Abstract
Acute respiratory distress syndrome (ARDS) remains one of the leading causes of morbidity and mortality in critically ill patients despite advancements in the field. Mechanical ventilatory strategies are a vital component of ARDS management to prevent secondary lung injury and improve patient outcomes. Multiple strategies including utilization of low tidal volumes, targeting low plateau pressures to minimize barotrauma, using low FiO2 (fraction of inspired oxygen) to prevent injury related to oxygen free radicals, optimization of positive end expiratory pressure (PEEP) to maintain or improve lung recruitment, and utilization of prone ventilation have been shown to decrease morbidity and mortality. The role of other mechanical ventilatory strategies like non-invasive ventilation, recruitment maneuvers, esophageal pressure monitoring, determination of optimal PEEP, and appropriate patient selection for extracorporeal support is not clear. In this article, we review evidence-based mechanical ventilatory strategies and ventilatory adjuncts for ARDS.
Highlights
Academic Editor: Michele UmbrelloAcute respiratory distress syndrome (ARDS) is an acute, severe lung injury that is characterized by inflammatory cascades, hypoxemia, and diffuse lung involvement
A subsequent trial, EPVENT2, revealed that in patients with moderate-to-severe ARDS, titration of positive end expiratory pressure (PEEP) guided by esophageal pressure did not significantly improve mortality or reduce days free from mechanical ventilation, it did result in use of less rescue therapy, notably need for extracorporeal membrane oxygenation (ECMO) [17]
FLORALI trial suggests that while intubation rates of Non-invasive ventilation (NIV) and high-flow oxygen therapy for acute hypoxic respiratory failure resulted in similar intubation rates, high-flow oxygen therapy was superior in regard to 90-day mortality [55]
Summary
Acute respiratory distress syndrome (ARDS) is an acute, severe lung injury that is characterized by inflammatory cascades, hypoxemia, and diffuse lung involvement. The diagnostic criteria are summarized as an acute injurious lung event with diffuse bilateral lung opacities of non-cardiogenic origin on imaging (See Figure 1). The age-adjusted incidence of ARDS in individuals with PaO2 /FiO2 (arterial partial pressure of oxygen/fraction of inspired oxygen) ratio ≤ 300 mmHg is 86 per 100,000 person-years and 64 per 100,000 person-years for individuals with PaO2 /FiO2 ratio ≤ 200 mmHg [3]. This approximates to 10% of intensive care unit (ICU) patients and 23% of patients on mechanical ventilation [4].
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