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

Immediate Treatment for Acute Respiratory Distress Syndrome (ARDS)

The immediate treatment for ARDS should focus on lung-protective mechanical ventilation with low tidal volumes (4-8 mL/kg predicted body weight) and limiting plateau pressures (<30 cmH2O), which is strongly recommended as the cornerstone of management to reduce mortality. 1

Initial Ventilation Strategy

• Implement lung-protective ventilation with:

  • Low tidal volumes: 4-8 mL/kg predicted body weight 1, 2
  • Plateau pressure limit: <30 cmH2O 1
  • Higher PEEP (>12 cmH2O) for moderate to severe ARDS (PaO₂/FiO₂ <200 mmHg) 2, 3
  • Avoid routine use of high-frequency oscillatory ventilation (HFOV) as it may be harmful 1
  • Consider recruitment maneuvers in moderate to severe ARDS, but avoid prolonged maneuvers 1, 2

• Oxygenation targets:

  • Maintain SpO₂ no higher than 96% to avoid oxygen toxicity 2
  • Consider high-flow nasal cannula (HFNC) before proceeding to invasive ventilation in early ARDS 2

Positioning and Adjunctive Therapies

• Implement prone positioning for patients with severe ARDS (PaO₂/FiO₂ <100 mmHg):

  • Position for >12 hours per day 1, 2, 4
  • Start early (within 48 hours of ARDS onset) 3
  • Continue with repeated sessions as needed 3

• Consider neuromuscular blocking agents:

  • Use in early severe ARDS, especially with ventilator-patient dyssynchrony 1, 2
  • Cisatracurium is preferred, limited to first 48 hours after ARDS onset 1, 3
  • Avoid routine continuous infusion in moderate ARDS 1

• Corticosteroids:

  • Consider short-term use (3-5 days) based on degree of dyspnea and chest imaging progression 1
  • Limit dose to equivalent of 1-2 mg/kg methylprednisolone per day 1

Fluid Management

• Implement conservative fluid management for ARDS patients without tissue hypoperfusion 1
• Use vasoactive drugs as needed to maintain adequate organ perfusion while avoiding fluid overload 1, 2
• Target mean arterial pressure (MAP) ≥65 mmHg in adults with septic shock 1

Advanced Support for Refractory Cases

• Consider extracorporeal membrane oxygenation (ECMO) for severe refractory hypoxemia:

  • Indicated when standard therapies are failing 2
  • Consider for severe ARDS patients with lung injury score >3 or pH <7.2 due to uncompensated hypercapnia 1
  • Should only be performed at centers with appropriate expertise 1

• Venovenous ECMO (VV-ECMO) is preferred for isolated respiratory failure 1

• Avoid routine use of inhaled nitric oxide 2

Supportive Care

• Provide standard supportive care:

  • Prevention of deep vein thrombosis 1
  • Prevention of stress-induced gastrointestinal bleeding 1
  • Blood glucose control 1
  • Enteral nutrition when appropriate 1

• Infection control:

  • Use empirical antibiotics targeting suspected potential infections 1
  • Avoid blind or improper combinations of broad-spectrum antibiotics 1

Common Pitfalls to Avoid

• Underutilization of evidence-based strategies like prone positioning 2, 4
• Excessive fluid administration worsening pulmonary edema 2
• Delaying prone positioning in severe ARDS 3
• Using hydroxyethyl starch fluids in resuscitation 4
• Routine use of high-frequency oscillatory ventilation 1
• Supplemental nutrition with omega-3 fatty acids and antioxidants 1
• Inhaled or intravenous beta-adrenergic agonists to promote alveolar fluid clearance 1