What is the management of Acute Respiratory Distress Syndrome (ARDS)?

Management of 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), limiting plateau pressure (<30 cmH2O), and using higher PEEP in moderate to severe cases, along with adjunctive therapies including prone positioning, neuromuscular blockers, and corticosteroids based on ARDS severity. 1, 2, 3

Ventilation Strategy

• Use low tidal volume ventilation (4-8 ml/kg predicted body weight) with plateau pressure ≤30 cmH2O to prevent ventilator-induced lung injury 1, 3
• Apply higher PEEP without prolonged lung recruitment maneuvers in moderate to severe ARDS (PaO₂/FiO₂ <200 mmHg) 1, 2
• Avoid prolonged lung recruitment maneuvers in moderate to severe ARDS as they may increase mortality 1, 4
• Target driving pressure (plateau pressure minus PEEP) minimization to reduce ventilator-induced lung injury 5
• Monitor respiratory system compliance, driving pressure, and plateau pressure regularly 3

Positioning Therapy

• Implement prone positioning for >12 hours daily in severe ARDS (PaO₂/FiO₂ <100 mmHg), which has been shown to improve survival 1, 2, 3
• Consider early implementation of prone positioning (within 48 hours of ARDS onset) for maximum benefit 6
• Ensure proper technique and monitoring during prone positioning to prevent complications 3

Pharmacological Interventions

• Consider neuromuscular blocking agents (e.g., cisatracurium) in early severe ARDS for 48 hours to improve ventilator synchrony and reduce oxygen consumption 1, 2, 7
• Use corticosteroids in ARDS patients as they may improve outcomes (conditional recommendation with moderate certainty of evidence) 1, 4
• Implement conservative fluid management strategy to minimize pulmonary edema while ensuring adequate organ perfusion 3, 6
• Provide prophylaxis for stress ulcers and venous thromboembolism 8

Advanced Rescue Therapies

• Consider venovenous extracorporeal membrane oxygenation (VV-ECMO) in selected patients with severe ARDS who fail conventional therapy 1, 3, 5
• Consider inhaled pulmonary vasodilators as a temporary rescue measure for refractory hypoxemia, though they have not been shown to reduce mortality 5, 9
• Avoid high-frequency oscillatory ventilation in moderate to severe ARDS 3, 9

Monitoring and Supportive Care

• Classify ARDS severity based on PaO₂/FiO₂ ratio: mild (200-300 mmHg), moderate (100-200 mmHg), or severe (<100 mmHg) 4, 8
• Provide adequate nutritional support to prevent malnutrition and support recovery 4, 8
• Implement sedation protocols using validated scales to minimize oversedation, particularly when using neuromuscular blockade 7
• Monitor for and treat the underlying cause of ARDS (e.g., pneumonia, sepsis, trauma) 8, 6

Liberation from Mechanical Ventilation

• Perform daily spontaneous breathing trials as the patient's condition improves to assess readiness for ventilator weaning 1
• Consider tracheostomy when prolonged mechanical ventilation is anticipated 1
• Implement post-extubation noninvasive ventilation in high-risk patients to reduce ICU length of stay 1

Common Pitfalls to Avoid

• Avoid excessive fluid administration which can worsen pulmonary edema and outcomes 3, 6
• Avoid delaying prone positioning in severe ARDS 4, 6
• Avoid underutilization of evidence-based strategies like lung-protective ventilation and prone positioning 4, 9
• Recognize that ARDS survivors are at risk for decreased functional capacity, mental illness, and reduced quality of life, requiring ongoing care 8