Acute Respiratory Distress Syndrome (ARDS) adalah cedera paru akut difus inflamasi yang terjadi peningkatan permeabilitas vaskuler paru dan kehilangan pengisian udara pada jaringan paru (Aboet & Maskoen, 2018).
Sindrom gangguan pernapasan akut didefinisikan secara klinis dengan timbulnya gagal napas akut dengan hipoksemia dan infiltrat paru bilateral pada pencitraan dada yang tidak dapat dikaitkan terutama dengan kelebihan volume, disfungsi ventrikel kiri, atau penyakit paru-paru kronis (Matthay et al., 2020).
Acute respiratory Distress Syndrome merupakan sindroma gagal nafas yang diakibatkan oleh peradangan yang cepat di paru-paru. Keadaan ini ditandai dengan sesak nafas, peningkatan laju pernafasan, dan sianosis. ARDS berkembang pada pasien kritis yang mempunyai pneumonia, sepsis, dan aspirasi isi lambung.
Kriteria ARDS didasarkan pada definisi Berlin 2012 yang didasarkan pada derajat hipoksemia pasien, yaitu:
| tingkat hipoksemia | PaO2/fIo2 (mmHg) |
| mild | 200 – 300 |
| moderate | 100 – 200 |
| severe | < 100 |
Respiratory Driven (Penggerak pernafasan)
Otak (Batang otak-Medula oblogata) menjadi yang bertanggungjawab dalam pernafasan, melalui saraf neuron memberikan sinyal kepada otot pernafasan untuk menghasilkan inspirasi dan pasang-surut pernafasan. Pernafasan manusia berlangsung dalam dua cara yaitu proses otomatis (input kemosensori) dan proses turunan (perilaku/ behavioral).
Input kemosensori adalah refleks umpan balik yang dimediasi oleh serabut aferen dari kemoreseptor pusat dan perifer. Reflek umpan-balik berfungsi untuk mengoreksi hipoksemia, dan menekan terjadinya fluktuasi pH dan PaCO2. proses turunan merupakan perubahan adaptif dari pola pernafasan selama kegiatan kompleks seperti aktifitas fisik dan beban mental. Dalam fisiologi peningkatan PaCo2 diukur melalui ventilasi permenit (minute ventilation), terdapat permintaan dan kebutuhan PaCo2 yang digambarkan secara baik melalui kurva otak dan kurva ventilasi. kurva otak adalah ventilasi permenit yang dibutuhkan oleh penggerak pernafasan untuk diberikan PaCo2 sedangkan kurva ventilasi merupakan ventilasi permenit aktual dari subjek yang diberikan PaCo2. Dalam keadaan sehat, kurva otak sama dengan kurva ventilasi namun pada keadaan ARDS kedua kurva akan saling berjauhan.
Untuk mengontrol pernafasan pada pasien ARDS yaitu dengan cara mengurangi disosiasi kurva otak dan kurva ventilasi. Contoh pada hiperkapnia dan hipoksemia maka stimulus pernafasan yang tinggi dapat memperbaiki kedua keadaan tersebut.
Fenotipe pada ARDS
ARDS bersifat heterogen dalam hal faktor risiko klinis, fisiologi cedera paru, mikrobiologi, dan biologi. Mungkin inilah yang menjadi sebab sebagian besar pengobatan mengalami kegagalan. Mengidentifikasi fenotipe mungkin dapat meningkatkan keberhasilan terapi. Contoh pada pandemi Covid-19, identifikasi patogen pada pneumonia telah memberikan kemanfaatan dalam hal pilihan terapi dan keberhasilan terapi tersebut. Pengelompokan ARDS juga bermanfaat seperti pada pasien dengan hipoksemia sedang – berat (P/F <150 mmHg) yang mendapat manfaat terapi posisi tengkurap (prone position).
Penyebab
ARDS disebabkan oleh banyak hal seperti pneumonia (bakteri ataupun virus), sepsis, trauma paru, cedera paru akibat transfusi (TRALI), perdarahan hebat, dan odema paru (non kardiogenik). Sepsis merupakan penyebab utama ARDS, mediator inflamasi yang dilepaskan pada saat pasien mengalami sepsis dapat merusak paru-paru dan berdampak pada terganggunya pertukaran gas (Semedi, 2015).
