What is the treatment for Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

The treatment of Acute Respiratory Distress Syndrome (ARDS) should prioritize lung-protective ventilation strategies, including mechanical ventilation with lower tidal volumes (4–8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure ≤ 30 cm H2O), as recommended by the most recent guideline update 1. The cornerstone of ARDS management is low tidal volume ventilation, with plateau pressures maintained below 30 cmH2O to prevent ventilator-induced lung injury.

• Key considerations in ARDS treatment include:
  • Mechanical ventilation strategies that limit tidal volume and inspiratory pressures 1
  • Prone positioning for more than 12 hours a day in severe ARDS, as it improves ventilation-perfusion matching 1
  • Positive end-expiratory pressure (PEEP) optimization, with higher PEEP potentially beneficial in moderate to severe ARDS 1
  • Conservative fluid management to reduce pulmonary edema
  • Neuromuscular blocking agents, such as cisatracurium, may be considered in severe cases to improve ventilator synchrony 1
  • Corticosteroids, like methylprednisolone, can be beneficial in persistent ARDS 1
  • Rescue therapies, including inhaled nitric oxide, recruitment maneuvers, and extracorporeal membrane oxygenation (ECMO) in specialized centers, for refractory hypoxemia Throughout treatment, it's essential to identify and treat the underlying cause of ARDS, implement ventilator-associated pneumonia prevention measures, provide adequate nutrition, and maintain appropriate sedation to optimize outcomes.
• The most recent guideline update 1 provides conditional recommendations for the use of corticosteroids, venovenous extracorporeal membrane oxygenation (VV-ECMO), and neuromuscular blockers in selected patients with severe ARDS.

From the Research

ARDS Treatment Overview

• The mainstay of treatment for acute respiratory distress syndrome (ARDS) includes proning, conservative fluid management, and lung protective ventilation 2.
• Ventilator settings should be individualized to improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI) 2, 3.
• Positive end-expiratory pressure (PEEP) can be individualized by titrating to best respiratory system compliance, or by using advanced methods such as electrical impedance tomography or esophageal manometry 2, 4.

Mechanical Ventilation Strategies

• Protective ARDS mechanical ventilation strategies with low tidal volumes can reduce mortality 3.
• Driving pressure is the most reasonable parameter to optimize tidal volume 3.
• Higher PEEP levels during the first 3 days of extracorporeal membrane oxygenation (ECMO) support were associated with lower mortality 5.
• Lower positive end-expiratory pressure levels and significantly lower plateau pressures during ECMO were used in some centers 5.

Adjunctive Therapies

• Adjunctive therapies such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids may improve oxygenation, but do not clearly reduce mortality 2.
• Salvage modes of ventilation such as high frequency oscillatory ventilation and airway pressure release ventilation are additional options that may be appropriate in select patients 2, 3.
• Extracorporeal membrane oxygenation (ECMO) may be used in select, refractory cases to improve gas exchange and modestly improve survival 2, 6.

Management and Treatment

• Management of patients with ARDS includes low tidal volume ventilation, prone ventilation, paralysis in certain patient populations, and perhaps ECMO 6.
• The definition of ARDS has evolved over the years, with the most recent and agreed upon diagnostic criteria based on the Berlin criteria for ARDS 6.
• Further research is needed to identify the best methods for guiding lung ventilation in severe ARDS and patients on ECMO 6, 4.