Elsevier

Critical Care Clinics

Volume 33, Issue 2, April 2017, Pages 259-275
Critical Care Clinics

Optimal Strategies for Severe Acute Respiratory Distress Syndrome

https://doi.org/10.1016/j.ccc.2016.12.010Get rights and content

Section snippets

Key points

  • Acute respiratory distress syndrome (ARDS) occurs in more than 10% of intensive care unit admissions and nearly 25% of ventilated patients.

  • Low-volume, low-pressure lung protective ventilation remains the mainstay of ARDS management.

  • In severe ARDS, early use of neuromuscular blockade and prone positioning improve survival.

  • High-frequency oscillatory ventilation has no clear mortality benefit and may harm some patients.

  • Extracorporeal membrane oxygenation consultation should be obtained early to

Epidemiology of severe acute respiratory distress syndrome

The review of acute lung injury (ALI) and ARDS epidemiology by Blank and Napolitano9 summarized the most current trends in respiratory survival development and outcomes in modern ICU care. These investigators made the following observations:

  • This is a heterogeneous condition that occurs in heterogeneous ICU populations

  • The incidence of ALI/ARDS is declining because of a decrease in hospital-acquired respiratory failure

  • The mortality associated with ARDS remains high at 20% to 25% in randomized

Standard Ventilator Management

The goal of the management of severe ARDS is to safely support gas exchange without further injuring the patient’s lungs.16 The optimal initial approach seems to be a low-volume, low-pressure ventilation strategy with volume control ventilation, which showed a survival benefit in the ARDSNet ARMA (Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome) trial.17 This lung protective strategy limits the

Advances in nonventilator management

Nonventilatory adjunctive therapies also play an important role in the management of patients with moderate to severe ARDS. In recent years, important studies have shown a potential survival benefit with the use of these therapies, whereas others have not been proved beneficial or have even been found to be associated with harm. The roles of neuromuscular blockade, prone positioning, and inhaled pulmonary vasodilators in patients with severe ARDS are discussed later in this article.

Extracorporeal membrane oxygenation

Venovenous ECMO (VV ECMO) has assumed an important role in the management of patients with severe ARDS (Fig. 4). In the past decade, the number of adults with severe ARDS managed with ECMO and the number of self-identifying adult ECMO centers has increased greatly.49, 50 The landmark Conventional Ventilation or ECMO for Severe Adult Respiratory Failure (CESAR) trial and the influenza A (H1N1) pandemic served to raise awareness of the technologic advances in this field and of the excellent

Summary

Several insights into the clinical entity of ARDS have been gleaned over the past several years even as the care of these patients has continued to advance in many ways. Nonetheless, much work is still required to promote early diagnosis of ARDS and the application of evidence-based ventilator management principles in these patients. High-frequency ventilation has not shown a clear benefit in patients with severe ARDS, but other modes of ventilator support, such as APRV, may have a continued

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    • Prone positioning in patients with acute respiratory distress syndrome, translating research and implementing practice change from bench to bedside in the era of coronavirus disease 2019

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      The first task the PWC undertook was a critical review of the relevant literature related to proning and assessing the level of evidence for the PPP. The PWC reviewed the literature, meta-analysis, and guidelines published on ARDS management over the last ten years.6,15,16,22,24–30 Based on the findings from the review of the literature, as well as current international guidelines and procedures, the PWC planned and wrote the work unit guidelines.

    • Initial emergency department mechanical ventilation strategies for COVID-19 hypoxemic respiratory failure and ARDS

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      In COVID-19 related respiratory failure, care is focused on maintaining oxygenation while preventing VILI with lung protective ventilation (LPV). The mainstays of LPV are low VT, sufficient PEEP to maintain lung recruitment, and low airway pressures [17,30-34]. Though ARDS is a heterogeneous syndrome, the following is recommended for all ARDS patients: (1) VT of 4 to 8 mL/kg predicted body weight (PBW) and (2) targeting a PPlat <30 cm H2O (Tables 3 and 4) [15,34,35].

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      Selection of PEEP was based on gas exchange and hemodynamics and was adjusted by one of the ARDSNet PEEP/FiO2 tables.11–14 Although this protocolized approach has been associated with inadequate venous return and barotrauma, a trend towards improved mortality using the high-PEEP table has been reported.15,16 However, other studies demonstrated no benefit or an association with further lung injury.7,17–19

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      The Berlin definition categorizes severe ARDS based on the degree of hypoxemia, as a Pa02/FiO2 ratio less than 100, with a mortality rate of 45% [1]. According to the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory failure (LUNGSAFE study), the estimated incidence of ARDS is around 34 cases per 100, 000 patients per year in the United States [2,3]. 23.4% of the patients in this group had severe ARDS defined based on the Berlin criteria [2].

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    The opinions expressed in this document are solely those of the authors and do not represent an endorsement by or the views of the United States Air Force, the Department of Defense, or the United States government.

    Disclosure: Dr D. Brodie is currently on the medical advisory boards of ALung Technologies and Kadence. All compensation for these activities is paid to Columbia University. Drs J.W. Cannon and J.T. Gutsche report nothing to disclose.

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