Critical care clinics
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The optimal fluid management for acute respiratory distress syndrome (ARDS) remains unknown. Liberal fluid management may improve cardiac function and end-organ perfusion, but may lead to increased pulmonary edema and inhibit gas exchange. ⋯ Recent discoveries suggest there is large heterogeneity in ARDS, and varying phenotypes of ARDS respond differently to fluid treatments. Future advances in management will require real-time assignment of ARDS phenotypes, which may facilitate inclusion into clinical trials by ARDS phenotype and guide development of targeted therapies.
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Critical care clinics · Oct 2021
ReviewThe Epidemiology of Acute Respiratory Distress Syndrome Before and After Coronavirus Disease 2019.
Acute respiratory distress syndrome (ARDS) is a heterogeneous syndrome of high morbidity and mortality with global impact. Current epidemiologic estimates are imprecise given differences in patient populations, risk factors, resources, and practice styles around the world. Despite improvement in supportive care which has improved mortality, effective targeted therapies remain elusive. ⋯ Intensive care unit rates of death have varied widely in studies to date because of a variety of patient and hospital-level factors. Despite some controversy, the best management of these patients is likely the same supportive measures shown to be effective in classical ARDS. Further epidemiologic studies are needed to help characterize the epidemiology of ARDS subphenotypes to facilitate identification of targeted therapies.
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Critical care clinics · Oct 2021
ReviewCOVID-19-Associated Acute Respiratory Distress Syndrome: Lessons from Tissues and Cells.
Reports examining lung histopathology in coronavirus disease 2019 (COVID-19) infection provide an essential body of information for clinicians and investigators. Severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2)-induced lung injury is complex, involving the airways, alveoli, and pulmonary vessels. ⋯ The biological and molecular mechanisms that drive this pattern of injury are unknown, and the relationship of SARS-CoV-2-induced DAD to physiologic alterations and clinical outcomes in COVID-19-associated acute respiratory distress syndrome is undefined. Additional histologic patterns that may be variant phenotypes have been reported.
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Critical care clinics · Oct 2021
ReviewAcute Kidney Injury and Acute Respiratory Distress Syndrome.
Acute kidney injury (AKI) complicates approximately a third of all acute respiratory distress syndrome (ARDS) cases, and the combination of the two drastically worsens prognosis. Recent advances in ARDS supportive care have led to improved outcomes; however, much less is known on how to prevent and support patients with AKI and ARDS together. ⋯ This article summarizes key concepts for the critical care physician managing a patient with ARDS complicated by AKI. Also provided is a discussion of AKI in the COVID-19 era.
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Critical care clinics · Oct 2021
ReviewPathophysiology of Acute Respiratory Distress Syndrome and COVID-19 Lung Injury.
The pathophysiology of acute respiratory distress syndrome (ARDS) is marked by inflammation-mediated disruptions in alveolar-capillary permeability, edema formation, reduced alveolar clearance and collapse/derecruitment, reduced compliance, increased pulmonary vascular resistance, and resulting gas exchange abnormalities due to shunting and ventilation-perfusion mismatch. Mechanical ventilation, especially in the setting of regional disease heterogeneity, can propagate ventilator-associated injury patterns including barotrauma/volutrauma and atelectrauma. Lung injury due to the novel coronavirus SARS-CoV-2 resembles other causes of ARDS, though its initial clinical characteristics may include more profound hypoxemia and loss of dyspnea perception with less radiologically-evident lung injury, a pattern not described previously in ARDS.