RESUMO
Acute Respiratory Distress Syndrome (ARDS) is a condition of varied etiology characterized by the acute onset (within 1 week of the inciting event) of hypoxemia, reduced lung compliance, diffuse lung inflammation and bilateral opacities on chest imaging attributable to noncardiogenic (increased permeability) pulmonary edema. Although multi-organ failure is the most common cause of death in ARDS, an estimated 10-15% of the deaths in ARDS are caused due to refractory hypoxemia, i.e.- hypoxemia despite lung protective conventional ventilator modes. In these cases, clinicians may resort to other measures with less robust evidence -referred to as "salvage therapies". These include proning, 48â¯h of paralysis early in the course of ARDS, various recruitment maneuvers, unconventional ventilator modes, inhaled pulmonary vasodilators, and Extracorporeal membrane oxygenation (ECMO). All the salvage therapies described have been associated with improved oxygenation, but with the exception of proning and 48â¯h of paralysis early in the course of ARDS, none of them have a proven mortality benefit. Based on the current evidence, no salvage therapy has been shown to be superior to the others and each of them is associated with its own risks and benefits. Hence, the order of application of these therapies varies in different institutions and should be applied following a risk-benefit analysis specific to the patient and local experience. This review explores the rationale, evidence, advantages and risks behind each of these strategies.
Assuntos
Hipóxia/complicações , Hipóxia/terapia , Síndrome do Desconforto Respiratório/etiologia , Terapia de Salvação/métodos , Administração por Inalação , Pressão Positiva Contínua nas Vias Aéreas/métodos , Oxigenação por Membrana Extracorpórea/métodos , Humanos , Hipóxia/mortalidade , Bloqueadores Neuromusculares/uso terapêutico , Óxido Nítrico/administração & dosagem , Óxido Nítrico/uso terapêutico , Estudos Observacionais como Assunto , Decúbito Ventral/fisiologia , Prostaglandinas I/administração & dosagem , Prostaglandinas I/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Síndrome do Desconforto Respiratório/fisiopatologia , Medição de Risco , Vasodilatadores/administração & dosagem , Vasodilatadores/uso terapêuticoRESUMO
A 34-year-old white woman who was 30 weeks' pregnant initially presented to her primary care physician with a cough for which she was given antibiotics, but she had persistent symptoms. These were followed by chest pain, as a result of which she was referred to our department. She had a past medical history of hypertension, and currently was in her sixth pregnancy, with no reported complications in the previous pregnancies. Review of systems was otherwise negative. She had a three-pack-year smoking history, but denied smoking during her current pregnancy.