Hemodynamic Monitoring and Fluid Management in ARDS
Acute respiratory distress syndrome (ARDS) is a major cause of morbidity and mortality in the ICU affecting as many as 10% of critically ill patients and almost a quarter of mechanically ventilated patients [1, 2]. ARDS is characterized by increased perme
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Hemodynamic Monitoring and Fluid Management in ARDS Dusan Hanidziar and Edward A. Bittner
8.1
Introduction
Acute respiratory distress syndrome (ARDS) is a major cause of morbidity and mortality in the ICU affecting as many as 10% of critically ill patients and almost a quarter of mechanically ventilated patients [1, 2]. ARDS is characterized by increased permeability of the alveolar-capillary membrane due to dysregulated, tissue-destructive inflammation. Pulmonary edema, the result of fluid maldistribution, has an adverse impact on respiratory function at several levels including decreased lung compliance, impaired gas exchange, reduction of surfactant levels, and pulmonary hypertension [3]. In the early phase of ARDS, a systemic inflammatory state is usually responsible for hypovolemia. In this phase, early and adequate fluid resuscitation is essential to prevent the development of multiorgan dysfunction, which can impact mortality in patients with ARDS [4]. As the inflammatory state resolves, the excessive fluid can have a detrimental impact on patient outcome. Transition from one phase to another is complex and can often be difficult to distinguish. However, identifying the transition between these two phases is likely to be important for optimization of fluid balance and improving patient outcomes. Hemodynamic monitoring and modulation of fluid status in patients with ARDS have been the focus of a number of studies – some promising and others disappointing in their physiological effects and impact on patient outcomes. While such investigations may ultimately improve patient-centered outcomes, fluid management in ARDS continues to be a source of great controversy. Fluid management is a complex issue and one of the most challenging aspects of critical care. The focus of this chapter is to review the current literature on hemodynamic monitoring and fluid management of patients with ARDS with a goal toward improving patient outcomes and identifying opportunities for further investigation. D. Hanidziar, MD, PhD (*) • E.A. Bittner, MD, PhD Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital/Harvard Medical School, Boston, MA, USA e-mail: [email protected]; [email protected] © Springer International Publishing Switzerland 2017 D. Chiumello (ed.), Acute Respiratory Distress Syndrome (ARDS), DOI 10.1007/978-3-319-41852-0_8
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D. Hanidziar and E.A. Bittner
Pathophysiology
An understanding of the pathophysiology of ARDS with its associated fluid maldistribution and accumulation is essential for developing an approach to management. While ARDS can be triggered by a wide range of pulmonary and extrapulmonary processes, the syndrome shares a common pattern of an acutely developed alveolar- capillary injury. The early phase of ARDS is characterized by diffuse alveolar damage, with disruption of the alveolar epithelial and endothelial cell layers. As a result of increased alveolar-capillary permeability, protein-rich pulmonary edema fluid accumulates in the alveolar
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