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

From the Guidelines

Management of Acute Respiratory Distress Syndrome (ARDS) should prioritize lung-protective ventilation strategies, including low tidal volume ventilation and optimized positive end-expiratory pressure (PEEP), as well as supportive care, with consideration of corticosteroids, venovenous extracorporeal membrane oxygenation, and neuromuscular blockers in selected patients, as recommended by the most recent guidelines 1. The cornerstone of ARDS management is low tidal volume ventilation using 4-6 mL/kg of predicted body weight, with plateau pressures maintained below 30 cmH2O to prevent ventilator-induced lung injury.

• Key considerations in ARDS management include:
  • Optimized PEEP, typically starting at 8-10 cmH2O and titrated based on oxygenation response and hemodynamic tolerance
  • Prone positioning for 12-16 hours daily in patients with moderate-to-severe ARDS (PaO2/FiO2 < 150) to improve ventilation-perfusion matching and reduce mortality
  • Conservative fluid management to minimize pulmonary edema while maintaining adequate organ perfusion
  • Use of neuromuscular blocking agents, such as cisatracurium, in the first 48 hours in severe cases to improve ventilator synchrony
  • Rescue therapies for refractory hypoxemia, including inhaled nitric oxide, recruitment maneuvers, and extracorporeal membrane oxygenation (ECMO) in specialized centers
  • Consideration of corticosteroids, particularly in COVID-19 related ARDS, as suggested by recent guidelines 1 Treating the underlying cause of ARDS, whether pneumonia, sepsis, trauma, or other conditions, is essential for recovery, and individual patient and illness characteristics should be factored into clinical decision making, as emphasized in the latest American Thoracic Society clinical practice guideline 1.

From the Research

Management Strategies for ARDS

• Lung-protective mechanical ventilation strategies are the cornerstone in the management of ARDS 2
• Several therapeutic options are available, including fluid management, neuromuscular blocking agents, prone positioning, extracorporeal membrane oxygenation, corticosteroids, and inhaled pulmonary vasodilating agents (prostacyclins and nitric oxide) 2
• Combining low tidal volume with prone ventilation is associated with the greatest reduction in mortality for critically ill adults with moderate-to-severe ARDS 3

Ventilation Strategies

• Low tidal volume (Vt) is recommended as the best strategy for ARDS management 3
• High positive end-expiratory pressure (PEEP) combined with low Vt is rated intermediately 3
• High Vt is rated worst and is associated with increased mortality 3
• Venovenous extracorporeal membrane oxygenation (VV ECMO) is also rated among the best strategies, but with lower certainty due to its restriction to very severe ARDS 3

Precision Medicine in ARDS

• Lung-protective ventilation strategies need to take an innovative approach that accounts for the heterogeneity of injured lungs 4
• Precision medicine can be implemented in the field of ARDS by individualizing PEEP with esophageal balloon manometry, lung recruitability, and electrical impedance tomography 4
• Adjunctive therapies, such as recruitment maneuvers, inhaled pulmonary vasodilators, neuromuscular blockers, or glucocorticoids, may improve oxygenation, but do not clearly reduce mortality 5

Future Directions

• Future studies are needed to identify ARDS subgroups to individualize therapies and advance care 5
• Ongoing research may suggest interventions to improve the outcome of ARDS and of critical illness in general 6
• The role of corticosteroids in the late phase of ARDS is unclear and remains a very important unanswered question 6