What is the approach to Acute Respiratory Distress Syndrome (ARDS) in Chronic Lung Disease (CLD)?

From the Guidelines

The approach to Acute Respiratory Distress Syndrome (ARDS) in patients with chronic liver disease (CLD) should prioritize lung-protective ventilation strategies, with a strong recommendation for mechanical ventilation using lower tidal volumes (4–8 ml/kg predicted body weight) and lower inspiratory pressures (plateau pressure < 30 cm H2O) 1.

Key Considerations

• Start with low tidal volumes of 4-6 mL/kg predicted body weight and maintain plateau pressures below 30 cmH2O to minimize lung injury.
• Use appropriate positive end-expiratory pressure (PEEP) to optimize oxygenation while preventing alveolar collapse, typically in the range of 8-15 cmH2O.
• Prone positioning for more than 12 hours daily should be considered for patients with severe ARDS, as it has been shown to improve outcomes 1.
• Fluid management should be conservative to reduce pulmonary edema while maintaining adequate organ perfusion, which is particularly important in CLD patients who may have baseline fluid and electrolyte abnormalities.
• Neuromuscular blockade with cisatracurium may be necessary for the first 48 hours in severe cases, but its use should be balanced against the potential risks.
• Corticosteroids can be considered for persistent ARDS, but their use should be cautious in CLD due to infection risks 1.

Additional Recommendations

• Avoid excessive sedation to prevent hepatic encephalopathy, and closely monitor liver function, coagulation parameters, and ammonia levels, as respiratory failure can worsen hepatic dysfunction.
• Early consideration of extracorporeal membrane oxygenation (ECMO) may be necessary in refractory cases, though CLD presents additional challenges for ECMO candidacy due to coagulopathy risks 1.

Evidence-Based Practice

The most recent and highest quality evidence supports the use of lung-protective ventilation strategies and prone positioning in the management of ARDS in patients with CLD 1. However, the decision to use corticosteroids, neuromuscular blockade, and ECMO should be individualized based on the patient's specific clinical circumstances and the potential risks and benefits of these interventions.

From the Research

Approach to ARDS in CLD

• The approach to Acute Respiratory Distress Syndrome (ARDS) in Chronic Lung Disease (CLD) involves various strategies, including nonventilatory interventions and mechanical ventilation techniques 2.
• Nonventilatory interventions include fluid restriction, exogenous surfactant, inhaled nitric oxide, manipulation of production or administration of eicosanoids, neuromuscular blocking agents, prone position ventilation, glucocorticoids, extracorporeal membrane oxygenation, and administration of beta-agonists 2.
• Mechanical ventilation techniques, such as prone ventilation and lateral-prone ventilation, can also be used to manage ARDS patients, with lateral-prone ventilation showing promise in reducing mechanical power and mitigating the risk of ventilator-induced lung injury (VILI) 3.

Non-Invasive Ventilatory Support

• Non-invasive ventilatory support, including high-flow nasal oxygen and noninvasive ventilation, can be used as first-line treatment for acute hypoxemic respiratory failure and ARDS, especially in mild-to-moderate cases 4.
• However, in moderate-to-severe cases, noninvasive strategies may yield delayed intubation with increased mortality, and strict physiological monitoring is necessary to promptly detect the need for endotracheal intubation 4.

Management of ARDS

• The management of ARDS is largely supportive, focusing on protective mechanical ventilation and the avoidance of fluid overload 5.
• Patients with severe hypoxaemia can be managed with early short-term use of neuromuscular blockade, prone position ventilation, or extracorporeal membrane oxygenation, while inhaled nitric oxide, β2 agonists, and late corticosteroids should be avoided 5.
• The strategic focus has shifted to identifying potential or high-risk ARDS patients during the early stages of the disease and implementing treatment strategies aimed at reducing ARDS and related organ failure 6.