What are the implications of Acute Respiratory Distress Syndrome (ARDS) in a patient with Chronic Lung Disease (CLD)?

From the Guidelines

ARDS in a CLD patient should be managed with lung-protective ventilation strategies, including low tidal volumes and plateau pressures below 30 cmH2O, as recommended by the American Thoracic Society and supported by recent guidelines 1. The management of Acute Respiratory Distress Syndrome (ARDS) in patients with chronic liver disease (CLD) is complex and requires careful consideration of the interplay between these two conditions. Key aspects of management include:

• Lung-protective ventilation with low tidal volumes (4-6 mL/kg predicted body weight) and plateau pressures below 30 cmH2O to prevent further lung injury, as emphasized in the American Thoracic Society guidelines 1
• Prone positioning for 12-16 hours daily for moderate to severe ARDS, which has been shown to improve outcomes in ARDS patients
• Conservative fluid management to prevent worsening edema while maintaining adequate organ perfusion, taking into account the compromised hepatic function in CLD patients
• Avoiding hepatotoxic medications and closely monitoring coagulation parameters due to potential bleeding risks, with adjustments made for hepatic clearance of medications
• Short-term use of neuromuscular blocking agents like cisatracurium for severe cases to improve ventilator synchrony, as recommended by expert opinion 1
• Addressing the underlying cause of ARDS, whether it's sepsis, pneumonia, or other triggers, and optimizing nutritional support with attention to protein requirements while avoiding overfeeding. Given the significantly higher mortality risk when ARDS occurs in CLD patients due to compromised hepatic function affecting multiple organ systems, early intervention and multidisciplinary management are critical for improving outcomes, as highlighted in recent clinical practice guidelines 1.

From the Research

ARDS in CLD Patient

• Acute Respiratory Distress Syndrome (ARDS) is a rapidly progressing, inflammatory lung disease with a high mortality rate and no specific pharmacological treatment available 2.
• The management of the ventilator in patients with ARDS has a dramatic effect on the overall outcome, and evidence-based interventions have been shown to improve outcomes 3.
• Different prone ventilation strategies may have varying effects on mechanical power and respiratory mechanics in ARDS patients, and the early adoption of lateral-prone ventilation may help mitigate the risk of ventilator-induced lung injury (VILI) 4.

Treatment Options

• Extracorporeal membrane oxygenation (ECMO) can provide a safe and effective alternative to lung-protective mechanical ventilation in carefully selected patients with severe ARDS 5.
• Corticosteroids may potentially improve mortality, shorten ventilation times, and increase the number of ventilator-free days in patients with ARDS, although the quality of included studies ranged from critically low to high, demonstrating inconsistency in risk of bias 6, 2.
• The effect of corticosteroids on mortality was observed to be still inconsistent, whereas significant improvement was observed with ICU and ventilator outcomes compared with the control group 6.

Ventilator Strategies

• Prone ventilation and lateral-prone ventilation are two different strategies that may have varying effects on mechanical power and respiratory mechanics in ARDS patients 4.
• The use of ECMO can facilitate participation in physical therapy and avoid complications associated with mechanical ventilation 5.
• Ventilator strategies for ARDS patients should be evidence-based and tailored to the individual patient's needs to improve outcomes 3.