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A Review of Acute Respiratory Distress Syndrome (ARDS) by George T. Abdallah, PharmD, BCCCP, BCCP

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– Treat underlying condition

– Support oxygenation and ventilation

– Consider pharmacotherapy

– Rescue options for refractory hypoxemia

  • A lung-protective ventilatory strategy is advocated to reduce lung injury.
  • The ARDS Clinical Network Mechanical Ventilation Protocol (ARDSnet) sets the following goals:
    • Tidal volume (V) from 4 to 8 mL/kg of ideal body weight (IBW)
    • Respiratory rate (RR) up to 35 bpm
    • SpO2 88% to 95%
    • Plateau pressure (P) less than 30 cm H2O
    • pH goal 7.30 to 7.45, and inspiratory-to-expiratory time ratio less than 1.
  • High tidal volumes may promote further lung injury:
    • Volutrauma
    • Barotrauma
  • Guideline Recommendation: We recommend limiting tidal volume to 4–8 mL/kg for mechanically ventilated adult patients with ARDS (GRADE 1D).

Mechanical Ventilation


  • Increased lung edema is present due to capillary leak
    • Impairs oxygen diffusion at alveolar level
    • Goal: Reduce extra-vascular lung edema and reduce preload filling pressures
  • Guideline Recommendation: We suggest performing the restrictive fuid management strategies for adult patients with ARDS (weak recommendation/moderate certainty of evidence: GRADE 2B).
  • The pathogenesis of ARDS is a permeability pulmonary edema due to nonspecific inflammation, and whether anti-inflammatory corticosteroids improve clinical outcomes is an important clinical question.
  • Investigated in:
    • Early ARDS (< 72 hours)
    • Late ARDS ( > 7 days)
  • Guideline Recommendation:
    • We suggest against using high-dose corticosteroids for adult patients with ARDS. (GRADE 2C).
    • We recommend using low-dose corticosteroids for adult patients with ARDS. (GRADE 1B).

  • Muscular paralysis induced by NMBA will prevent spontaneous respiratory movements, reducing desynchrony and improving gas exchange
  • Additional benefits include increasing chest wall compliance and improve MV during ARDS
  • Allows for better adaptation to protective ventilation strategy
  • Reduction in pulmonary inflammation possibly leading to improvement in oxygenation
  • Guideline Recommendation:
    • We suggest administering neuromuscular blockers at an early phase for adult patients with moderate or severe ARDS (GRADE 2D).

  • Proning: Patient turned to face down
  • Theoretical Benefit:
    • May also allow the abdomen to expand more and facilitate better movement of diaphragm
    • Facilitate drainage of pulmonary secretions
    • Eliminate compression of lungs by the heart
  • Guideline Recommendation: We suggest performing the prone positioning in adult patients with moderate or severe ARDS for long periods of time (GRADE 2D).