Management of acute respiratory distress syndrome (ARDS) – what works and what does not

Key points

• Lung protective ventilation with a tidal volume of 4-8 mL/kg predicted body weight and plateau pressure below 30 cm H2O is strongly recommended in all patients with ARDS.
• Prone positioning for more than 12 hours a day is strongly recommended in ventilated patients with severe ARDS.
• Higher PEEP and recruitment maneuvers carry conditional recommendations in moderate to severe ARDS, while high frequency oscillatory ventilation is strongly recommended against.
• In moderate to severe ARDS, methylprednisolone should be considered: 1 mg/kg/day early (up to 7 days from onset) or 2 mg/kg/day later, weaned slowly over 6-14 days.
• ECMO should be considered in selected patients with severe ARDS on lung protective ventilation, for example with a Murray score above 3.

Overview

This review summarises current evidence and guidelines on managing acute respiratory distress syndrome. ARDS affects about 200,000 people and causes 74,500 deaths a year in the United States, with about 3 million cases globally; it accounts for about 10% of ICU admissions and mortality ranges from 35% to 46%. The Berlin definition grades severity by hypoxemia, and mechanical ventilation remains the most important part of management. This overview is based on the abstract and the recommendation statements and tables of the article.

Ventilation

PEEP is recommended in all patients with ARDS, and higher PEEP may be considered case by case in moderate to severe ARDS. Volume and pressure control show no difference in mortality, so standard modes are recommended; APRV/BiLevel shows no benefit, and higher driving pressure is associated with increased mortality.

Drugs

Neuromuscular blockers should not be used routinely; cisatracurium has a weak recommendation when the PaO2/FiO2 ratio is below 150, and use should be individualized. Early corticosteroids within 14 days of onset of moderate to severe ARDS can shorten mechanical ventilation and reduce mortality if there are no contraindications. Inhaled vasodilators are not recommended routinely but may bridge to ECMO. Inhaled nitric oxide, aspirin, statins and surfactant showed no benefit, and intravenous salbutamol and keratinocyte growth factor caused harm.

FAQ

What tidal volume is recommended in ARDS?

4-8 mL/kg of predicted body weight, keeping plateau pressure below 30 cm H2O, in all patients with ARDS.

Are corticosteroids recommended in ARDS?

Methylprednisolone should be considered in moderate to severe ARDS within 14 days of onset if there are no contraindications, and it should be tapered slowly rather than stopped abruptly.

Should all patients with severe ARDS receive neuromuscular blockers?

No. They are likely beneficial only in selected patients with refractory hypoxemia, patient-ventilator dyssynchrony and high risk of barotrauma.

Source

Banavasi H, Nguyen P, Osman H, Soubani AO. Management of ARDS - What Works and What Does Not. Am J Med Sci 2021;362(1):13-23. DOI: 10.1016/j.amjms.2020.12.019. © 2021 Southern Society for Clinical Investigation, all rights reserved; free access via the Elsevier COVID-19 resource centre. Summary prepared by Medpresso from the original publication; it is not a substitute for the full text or for medical advice.