Treatment of Acute Respiratory Distress Syndrome (ARDS)
The cornerstone of ARDS treatment is lung-protective mechanical ventilation using low tidal volumes (4-8 mL/kg predicted body weight) and limiting plateau pressures (<30 cmH₂O), with prone positioning for >12 hours daily in severe ARDS cases. 1, 2
Ventilation Strategy
- Implement lung-protective ventilation with low tidal volumes (4-8 mL/kg predicted body weight) and limit plateau pressures (<30 cmH₂O) to prevent ventilator-induced lung injury 1, 2, 3
- Use higher PEEP without prolonged lung recruitment maneuvers in moderate to severe ARDS (PaO₂/FiO₂ <200 mmHg) 2, 4
- Avoid routine use of high-frequency oscillatory ventilation in moderate or severe ARDS 1
- Consider recruitment maneuvers in moderate to severe ARDS, but avoid prolonged maneuvers 1, 2
- Maintain SpO₂ no higher than 96% to avoid oxygen toxicity 2, 5
- Consider high-flow nasal cannula (HFNC) over conventional oxygen therapy before proceeding to invasive ventilation in milder cases 2, 6
Positioning and Adjunctive Therapies
- Implement prone positioning for >12 hours daily in severe ARDS (PaO₂/FiO₂ <100 mmHg) 1, 2
- Consider neuromuscular blocking agents (NMBAs) in early severe ARDS to improve ventilator synchrony and reduce oxygen consumption 2, 4
- Administer systemic corticosteroids for ARDS, which has shown mortality benefit 2, 7
- Avoid routine use of inhaled nitric oxide as it has not demonstrated mortality benefit in adult ARDS 2, 8
Fluid Management
- Implement a conservative fluid management strategy to minimize pulmonary edema while maintaining adequate organ perfusion 2, 7
- Avoid fluid overload, which can worsen pulmonary edema and promote right ventricular failure 2, 9
Advanced Support for Refractory Cases
- Consider venovenous extracorporeal membrane oxygenation (VV-ECMO) in selected patients with severe ARDS (PaO₂/FiO₂ <100 mmHg) who fail conventional management 2, 4
- Consider a trial of inhaled pulmonary vasodilator as rescue therapy for severe hypoxemia despite optimized ventilation; discontinue if no rapid improvement in oxygenation 2, 7
Monitoring Requirements
- Continuously monitor oxygen saturation, respiratory mechanics (compliance, driving pressure), and hemodynamics 2, 5
- Use echocardiography to assess right ventricular function and detect acute cor pulmonale in severe cases 2, 7
- Closely monitor for worsening respiratory status in patients receiving non-invasive ventilation or HFNC, with early intubation in a controlled setting if deterioration occurs 2, 6
Common Pitfalls to Avoid
- Underutilization of evidence-based strategies like prone positioning and lung-protective ventilation 2, 10
- Excessive fluid administration worsening pulmonary edema and outcomes 2, 7
- Delaying prone positioning in severe ARDS 2, 9
- Using high tidal volumes (>8 mL/kg) which increase mortality 3, 10
- Failing to recognize deterioration in patients on non-invasive support, leading to emergent rather than controlled intubation 2, 6