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

Management Strategies for Acute Respiratory Distress Syndrome (ARDS)

The cornerstone of ARDS management is lung-protective ventilation with low tidal volumes (4-8 mL/kg predicted body weight) and limited plateau pressures (<30 cmH2O), supplemented by higher PEEP, prone positioning for severe cases, and adjunctive therapies including corticosteroids, neuromuscular blockade, and VV-ECMO for selected patients with refractory hypoxemia. 1

Initial Management: Ventilation Strategy

• Implement lung-protective ventilation for all ARDS patients:

  • Use low tidal volumes (4-8 mL/kg predicted body weight) 1, 2
  • Limit plateau pressure to <30 cmH2O 2, 3
  • Target oxygen saturation 88-95% 3
  • Monitor driving pressure and mechanical power to minimize ventilator-induced lung injury 4

• Apply higher PEEP without prolonged lung recruitment maneuvers in moderate to severe ARDS (conditional recommendation, low to moderate certainty) 1

  • Avoid prolonged lung recruitment maneuvers (strong recommendation, moderate certainty) 1
  • PEEP should be titrated to optimize alveolar recruitment while avoiding overdistention 5

Adjunctive Therapies Based on ARDS Severity

For Moderate to Severe ARDS (PaO₂/FiO₂ <200 mmHg):

• Implement prone positioning for >12 hours daily (strong recommendation) 2, 6

  • Most beneficial in severe ARDS (PaO₂/FiO₂ <100 mmHg) 3
  • Should be initiated early in the course of ARDS 2

• Consider systemic corticosteroids (conditional recommendation, moderate certainty of evidence) 1

  • Most effective when initiated within the first 14 days of ARDS 2

For Severe ARDS (PaO₂/FiO₂ <100 mmHg):

• Consider neuromuscular blocking agents in early severe ARDS (conditional recommendation, low certainty of evidence) 1

  • Improves ventilator synchrony and reduces oxygen consumption 6
  • Most beneficial in the first 48 hours 3

• Consider VV-ECMO for selected patients with severe ARDS who fail conventional therapy (conditional recommendation, low certainty of evidence) 1

  • Should be performed at experienced centers 2
  • Consider when patients fail to improve despite optimal conventional therapy 4

Fluid Management and Supportive Care

• Implement conservative fluid management strategy to reduce pulmonary edema while maintaining adequate organ perfusion 2, 3

• Provide appropriate nutritional support 7

• Implement prophylaxis for:

  • Stress ulcers 7
  • Venous thromboembolism 7

Monitoring and Assessment

• Classify ARDS severity based on PaO₂/FiO₂ ratio: 2

  • Mild: 200-300 mmHg
  • Moderate: 100-200 mmHg
  • Severe: <100 mmHg

• Monitor for complications:

  • Ventilator-induced lung injury 4
  • Acute cor pulmonale 6, 4
  • Physical debility and neurocognitive deficits 4

• As patient improves, conduct daily spontaneous breathing trials to assess readiness for ventilator weaning 2, 7

Important Caveats and Pitfalls

• Inhaled nitric oxide is ineffective in adult ARDS and should not be routinely used 8

• High frequency oscillatory ventilation is not recommended for ARDS 6, 3

• Delaying prone positioning in severe ARDS may miss the window of opportunity for this effective intervention 2

• Initiating corticosteroids too late (>2 weeks after ARDS onset) may be harmful 2

• Excessive fluid administration can worsen oxygenation and outcomes 6

• Underutilization of evidence-based strategies is associated with increased mortality 2

• Noninvasive ventilation has a high failure rate in moderate to severe ARDS; close monitoring for deterioration is crucial 6