From the Guidelines
The management of Acute Respiratory Distress Syndrome (ARDS) should prioritize lung-protective mechanical ventilation with low tidal volumes and individualized positive end-expiratory pressure (PEEP) to minimize ventilator-induced lung injury, as recommended by the most recent guidelines 1. The treatment of ARDS focuses on supportive care, with the goal of maintaining adequate gas exchange while preventing further lung injury. Key components of this approach include:
- Lung-protective mechanical ventilation using low tidal volumes (6 ml/kg of ideal body weight) and limiting plateau pressures to less than 30 cmH2O 1
- Individualized PEEP, typically 10-15 cmH2O, to maintain adequate oxygenation while preventing lung injury 1
- Prone positioning for at least 16 hours daily in patients with moderate to severe ARDS (PaO2/FiO2 ratio <150) 1
- Conservative fluid management to reduce pulmonary edema
- Neuromuscular blocking agents like cisatracurium (37.5 mg/hr infusion) may be used for the first 48 hours in severe cases to improve ventilator synchrony 1
- Corticosteroids such as dexamethasone 6 mg daily for 10 days can reduce inflammation and mortality in moderate to severe cases 1
- Rescue therapies for refractory hypoxemia include inhaled nitric oxide, recruitment maneuvers, and extracorporeal membrane oxygenation (ECMO) 1 It is essential to identify and treat the underlying cause of ARDS, whether it's sepsis, pneumonia, trauma, or other conditions. ARDS has a mortality rate of 30-40%, with survivors often experiencing long-term pulmonary, cognitive, and psychological impairments requiring comprehensive rehabilitation 1.
From the Research
Definition and Overview of ARDS
- Acute respiratory distress syndrome (ARDS) is a leading cause of morbidity and mortality in critically ill patients, despite advancements in the field 2.
- ARDS remains a common complication associated with significant negative outcomes in critically ill patients 3.
Management Strategies for ARDS
- Lung-protective mechanical ventilation strategies are the cornerstone in the management of ARDS 2, 3.
- Mechanical ventilatory strategies, including low tidal volumes, low plateau pressures, low FiO2, and optimization of positive end-expiratory pressure (PEEP), have been shown to decrease morbidity and mortality 2.
- Other management strategies, such as prone positioning, extracorporeal membrane oxygenation, corticosteroids, and inhaled pulmonary vasodilating agents, may be considered in certain cases 3, 4.
- Individualized ventilator settings, including titration of PEEP to best respiratory system compliance, may improve patient-ventilator synchrony and reduce ventilator-induced lung injury (VILI) 4.
Therapies for Refractory Hypoxemia
- Salvage modes of ventilation, such as high frequency oscillatory ventilation and airway pressure release ventilation, may be considered in select patients with refractory hypoxemia 4.
- Adjunctive therapies, including recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, and glucocorticoids, may improve oxygenation, but do not clearly reduce mortality 4.
- Veno-venous extracorporeal membrane oxygenation (V-V ECMO) may improve gas exchange and modestly improve survival in select, refractory cases 4.
Standard of Care for Severe ARDS
- Early identification and treatment of hypoxemia is mandatory, with typical clinical determinations including arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO2/FIO2 < 100 5.
- Recommended mechanical ventilation settings include limitation of tidal volume, adequate high PEEP, and a 'balanced' respiratory rate 5.
- Prone positioning, early and prolonged, improves survival, and advanced infection management/control is essential to improve outcomes 5.