What are the management strategies for Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

Management of Acute Respiratory Distress Syndrome (ARDS) requires a lung-protective ventilation strategy as the cornerstone of treatment, with the most recent and highest quality evidence recommending the use of low tidal volumes, optimized PEEP, and prone positioning for patients with moderate to severe ARDS 1. The management strategies for ARDS include:

• Ventilating patients with low tidal volumes of 4-6 mL/kg of predicted body weight and plateau pressures kept below 30 cmH2O to prevent ventilator-induced lung injury 1
• Optimizing PEEP, typically starting at 8-10 cmH2O and titrated based on oxygenation response and hemodynamic tolerance 1
• Prone positioning for 16+ hours daily is recommended for patients with moderate-to-severe ARDS (PaO2/FiO2 < 150) as it improves ventilation-perfusion matching and mortality 1
• Conservative fluid management should be implemented once hemodynamic stability is achieved to reduce pulmonary edema 1
• Neuromuscular blockade with cisatracurium may be considered for 48 hours in severe cases with PaO2/FiO2 < 120 to improve ventilator synchrony 1
• Rescue therapies for refractory hypoxemia include inhaled nitric oxide, recruitment maneuvers, and consideration of ECMO in specialized centers 1
• Corticosteroids may be beneficial, particularly in COVID-19 related ARDS 1
• Treating the underlying cause of ARDS is essential, including appropriate antibiotics for pneumonia, source control for sepsis, or other specific interventions based on etiology
• Supportive care includes DVT prophylaxis, stress ulcer prevention, nutritional support, and glycemic control to prevent complications during the recovery phase

The most recent and highest quality evidence supports the use of corticosteroids, venovenous extracorporeal membrane oxygenation, and neuromuscular blockers in selected patients with ARDS 1. Key considerations in the management of ARDS include:

• Early recognition and diagnosis of ARDS
• Implementation of lung-protective ventilation strategies
• Optimization of PEEP and prone positioning
• Conservative fluid management
• Consideration of rescue therapies for refractory hypoxemia
• Treatment of the underlying cause of ARDS
• Supportive care to prevent complications during the recovery phase

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 management strategies for Acute Respiratory Distress Syndrome (ARDS) are not directly supported by the use of nitric oxide (INH), as it has been shown to be ineffective in improving outcomes in adult patients with ARDS 2.

• The study found no effect of INOmax on the primary endpoint of days alive and off ventilator support.
• INOmax is not indicated for use in ARDS.

From the Research

Management Strategies for Acute Respiratory Distress Syndrome (ARDS)

The management of ARDS involves several strategies to improve oxygenation and prevent ventilator-induced lung injury (VILI). Some of the key strategies include:

• Using low tidal volumes (6 ml/kg predicted body weight) and keeping the end-inspiratory airway pressure below 30 cm H(2)O to prevent VILI 3
• Recruiting non-aerated or poorly aerated lung areas and keeping them recruited, although this strategy may require higher alveolar pressures and can lead to hemodynamic impairment 3
• Utilizing low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals 4
• Optimizing positive end-expiratory pressure (PEEP) to maintain or improve lung recruitment 4
• Using prone ventilation to decrease morbidity and mortality 4

Mechanical Ventilatory Strategies

Mechanical ventilatory strategies are a vital component of ARDS management. Some of the strategies that have been shown to be effective include:

• Low tidal volume ventilation (6 ml/kg predicted body weight) 5, 6
• Low plateau pressure ventilation (<30 cm H(2)O) 5, 6
• Daily assessment with spontaneous breathing trial to liberate patients from mechanical ventilation in a timely manner 5
• Prevention of volutrauma, atelectasis, and hyperoxia 6
• Use of extracorporeal CO2 removal to allow for very low tidal volume ventilation (≈3 ml/kg) 7

Ventilatory Adjuncts

Ventilatory adjuncts, such as non-invasive ventilation, recruitment maneuvers, and esophageal pressure monitoring, may also be used in the management of ARDS. However, the role of these adjuncts is not yet clear 4.