Original investigation
Diagnosis and therapy of acute respiratory distress syndrome in adults: An international survey

https://doi.org/10.1016/S0883-9441(96)90015-5Get rights and content

Abstract

In an attempt to identify the range of opinions influencing the diagnosis and therapy of patients with the adult respiratory distress syndrome (ARDS), a postal survey was mailed to 3,164 physician members of the American Thoracic Society Critical Care Assembly. The questionnaire asked opinions regarding the factors important in the diagnosis of ARDS and its treatment. Thirty-one percent of physicians surveyed responded within 4 weeks, the vast majority of which were board certified or eligible in Internal Medicine, Pulmonary Disease, and/or Critical Care Medicine. A known predisposing cause, measure of oxygenation efficiency, and a chest radiograph depicting pulmonary edema were reported to be the most important criteria for a clinical and research diagnosis of ARDS. Lung compliance and bronchoalveolar lavage neutrophil or protein content were reportedly less important. The initial treatment of patients with ARDS was reported to be most commonly accomplished using volume-cycled ventilation in the assist/control mode. Nearly half the responders reported using lower tidal volumes (5 to 9 mL/kg) than the traditionally recommended 10 to 15 mL/kg. Most respondents indicated they have intentionally allowed C02 retention. On average, oxygen toxicity was thought to begin at an F102 between 0.5 and 0.6. It was reported that modest levels of positive end-expiratory pressure (PEEP) were used in incremental fashion as FiO2 requirements increased. Perceived indications for insertion of pulmonary artery catheters and compensation of the effects of PEEP on the pulmonary artery occlusion pressure varied widely among the responders. We conclude that reported practice patterns regarding the care of ARDS patients vary widely even within a relatively homogenous group of critical care practitioners.

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      Nevertheless, some doctors do not believe the question of prophylactic PEEP has been resolved because the trial enrolled patients with various diseases at very different risks of acute lung injury, and used modest amounts of (8 cm H2O) of PEEP. Although not protective against the development of acute lung injury, a low amount of PEEP is given to most ventilated patients to prevent atelectasis.50 In established acute lung injury, PEEP is routinely used to recruit the lung or prevent reversal of recruitment, thereby decreasing oxygen requirements, and improving other measures of lung function such as shunt fraction and compliance.

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    Supported in part by National Institutes of Health Grant Nos. HL 43167 and HL 07123 and the American Thoracic Society.

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