A Focused Review of the Initial Management of Patients with Acute Respiratory Distress Syndrome

Abstract

At present, the management of patients with acute respiratory distress syndrome (ARDS) largely focuses on ventilator settings to limit intrathoracic pressures by using low tidal volumes and on FiO2/PEEP relationships to maintain optimal gas exchange. Acute respiratory distress syndrome is a complex medical disorder that can develop in several primary acute disorders, has a rapid time course, and has several classifications that can reflect either the degree of hypoxemia, the extent of radiographic involvement, or the underlying pathogenesis. The identification of subtypes of patients with ARDS would potentially make precision medicine possible in these patients. This is a very difficult challenge given the heterogeneity in the clinical presentation, pathogenesis, and treatment responses in these patients. The analysis of large databases of patients with acute respiratory failure using statistical methods such as cluster analysis could identify phenotypes that have different outcomes or treatment strategies. However, clinical information available on presentation is unlikely to separate patients into groups that allow for secure treatment decisions or outcome predictions. In some patients, non-invasive positive pressure ventilation provides adequate support through episodes of acute respiratory failure, and the development of specialized units to manage patients with this support might lead to the better use of hospital resources. Patients with ARDS have capillary leak, which results in interstitial and alveolar edema. Early attention to fluid balance in these patients might improve gas exchange and alter the pathophysiology underlying the development of severe ARDS. Finally, more attention to the interaction of patients with ventilators through complex monitoring systems has the potential to identify ventilator dyssynchrony, leading to ventilator adjustments and potentially better outcomes. Recent studies with COVID-19 patients provide tentative answers to some of these questions. In addition, expert clinical investigators have analyzed the promise and difficulties associated with the development of precision medicine in patients with ARDS.

Mechanical power during mechanical ventilation

“…However, this support can also cause ventilator-induced lung injury. 1 The usual classification for ventilator-induced lung injury includes barotrauma, volutrauma, atelectrauma associated with the repeated opening and closing areas of the lung parenchyma, and biotrauma with the release of inflammatory markers into the lung and systemic circulation. Determining whether or not ventilator-induced lung disease develops in a patient on mechanical ventilation is difficult since the initial disorder causing acute respiratory failure causes lung injury with edema formation, inflammation, and potentially fibrosis.…”

“…Patients with very poor gas exchange may benefit from short-term use of paralytic drugs and the use of prone positioning. 1 This approach to ventilator management focuses on static…”