs re-inflate. If
pressure builds within the collapsed lung a tension pneumothorax can occur. A tension
pneumothorax will cause a mediastinal shift and the potential for cardiac tamponade if left
untreated.

Complications of ARDS
Subcutaneous Emphysema
Air may also enter the space between the membranes that line the abdomen
(pneumoperitoneum) or the soft tissue under the skin (subcutaneous emphysema). Some
people describe subcutaneous emphysema as “rice krispies” under the skin. Subcutaneous
emphysema is generally not treated.

Each complication is treated as it arises. Adhering to recommended hand hygiene guidelines

and careful hand washing by hospital staff and visitors helps reduce infections. More refined
ventilator treatments will also help reduce the incidence of pneumothorax.

Recovering from ARDS

Some people who survive ARDS heal quickly and recover completely in a relatively short
time. Survivors often recover much of their lung function in the first 3-6 months after leaving
the hospital and continue to recover for up to a year or more.

Other individuals will recover more slowly. Some ARDS survivors never recover completely
and have continuing problems with their lungs. Every case is different. Individuals who are
younger and healthier when they develop ARDS are more likely to recover quickly than those
who are older or who have more health problems.

After leaving the hospital, ARDS survivors require follow up with their healthcare provider
during recovery to check lung function. The healthcare provider will follow their pulmonary
function to ensure they are improving. The healthcare provider might also measure the SaO2
to check the amount of oxygen in the blood or obtain arterial blood gases if they were
concerned with perfusion.

After going home from the hospital, the ARDS survivors require wide range of support.
While recovering from ARDS at home, a person may:
• Need to use oxygen at home or when going out of the home, at least temporarily

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• Need to have physical, occupational, or other therapy
• Have shortness of breath, cough, or phlegm
• Have hoarseness from the endotracheal tube
• Feel tired and not have much energy
• Have muscle weakness

Information for Family and Friends

While a patient is in the hospital being treated for ARDS, family and friends may feel very
stressed. One day the patient may seem to be recovering, and the next day the patient may
take a turn for the worse. It can be a frightening experience to see someone you care about
intubated and on a ventilator.

Healthcare providers should explain to family members and significant others that a team of
medical and healthcare professionals will be providing effective care to their loved one. For
example, an infectious disease specialist might be involved to help make sure that the initial
infection or an infectious complication is properly treated. A pulmonologist may be managing
the ventilator and a renal specialist may be required if kidney failure occurs. Members of the
team will communicate with one another regularly to make sure that care is given in a
coordinated manner.

Information for Family and Friends

Although family members may feel helpless, they are an important asset in supporting the
patient while they are receiving care.
This includes:
• Asking questions about the patient's condition and care, and finding out how they can
support their loved one.
• Talking to the patient, even if he or she is not responsive. Suggest talking about fun things
they did together and laugh about silly things going on in your life. Many survivors say
they were, at some level, aware of the people and things around them. They also recall
dreams they had while in a sleep-induced state; the dreams were described as being
calming or frightening. Talking to the patient about happy and fun things may help make
the dreams more positive.
• Encouraging family members to put family photos near the patient, play music at low
volume, or rub lotion into the patient's feet and hands. Many survivors are aware of people
and things around them. This may help to trigger their senses of hearing, touch, and
seeing.
• Trying to help families leave fears and worries at the door. Make sure everyone is
encouraging and hopeful while with the patient.
• Keep a journal or record of events for the patient to read after leaving the hospital. ARDS
survivors want to know every detail of what happened while they were so ill.
• Reminding family members to take care of themselves, too. Try to get enough rest and
sleep, eat well, and exercise. Encourage family members and friends to sit with the
patient so that each can have a break. The recovering ARDS patient will need strength
and support over what may be a long recovery period.

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Information for Family and Friends
The family members and friends of people who have had ARDS often are deeply affected by
the experience. The "roller-coaster" ride of emotions while the ARDS patient is in the hospital
can be exhausting and stressful. Caring for the ARDS survivor at home can also be stressful
and tiring. Encourage them to ask for help from others or your healthcare providers if needed.
Most hospitals have individuals such as social workers or discharge planners who can help
family member cope with these issues.

