Recognition and optimizing treatment of Acute Respiratory Distress Syndrome (ARDS)

ARDS is a syndrome that appears to be under recognized, undertreated, and associated with a high mortality rate. ARDS is progressive with an early treatment window that can be exploited.[1]

The challenge

Care for patients with ARDS is complicated and associated with long hospitalizations and consumes significant healthcare resources.[2]  ARDS appears to be undertreated in terms of the use of recommended approaches to mechanical ventilation and the use of some adjunctive measures. These findings indicate the potential for improvement in management of patients with ARDS. [1]

Clinical signs and symptoms of ARDS

ARDS remains under recognized, with only 60.2% of patients being recognized by clinicians.[1]

Clinical Signs Chart

Clinical sign ref. [3]; Severe ref. [4]

ARDS: The clinical challenge

Learn more about the challenge of recognizing and treating
Acute Respiratory Distress Syndrome (ARDS).

Download the ARDS brochure

The current recommendations

American Thoracic Society /European Society of Intensive Care Medicine / Society of Critical Care Medicine
Clinical Practice Guideline:
Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome[5],[6]
Treatment
Recommendation
Strength of Recommendation

Mechanical Ventilation using LTVs and Inspiratory Pressures

Recommended that adult patients with ARDS receive mechanical ventilation with tidal volumes limited to 4-8ml/kg PBW and
inspiratory plateau pressures <30cm H2O

Strong recommendation with moderate confidence in effect
estimates

Prone Positioning

Recommended that adult patients with severe ARDS receive prone positioning for more than 12 hours per day

Strong recommendation with moderate – high confidence in effect estimates

High-Frequency Oscillatory Ventilation (HFOV)

Recommend that HFOV not be used routinely in patients with moderate or severe ARDS

Strong recommendation with moderate-high confidence in effect estimates

High PEEP vs Low PEEP

Suggest that adult patients with moderate or severe ARDS receive higher rather than lower levels of PEEP

Conditional recommendation with moderate confidence in effect estimates

Recruitment Maneuvers (RMs)

Suggest that adult patients with ARDS receive RMs

Conditional recommendation with moderate confidence in effect estimates

Extra Corporeal Membrane Oxygenation (ECMO)

Additional evidence is necessary to make a definitive recommendation for or against ECMO in patients with severe ARDS

Recommend on-going research measuring clinical outcomes of severe ARDS patients receiving ECMO

To read more about the current recommendations:

1. Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Read abstract on PubMed.
Reference
Fan E, Del Sorbo L, Goligher EC, et al. American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017 May

2. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. Read abstract on PubMed.
Reference
Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018 Feb 20;319(7):698-710.

The importance of knowing volume status

Every day in the ICU, clinicians have to face this therapeutic dilemma for the patient with circulatory failure and lung impairment, should I opt for fluid administration?

In case of severe ARDS associated with shock, it has been suggested to consider using advanced monitoring devices at an earlier phase to assist in defining logical therapeutic approach.

 

Ref. [7]

The Goal of Ventilation

"The goal of mechanical ventilation in patients with ARDS is to maintain gas
exchange while avoiding the complications such as Ventilator-Induced Lung
Injury (VILI), Ventilator-Associated Pneumonia (VAP), or Ventilation-Induced
Diaphragm Dysfunction (VIDD)"[5]

See References [5], [8], [9]

Mechanical Ventilation

Easy to use critical care ventilators with tools to help you reduce complications and wean earlier during invasive and non-invasive ventilation; from ICU to intermediate care; and for all patient categories.

Read more about Mechanical Ventilation

Advanced Monitoring

Practice-oriented monitoring systems and disposables that are used for diagnosis and treatment of the critically ill patient. 

Read more about Advanced Monitoring

All references

  1. 1. Bellani G, Laffey JG, Pham T, et al. LUNG SAFE Investigators; ESICM Trials Group. Epidemiology, Patterns of Care, and Mor­tality for Patients With Acute Respiratory Distress Syndrome in Intensive Care Units in 50 Countries. JAMA. 2016 Feb 23;315(8):788- 800.

  2. 2. Bice T, Cox CE, Carson SS. Cost and health care utilization in ARDS--different from other critical illness? Semin Respir Crit Care Med. 2013 Aug;34(4):529-36.

  3. 3. Health Topic "ARDS" on National Heart, Lung, and Blood Institute

  4. 4. ARDS Definition Task Force, Ranieri VM, Rubenfeld GD, Thompson BT, Ferguson, et al. Acute respiratory distress syndrome: the Berlin Definition. JAMA. 2012 Jun

  5. 5. Fan E, Brodie D, Slutsky AS. Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment. JAMA. 2018 Feb 20;319(7):698-710.

  6. 6. Fan E, Del Sorbo L, Goligher EC, et al. American Thoracic Society, European Society of Intensive Care Medicine, and Society of Critical Care Medicine. An Official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine Clinical Practice Guideline: Mechanical Ventilation in Adult Patients with Acute Respiratory Distress Syndrome. Am J Respir Crit Care Med. 2017 May 1;195(9):1253-1263.

  7. 7. Teboul, JL., Saugel, B., Cecconi, M. et al. Intensive Care Med (2016) 42: 1350. hps://doi.org/10.1007/s00134-016-4375-7

  8. 8. Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med.2015 Feb 19;372(8):747-55.

  9. 9. Yoshida T,Fujino Y, Amato MB, Kavanagh BP. Fifty Years of Research in ARDS. Spontaneous Breathing during Mechanical Ventilation Risks, Mechanisms, and Management. Am J Respir Crit Care Med Vol 195, Iss 8, pp 985–992, Apr 15, 2017.

  10. 10. Ventetuolo CE, Muratore CS. Extracorporeal life support in critically ill adults. Am J Respir Crit Care Med. 2014;190(5):497–508.

  11. 11. Toshiyuki Aokage, Kenneth Palmér, Shingo Ichiba and Shinhiro Takeda; Extracorporeal membrane oxygenation for acute respiratory distress syndrome; Journal of Intensive Care20153:17

  12. 12. MacCallum NS1, Evans TW.; Epidemiology of acute lung injury. Curr Opin Crit Care. 2005 Feb;11(1):43-9.