What is the treatment for Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

The treatment for Acute Respiratory Distress Syndrome (ARDS) should prioritize lung-protective mechanical ventilation with low tidal volumes and limited plateau pressures, as well as the use of positive end-expiratory pressure (PEEP) and prone positioning, as recommended by the most recent guidelines 1. The cornerstone of management is supportive care while addressing the underlying cause, with a focus on minimizing ventilator-induced lung injury.

• Low tidal volumes (4–8 mL/kg predicted body weight) and inspiratory pressures should be used, as recommended by the 2024 guideline 1.
• Positive end-expiratory pressure (PEEP) should be applied, typically starting at 5-10 cmH2O and titrated based on oxygenation response, with higher PEEP suggested for patients with moderate to severe ARDS without lung recruitment maneuvers (LRMs) 1.
• Prone positioning for 12-16 hours daily is recommended for patients with moderate-to-severe ARDS (PaO2/FiO2 < 150) as it improves ventilation-perfusion matching, as supported by earlier studies 1.
• Conservative fluid management is crucial to minimize pulmonary edema while maintaining adequate organ perfusion.
• Neuromuscular blocking agents like cisatracurium may be used for 48 hours in severe cases to improve ventilator synchrony, as suggested by the 2024 guideline 1.
• Sedation with propofol, dexmedetomidine, or benzodiazepines is typically required.
• Corticosteroids (methylprednisolone 1-2 mg/kg/day) may be considered in persistent ARDS, though their use remains controversial, with a suggestion for their use in the 2024 guideline 1.
• Rescue therapies for refractory hypoxemia include inhaled nitric oxide, extracorporeal membrane oxygenation (ECMO), and high-frequency oscillatory ventilation, with venovenous ECMO suggested for selected patients with severe ARDS 1.
• Nutritional support, stress ulcer prophylaxis, and venous thromboembolism prevention are essential components of comprehensive care, as emphasized in various studies 1.

From the Research

Treatment Overview

The treatment for Acute Respiratory Distress Syndrome (ARDS) involves several strategies, including:

• Lung-protective mechanical ventilation strategies, which remain the cornerstone in the management of ARDS 2
• Fluid management, to prevent excessive fluid accumulation in the lungs
• Neuromuscular blocking agents, to facilitate mechanical ventilation
• Prone positioning, to improve oxygenation and reduce mortality 3, 4
• Extracorporeal membrane oxygenation (ECMO), to support gas exchange in severe cases 3, 4
• Corticosteroids, to reduce inflammation
• Inhaled pulmonary vasodilating agents, such as prostacyclins and nitric oxide, to improve oxygenation 2

Ventilator Settings

The optimal ventilator settings for ARDS patients include:

• Tidal volume of 4-8 ml/kg predicted body weight, to prevent volutrauma 5, 6
• Plateau pressure <30 cmH2O, to prevent lung injury 5
• Positive end-expiratory pressure (PEEP) ≥5 cmH2O, to prevent atelectasis 5
• Respiratory rate of 20-35 breaths per minute, to maintain adequate ventilation 5
• Inspired oxygen concentration titrated to peripheral oxygen saturation (SpO2) levels of 88-95%, to prevent hyperoxia 5

Adjunctive Therapies

Adjunctive therapies that may be used in the management of ARDS include:

• Recruitment maneuvers, to improve lung recruitment and oxygenation 3
• Inhaled pulmonary vasodilators, to improve oxygenation 2, 3
• Neuromuscular blockers, to facilitate mechanical ventilation 5, 3
• Glucocorticoids, to reduce inflammation 3
• Conservative fluid management, to prevent excessive fluid accumulation in the lungs 4

Individualized Approach

The management of ARDS should be individualized, taking into account the patient's specific needs and response to treatment 3. The use of advanced methods, such as electrical impedance tomography or esophageal manometry, may help to optimize ventilator settings and improve patient outcomes 3.