What is the management of Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

The management of Acute Respiratory Distress Syndrome (ARDS) should prioritize lung-protective ventilation strategies, including the use of 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 guidelines 1. The cornerstone of ARDS management is low tidal volume ventilation, with plateau pressures maintained below 30 cmH2O.

• PEEP should be optimized, typically starting at 8-10 cmH2O and titrated based on oxygenation response.
• Prone positioning for more than 12 hours daily is recommended for patients with severe ARDS, as it has been shown to improve outcomes 1.
• Conservative fluid management should be implemented to minimize pulmonary edema while maintaining adequate organ perfusion.
• Neuromuscular blockade with cisatracurium may be considered for 48 hours in severe cases with persistent ventilator dyssynchrony.
• Corticosteroids, particularly methylprednisolone, can be beneficial in moderate-to-severe ARDS, typically continued for 7-14 days with gradual tapering, as suggested by recent guidelines 1.
• Rescue therapies for refractory hypoxemia include inhaled nitric oxide or venovenous ECMO in specialized centers. These interventions aim to minimize ventilator-induced lung injury, improve oxygenation, and reduce inflammation while supporting the patient through the acute phase of illness. Key considerations in ARDS management include:
• The use of higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS, as conditionally recommended by recent guidelines 1.
• The avoidance of prolonged lung recruitment maneuvers in patients with moderate to severe ARDS, as strongly recommended against by recent guidelines 1.

From the Research

ARDS Management Overview

• Acute Respiratory Distress Syndrome (ARDS) is a life-threatening condition characterized by noncardiogenic pulmonary edema, rapidly progressive dyspnea, tachypnea, and hypoxemia 2.
• The diagnosis of ARDS is based on the onset of symptoms within one week of a known insult, profound hypoxemia, bilateral pulmonary opacities on radiography, and the inability to explain respiratory failure by cardiac failure or fluid overload 2.

Treatment Strategies

• The treatment of ARDS is supportive and includes mechanical ventilation, prophylaxis for stress ulcers and venous thromboembolism, nutritional support, and treatment of the underlying injury 2.
• Lung-protective mechanical ventilation strategies, such as low tidal volume and high positive end-expiratory pressure, improve outcomes in patients with ARDS 2, 3, 4, 5.
• Prone positioning is recommended for some moderate and all severe cases of ARDS 2, 6.
• Adjunctive therapies, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, may be applied judiciously to improve oxygenation, but do not clearly reduce mortality 3, 6.

Mechanical Ventilation

• The use of low tidal volume (6 ml/kg of predicted body weight) and low plateau pressure is recommended to prevent ventilator-induced lung injury 4, 5.
• Positive end-expiratory pressure can be individualized by titrating to best respiratory system compliance, or by using advanced methods, such as electrical impedance tomography or esophageal manometry 6.
• Adjustments to mitigate high driving pressure and mechanical power may be further beneficial to reduce ventilator-induced lung injury 6.

Weaning and Outcome

• Daily assessment with spontaneous breathing trial is essential to liberate patients from mechanical ventilation in a timely manner 4.
• Patients who survive ARDS are at risk of diminished functional capacity, mental illness, and decreased quality of life, and ongoing care by a primary care physician is beneficial for these patients 2.