What is the treatment for Acute Respiratory Distress Syndrome (ARDS)?

Treatment of Acute Respiratory Distress Syndrome (ARDS)

The cornerstone treatment for ARDS is lung-protective mechanical ventilation with low tidal volumes (4-8 mL/kg predicted body weight) and limited plateau pressures (<30 cmH2O), supplemented by prone positioning for severe cases, and consideration of corticosteroids, neuromuscular blockade, and ECMO in selected patients. 1

Ventilation Strategy

Primary Ventilation Approach

• 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
• Target driving pressure (plateau pressure minus PEEP) minimization, as this is independently associated with survival 3
• Use higher PEEP without prolonged lung recruitment maneuvers in moderate to severe ARDS (PaO2/FiO2 <200 mmHg) 1, 4
• Avoid prolonged lung recruitment maneuvers in moderate to severe ARDS 1, 5
• Avoid routine use of high-frequency oscillatory ventilation in moderate or severe ARDS 1

Positioning Therapy

• Implement prone positioning for >12 hours daily in severe ARDS (PaO2/FiO2 <100 mmHg) 1, 4
• Ensure proper technique and team training for prone positioning to prevent complications 2

Adjunctive Therapies

Pharmacological Interventions

• Consider systemic corticosteroids for ARDS (conditional recommendation, moderate certainty of evidence) 1, 4
• Consider neuromuscular blocking agents in early severe ARDS to improve ventilator synchrony and reduce oxygen consumption (conditional recommendation, low certainty of evidence) 1, 4
• Avoid routine use of inhaled nitric oxide as it has not shown mortality benefit in adult ARDS 6

Advanced Support for Refractory Cases

• Consider venovenous extracorporeal membrane oxygenation (VV-ECMO) in selected patients with severe ARDS who fail conventional management (conditional recommendation, low certainty of evidence) 1, 7
• When using ECMO, maintain lower plateau pressures as each 1 cmH2O increase is associated with 21% decrease in hospital survival odds 7

Fluid Management

• Implement a conservative fluid management strategy to minimize pulmonary edema while maintaining adequate organ perfusion 1, 5
• Avoid fluid overload, which can worsen pulmonary edema and outcomes 2, 5

Monitoring Requirements

• Continuously monitor oxygen saturation, respiratory mechanics (plateau pressure, driving pressure, compliance), and hemodynamics 4, 3
• Use echocardiography to assess right ventricular function and detect acute cor pulmonale in severe cases 4, 5
• Reclassify ARDS severity daily, as improvement within the first 24 hours may indicate a more favorable phenotype 1

Common Pitfalls to Avoid

• Underutilization of evidence-based strategies like prone positioning and lung-protective ventilation 2
• Excessive fluid administration worsening pulmonary edema and outcomes 2, 5
• Delaying prone positioning in severe ARDS 2
• Using excessive PEEP without monitoring its effect on hemodynamics and driving pressure 7
• Failing to recognize improvement or deterioration in the first 24-48 hours, which significantly impacts prognosis 1

Treatment Algorithm Based on ARDS Severity

Mild ARDS (PaO2/FiO2 200-300 mmHg)

• Lung-protective ventilation (4-8 mL/kg PBW, plateau pressure <30 cmH2O) 1
• Consider conservative fluid management 5
• Consider corticosteroids 1

Moderate ARDS (PaO2/FiO2 100-200 mmHg)

• Lung-protective ventilation (4-8 mL/kg PBW, plateau pressure <30 cmH2O) 1
• Higher PEEP strategy without prolonged recruitment maneuvers 1
• Conservative fluid management 5
• Consider corticosteroids 1
• Consider neuromuscular blockade if patient-ventilator dyssynchrony 1

Severe ARDS (PaO2/FiO2 <100 mmHg)

• Lung-protective ventilation (4-8 mL/kg PBW, plateau pressure <30 cmH2O) 1
• Higher PEEP strategy without prolonged recruitment maneuvers 1
• Prone positioning for >12 hours daily 1
• Consider neuromuscular blockade 1
• Consider corticosteroids 1
• Consider VV-ECMO if refractory hypoxemia persists despite optimal conventional therapy 1, 7

The evidence for lung-protective ventilation is particularly strong, based on landmark studies showing a 9% absolute mortality reduction when using low tidal volumes compared to traditional ventilation 8. Recent guidelines continue to emphasize this approach while adding evidence for adjunctive therapies like prone positioning, which has demonstrated mortality benefits in severe ARDS 1.