Pemeriksaan Penunjang ARDS
- Analisa Gas Darah (penurunan PO₂ , penurunan P/F rasio)
- Pemeriksaan thorak (penumpukan cairan di paru- paru)
- Kultur darah, kultur sputum
- BALF (cairan bronkoalveolar lavage)
- Pemeriksaan CT- Scan untuk diagnosa pembanding adanya tumor paru, dan Echocardiografi untuk pembanding diagnosa gagal jantung yang dapat menyebabkan odema paru yang mirip ARDS.
Manajemen Ventilasi Mekanik
Manajemen awal pasien ARDS adalah dengan bantuan pernafasan non infasif, menggunakan High Flow Nasal Cannula (HFNC), Continuos Positive Airway Pressure (CPAP), dan Non Invasive Ventilation (NIV). Pada ARDS berat, bantuan pernafasan non invasif mungkin dapat membantu ‘sebentar’. Masih belum secara jelas kapan dan kondisi bagaimana harus mengakhiri bantuan pernafasan non invasif dan meng-inisisasi bantuan pernafasan dengan ventilasi mekanis. Terdapat perbedaan dan kekhasan pada setiap pasien, sehingga membutuhkan kejelian dan pengalaman yang baik dari petugas medis.
Mayoritas pasien berkembang menjadi gagal nafas yang membutuhkan bantuan ventilasi mekanis. Namun ventilasi mekanis pun dapat menjadi penyebab cidera paru, pada pasien ARDS risiko cedera paru menjadi lebih tinggi. Sehingga prinsip penatalaksanaan ventilasi mekanis adalah dengan mengurangi Ventilator Associated Lung Injury (VALI) dengan metode low tidal volume ventilation.
*low tidal volume berfungsi untuk mengurangi cedera paru (volume trauma dan barotrauma). PEEP berfungsi untuk membatasi atelektrauma.
Beberapa dekade yang lalu, goal terapi ventilasi mekanik adalah untuk perbaikan pertukaran gas dan perbaikan gas darah arteri. Saat itu teknik yang dipakai adalah support ventilator secara agresif dengan harapan dapat meningkatkan PaO2 dan mengurangi intrapulmonary shunt. Paradigma lama tersebut kemudian berubah setelah adanya study yang memperlihatkan bahwa teknik ventilasi secara agresif dapat mengakibatkan cidera paru. Tidal volume yang rendah 6ml/KgBB ternyata lebih aman dan mampu menurunkan mortalitas daripada memakai tidal volume tinggi <12ml/KgBB (Gama de Abreu & Pelosi, 2012).
Standar Perawatan Pasien dengan Ventilator
| Standar Saat ini | Standar yang terus berkembang |
| Batasan Tidal Volume dengan target 6ml/KgBB | Driving pressure 15 cmH2O |
| Batasi Plateu pressure <30 cmH2O | Minimize delivered mechanical power |
| Titrasi PEEP menggunakan tabel PEEP/FiO2 atau atur agar Pplat <30 cmH2O | Titrasi PEEP menggunakan salah satu metode: compliance terbaik, tekanan transpulmoner, Measured recruitability (R:I), electrical impedance tomography (EIT). |
| Pemantauan ketat pernafasan spontan untuk menghindari terjadinya disinkronisasi | |
| Penggunaan mask NIV atau CPAP atau HFNC pada ARDS ringan sedang untuk menghindari intubasi. | |
| Memperkuat ventilasi | Memperkuat ventilasi |
| Posisi tengkurap (16jam/hari) pada pasien ARDS sedang- berat (P/F <150) | Blokade neuromuskuler bila ada indikasi; hipoksemia berat, disinkronisasi parah, peningkatan kerja pernafasan, kesulitan dalam menjalankan ventilasi yang aman. |
| ECMO setelah posisi tengkurap, jika: P/F <80, atau sulit menjalankan ventilasi yang aman. | |
Referensi:
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