What are the treatment options for Acute Respiratory Distress Syndrome (ARDS) in a patient on mechanical ventilation (vent)?

From the Guidelines

For a patient with Acute Respiratory Distress Syndrome (ARDS) on mechanical ventilation, the primary treatment should focus on lung-protective ventilation strategies, including the use of higher positive end-expiratory pressure (PEEP) without lung recruitment maneuvers (LRMs) and consideration of corticosteroids, as suggested by the most recent guidelines 1. The treatment options for ARDS in a patient on mechanical ventilation include:

• Using mechanical ventilation strategies that limit tidal volume (4–8 mL/kg predicted body weight) and inspiratory pressures, as recommended by the American Thoracic Society guideline 1
• Considering the use of corticosteroids for patients with ARDS, as suggested by the guideline 1
• Using higher PEEP without LRMs as opposed to lower PEEP in patients with moderate to severe ARDS, as conditionally recommended by the guideline 1
• Considering the use of venovenous extracorporeal membrane oxygenation (VV-ECMO) in selected patients with severe ARDS, as conditionally recommended by the guideline 1
• Using neuromuscular blockers in patients with early severe ARDS, as conditionally recommended by the guideline 1 The goal of these strategies is to minimize ventilator-induced lung injury, improve oxygenation, and support the patient while allowing time for lung healing. Key considerations include:
• Maintaining plateau pressures <30 cm H2O
• Targeting SpO2 88-95% or PaO2 55-80 mmHg
• Considering prone positioning for 12-16 hours daily if PaO2/FiO2 ratio <150
• Using a conservative fluid management strategy
• Providing adequate nutrition, stress ulcer prophylaxis, and DVT prophylaxis
• Treating the underlying cause of ARDS, such as pneumonia with antibiotics. The use of higher PEEP and consideration of corticosteroids, as suggested by the most recent guidelines 1, should be prioritized in the treatment of ARDS in patients on mechanical ventilation.

From the FDA Drug Label

In a randomized, double-blind, parallel, multicenter study, 385 patients with adult respiratory distress syndrome (ARDS) associated with pneumonia (46%), surgery (33%), multiple trauma (26%), aspiration (23%), pulmonary contusion (18%), and other causes, with PaO2/FiO2 <250 mm Hg despite optimal oxygenation and ventilation, received placebo (n=193) or INOmax (n=192), 5 ppm, for 4 hours to 28 days or until weaned because of improvements in oxygenation. Despite acute improvements in oxygenation, there was no effect of INOmax on the primary endpoint of days alive and off ventilator support. INOmax is not indicated for use in ARDS.

The treatment options for Acute Respiratory Distress Syndrome (ARDS) in a patient on mechanical ventilation are not specified in the provided drug label for nitric oxide (INH) 2, as the label states that INOmax is not indicated for use in ARDS.

From the Research

Treatment Options for Acute Respiratory Distress Syndrome (ARDS)

The treatment options for ARDS in patients on mechanical ventilation include:

• Mechanical ventilatory strategies such as low tidal volumes, low plateau pressures, low FiO2, and optimization of positive end-expiratory pressure (PEEP) to prevent secondary lung injury and improve patient outcomes 3
• Protective ARDS mechanical ventilation strategies with low tidal volumes to reduce mortality, and driving pressure as a parameter to optimize tidal volume 4
• Prone position ventilation, high frequency oscillatory ventilation, and extracorporeal membrane oxygenation as salvage treatments for refractory hypoxemia 4, 5
• Maintenance of spontaneous breathing via assisted ventilation modes such as bilevel positive airway pressure, pressure support ventilation, and neurally adjusted ventilation assist 4
• Limitation of tidal volume (6 ml/kg predicted body weight), adequate high PEEP (>12 cmH2O), recruitment maneuvers, and balanced respiratory rate (20-30/min) for mechanical ventilation 5
• Individualized PEEP and recruitment strategies, such as transpulmonary pressure, to guide PEEP and recruitment 5
• Early identification and treatment of hypoxemia, infection control, and supportive measures such as neuromuscular blockage and sedation strategy to improve survival 5

Ventilatory Settings

Recommended ventilatory settings for ARDS patients include:

• Low tidal volumes (6 ml/kg predicted body weight) 3, 4, 5, 6
• Low plateau pressures (< 30 cmH2O) 3, 6
• Low FiO2 to prevent injury related to oxygen free radicals 3
• Optimization of PEEP to maintain or improve lung recruitment 3, 4, 5
• High PEEP (>12 cmH2O) for severe ARDS 5
• Balanced respiratory rate (20-30/min) 5

Rescue Therapies

Rescue therapies for refractory hypoxemia in ARDS patients include:

• Prone position ventilation 4, 5
• High frequency oscillatory ventilation 4
• Extracorporeal membrane oxygenation 4, 5