What is the role of albumin in Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

Albumin is not routinely recommended for the management of Acute Respiratory Distress Syndrome (ARDS). Current evidence does not support the use of albumin infusions as a specific therapy for improving outcomes in ARDS patients 1. When managing fluid therapy in ARDS, a conservative fluid management strategy is generally preferred over liberal fluid administration, regardless of whether crystalloids or colloids like albumin are used.

Key Considerations

• If albumin is considered in ARDS patients, it would typically be for those with hypoalbuminemia (serum albumin <3 g/dL) and should be administered as 25% albumin at 50-100 mL over 30-60 minutes, potentially repeated based on clinical response and albumin levels.
• The theoretical benefit of albumin relates to its oncotic properties that might help maintain intravascular volume while limiting pulmonary edema, and its potential anti-inflammatory and antioxidant effects.
• However, these theoretical benefits have not translated to improved mortality or other important clinical outcomes in large trials, as seen in a 2014 systematic review that found no difference in mortality when albumin was compared with crystalloid in patients with ARDS (RR, 0.89; 95% CI, 0.62-1.28) 1.
• Additionally, albumin is considerably more expensive than crystalloids and carries potential risks including allergic reactions and transmission of infectious agents, though these risks are minimal with modern preparation methods.

Clinical Decision Making

• The decision to use albumin in ARDS patients should be made on a case-by-case basis, taking into account the individual patient's clinical condition, serum albumin levels, and potential risks and benefits.
• A multidisciplinary approach, involving critical care specialists, pulmonologists, and other relevant healthcare professionals, may be helpful in making informed decisions about the use of albumin in ARDS patients.
• It is essential to weigh the potential benefits of albumin against its potential risks and costs, and to consider alternative therapies that may be more effective or safer in improving outcomes for ARDS patients.

Evidence Summary

• A 2020 systematic review and sequential network analysis of RCTs in the setting of sepsis found that albumin was not superior to crystalloids for mortality or acute kidney injury 1.
• A 2018 Cochrane review found no difference in mortality in patients in the ICU when patients managed with crystalloids were compared with those managed with albumin at the end of follow-up (RR, 0.98; 95% CI, 0.92-1.06) 1.
• The largest randomized trial, the Saline Versus Albumin Fluid Evaluation trial, found no differences in outcomes, including 28-day mortality (RR, 0.99; 95% CI, 0.91-1.09), when 4% albumin was compared with 0.9% normal saline in critically ill patients 1.

From the FDA Drug Label

Adult Respiratory Distress Syndrome (ARDS)(2,5) This is characterized by deficient oxygenation caused by pulmonary interstitial edema complicating shock and postsurgical conditions. When clinical signs are those of hypoproteinemia with a fluid volume overload, Plasbumin-25 together with a diuretic may play a role in therapy

The role of albumin in Acute Respiratory Distress Syndrome (ARDS) is to potentially play a role in therapy when clinical signs are those of hypoproteinemia with a fluid volume overload, in combination with a diuretic. 2 2

From the Research

Role of Albumin in Acute Respiratory Distress Syndrome (ARDS)

• Albumin is often used in the treatment of patients with hypoalbuminemia, which is associated with fluid overload, the development of ARDS, and mortality 3
• The co-administration of albumin and diuretics may reduce hypotensive events and improve the ratio of partial pressure arterial oxygen and fraction of inspired oxygen (P/F ratio) at 24 hours in mechanically ventilated patients with hypoalbuminemia 3
• However, the use of albumin in ARDS is not directly addressed in the provided studies, and its role in the treatment of ARDS is not clearly defined

Pathophysiology and Treatment of ARDS

• ARDS is characterized by increased lung capillary permeability, leading to alveolar flooding and hypoxemia 4, 5, 6, 7
• Treatment of ARDS is supportive and includes mechanical ventilation, prophylaxis for stress ulcers and venous thromboembolism, nutritional support, and treatment of the underlying injury 4, 5, 6, 7
• Low tidal volume and high positive end-expiratory pressure improve outcomes in ARDS patients 4, 5, 7
• Prone positioning is recommended for some moderate and all severe cases of ARDS 4, 5, 6, 7

Albumin and Hypoalbuminemia in ARDS

• Hypoalbuminemia is associated with increased mortality and morbidity in ARDS patients 3
• Albumin administration may help to improve the P/F ratio and reduce hypotensive events in mechanically ventilated patients with hypoalbuminemia 3
• However, the evidence for the use of albumin in ARDS is limited, and further studies are needed to define its role in the treatment of ARDS 3