What are the most notable studies on Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

The most notable studies on Acute Respiratory Distress Syndrome (ARDS) include the PROSEVA trial, which demonstrated that prone positioning for severe ARDS reduces mortality, as well as other landmark studies that have shaped modern ARDS management. The PROSEVA trial 1 is the most recent and highest quality study, and it showed that prone positioning for severe ARDS (P/F ratio <150) for at least 16 hours daily reduced mortality from 33% to 16%. Some key points to consider when managing ARDS include:

• The use of low tidal volume ventilation, as established by the ARMA trial, which reduces mortality from 40% to 31% 1
• The application of sufficient PEEP, which can help minimize the risks of ventilator-induced lung injury (VILI) 1
• The use of prone positioning, which can improve oxygenation, lung recruitment, and stress distribution, and should be considered in the early phase of ARDS in patients with PaO2/FiO2 < 150 mmHg 1
• The consideration of neuromuscular blockade and ECMO in appropriate patients, as suggested by the ACURASYS and EOLIA trials, respectively 1
• The importance of judicious fluid management, as demonstrated by the FACTT trial, which improved lung function and shortened mechanical ventilation duration 1 It is essential to note that the management of ARDS should be individualized and based on the patient's specific needs and circumstances. The PROSEVA trial 1 provides the most recent and highest quality evidence for the use of prone positioning in severe ARDS, and its findings should be prioritized when making clinical decisions. In terms of specific recommendations, prone positioning should be considered in the early phase of ARDS in patients with PaO2/FiO2 < 150 mmHg, and should be applied for 16–20 hours per day, as suggested by the PROSEVA trial 1. Additionally, low tidal volume ventilation, sufficient PEEP, and judicious fluid management should be used in all patients with ARDS, as established by the ARMA, ALVEOLI, and FACTT trials, respectively 1. Overall, the management of ARDS requires a comprehensive and individualized approach, and should be based on the most recent and highest quality evidence available.

From the Research

Notable Studies on Acute Respiratory Distress Syndrome (ARDS)

• The study published in F1000Research in 2018 2 discusses recent advances in understanding and treating ARDS, including the Berlin definition of ARDS, epidemiological data from the LUNG-SAFE study, and the investigation of two distinct phenotypes of ARDS.
• A study published in the Annals of translational medicine in 2017 3 examines the use of prone positioning in ARDS patients, demonstrating its capability to improve oxygenation and prevent ventilator-induced lung injury.
• The SAGE-ANZ study published in Critical care and resuscitation in 2024 4 describes the characteristics and management of adult patients with moderate-severe ARDS in Australia and New Zealand, highlighting the low compliance with evidence-based practices such as lung protective ventilation and prone positioning.
• A synopsis of clinical ARDS published in Advances in experimental medicine and biology in 2021 5 discusses the history, clinical picture, and therapeutic approaches to ARDS, including lung-protective ventilation, prone positioning, and neuromuscular blockade.
• A narrative review published in the Journal of clinical medicine research in 2012 6 covers the pathophysiology and therapeutic options for ARDS, including refinements of mechanical ventilatory support, prone position, and supportive measures such as attention to fluid balance and minimization of sedatives.

Key Findings

• The Berlin definition of ARDS has replaced the American-European Consensus Conference definition 2.
• Prone positioning has been shown to improve oxygenation and prevent ventilator-induced lung injury in ARDS patients 3.
• Lung protective ventilation and prone positioning are not routinely employed in Australia and New Zealand, despite their proven benefits 4.
• No specific drug therapy is available for ARDS, and the mainstay of medical management is supportive with specific strategies for mechanical ventilation 5.
• Recent developments in therapeutic approaches to ARDS include refinements of mechanical ventilatory support and supportive measures such as attention to fluid balance and minimization of sedatives 6.

Therapeutic Options

• Lung-protective ventilation remains the predominant mainstay of ventilatory strategy in ARDS 2.
• Prone positioning has demonstrated mortality benefit and is recommended for use in severe ARDS patients 3, 4.
• Neuromuscular blockade has also demonstrated mortality benefit and is recommended for use in ARDS patients 2, 5.
• Corticosteroids may reduce mortality in ARDS patients, but their use is not universally recommended 6.
• Extracorporeal membrane oxygenation and other extracorporeal therapies may be useful as rescue therapy in patients with intractable hypoxemia 2, 6.