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

Management of Acute Respiratory Distress Syndrome (ARDS)

The cornerstone of ARDS management is implementing lung-protective ventilation with low tidal volumes (4-8 mL/kg predicted body weight) and limiting plateau pressures (<30 cmH₂O), along with higher PEEP for moderate to severe ARDS and prone positioning for >12 hours daily in severe ARDS. 1, 2, 3

Initial 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 2, 3
• Use higher PEEP without lung recruitment maneuvers for moderate to severe ARDS (PaO₂/FiO₂ <200 mmHg) 1, 2
• Avoid prolonged lung recruitment maneuvers in moderate to severe ARDS 2, 3
• Maintain SpO₂ no higher than 96% to avoid oxygen toxicity 2
• Consider high-flow nasal cannula (HFNC) over conventional oxygen therapy for acute hypoxemic respiratory failure before proceeding to invasive ventilation 2

Positioning and Adjunctive Therapies

• Implement prone positioning for >12 hours daily in severe ARDS (PaO₂/FiO₂ <100 mmHg) 1, 2, 3
• Consider neuromuscular blocking agents (NMBAs) in early severe ARDS 1, 2, 3
• Administer systemic corticosteroids for ARDS 1, 2, 3

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 1, 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
• Avoid routine use of inhaled nitric oxide 2

Fluid Management

• Implement a conservative fluid management strategy to minimize pulmonary edema while maintaining adequate organ perfusion 2, 3
• Avoid fluid overload, which can worsen pulmonary edema and promote right ventricular failure 2, 3
• For ARDS associated with acute pancreatitis, implement non-aggressive fluid resuscitation at a rate of 1.5 mL/kg/hr following an initial bolus of 10 mL/kg, with preference for Lactated Ringer's solution 3

Monitoring Requirements

• Continuously monitor oxygen saturation, respiratory mechanics, and hemodynamics 2, 3
• Use echocardiography to assess right ventricular function and detect acute cor pulmonale in severe cases 2, 3
• 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

Common Pitfalls to Avoid

• Underutilization of evidence-based strategies like prone positioning and lung-protective ventilation 3, 5
• Excessive fluid administration worsening pulmonary edema and outcomes 3
• Delaying prone positioning in severe ARDS 3
• Using hydroxyethyl starch fluids in resuscitation 3
• Aggressive fluid resuscitation rates that may worsen pulmonary edema 3

Special Considerations for COVID-19 ARDS

• Follow the same principles of lung-protective ventilation and prone positioning for COVID-19 ARDS as for other causes of ARDS 2
• Consider systemic corticosteroids for COVID-19 ARDS, which has shown mortality benefit 2
• Be vigilant for barotrauma when using higher PEEP strategies (PEEP >10 cm H₂O) in COVID-19 patients 2