Conclusion
ARDS is a type of breathing failure that can occur in critically ill persons with underlying
illnesses. It is a life-threatening condition that occurs when there is severe fluid build-up in
both lungs. Knowledge about its causes, treatments, and complications will help healthcare
professionals to more effectively manage patient care and provide support to family
members.

Appendix
This information is an example of an NHLBI ARDS study named FACTT.
Additional information about this study can be obtained on line at: http://www.ardsnet.org/node/733.

Prospective, Randomized, Multi-Center Trial of Pulmonary Artery Catheter (PAC) vs. Central
Venous Catheter (CVC) for Management of Acute Lung Injury (ALI) and Acute Respiratory
Distress Syndrom ARDS. and Prospective, Randomized, Multi-Center Trial of "Fluid
Conservative" vs. "Fluid Liberal" Management of Acute Lung Injury (ALI) and Acute
Respiratory Distress Syndrome (ARDS).

This is a Prospective, Randomized, Multi-Center Trial of evaluating the use of a Pulmonary Artery
Catheter (PAC) versus a less invasive alternative, the Central Venous Catheter (CVC) for
Management of patients with Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome
(ARDS). The study is combined with a second study evaluating a "Fluid Conservative" vs. "Fluid
Liberal" Management strategy in patients with ALI or ARDS. These studies are combined using a 2x2
factorial design. The goals of the studies are to 1) assess the safety and the efficacy of PAC vs. CVC
guided management in reducing mortality, need for mechanical ventilation, and morbidity in patients
with ALI and ARDS; and 2) assess the safety and efficacy of "fluid conservative" vs. "fluid liberal"
management strategies on lung function, non-pulmonary organ function, as well as mortality and the
need for mechanical ventilation. A maximum of approximately 1,000 patients will be enrolled. Patients
will be treated with the specific fluid management strategy (to which they were randomized) for 7 days
or until unassisted ventilation, whichever occurs first. Patients randomized to PAC will utilize this
catheter for at least 3 days and up to 7 days (depending on protocol defined stability criteria) or until
unassisted ventilation, whichever occurs first. If the PAC is discontinued according to protocol
between day 3 and day 7, the fluid management strategy will continue and will be guided by the CVC.
Patients randomized to CVC will utilize this catheter for 7 days or until unassisted ventilation,
whichever occurs first. The trial is being monitored by an independent Data and Safety Monitoring
Board (DSMB) and as of January 2005 has enrolled nearly 800 subjects. To assist in the completion
of this important study, eight new centers were added to the ARDS network.

Ref: The National Heart, Lung, and Blood Institute of the National Institutes of Health. Prospective,
Randomized, Multi-Center Trial of Pulmonary Artery Catheter (PAC) vs. Central Venous Catheter
(CVC) for Management of Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrom ARDS.
and Prospective, Randomized, Multi-Center Trial of "Fluid Conservative" vs. "Fluid Liberal"

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Management of Acute Lung Injury (ALI) and Acute Respiratory Distress Syndrome (ARDS). Retrieved
September 4, 2007 from: http://www.ardsnet.org/node/733.

Resources
ARDS Support Center
www.ards.org
The primary purpose of the ARDS Support Center is to provide information, education, care and
support for patients, survivors, family members and loved ones who have been confronted with the
many problems resulting from the onset, treatment and consequences of the devastating condition
known as Acute Respiratory Distress Syndrome.

ARDS Clinical Network

www.ardsnet.org
The goal of the Network is to efficiently test promising agents, devices, or management strategies to
improve the care of patients with ARDS.

ARDS Foundation
www.ardsil.com
The ARDS Foundation is a National Not for Profit Organization composed of a group of individuals
who have been personally affected by ARDS. We are dedicated to increasing public awareness,
education, and financial assistance to those engaged in medical research.

References
National Heart, Lung and Blood Institute (2004) Diseases and Conditions Index. ARDS.

National Heart, Lung & Blood Institute (1999) NHLBI Clinical Study Stopped Early: Successful
Ventilator Strategy Found for Intensive Care Patients on Life Support. Retrieved October 1, 2004 @
http://www.nhlbi.nih.gov/new/press/hlbi15-9.htm

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