Moderate to Severe Acute Respiratory Distress Syndrome Management Strategies: A Narrative Review

Abstract

Acute respiratory distress syndrome (ARDS) remains a common complication associated with significant negative outcomes in critically ill patients. Lung-protective mechanical ventilation strategies remain the cornerstone in the management of ARDS. Several therapeutic options are currently available including fluid management, neuromuscular blocking agents, prone positioning, extracorporeal membrane oxygenation, corticosteroids, and inhaled pulmonary vasodilating agents (prostacyclins and nitric oxide). Unfortunately, an evidence-based, standard-of-care approach in managing ARDS beyond lung-protective ventilation remains elusive, contributing to significant variability in clinical practice. Although the optimal therapeutic strategy for managing moderate to severe ARDS remains extremely controversial, therapies supported with more robust clinical evidence should be considered first. The purpose of this narrative review is to discuss the published clinical evidence for both pharmacologic and nonpharmacologic management strategies in adult patients with moderate to severe ARDS as well as to discuss practical considerations for implementation.

Comparison of Fixed-Dose Inhaled Epoprostenol and Inhaled Nitric Oxide for Acute Respiratory Distress Syndrome in Critically Ill Adults

“…4,8 Unfortunately, this has not translated into improved clinical outcomes. 4,8 A lack of large sample sizes, control of important confounders, and long-term follow-up poses a significant challenge in evaluating the impact of iEPO on mortality, hospital length of stay, and mechanical ventilation duration. 4,8 Although our study failed to find any significant differences in mortality or hospital length of stay, we did observe a significant increase in mechanical ventilation-free days with iEPO over iNO.…”

“…4,8,9 Many institutions have favored the use of inhaled epoprostenol (iEPO) over inhaled nitric oxide (iNO) in ARDS primarily attributed to associated costs considering comparable safety and efficacy. 4,9 Beneficial effects on pulmonary hemodynamics and oxygenation parameters have been observed with fixed-dose iEPO administration schemes in cardiac surgery patients. 10 –14 However, studies directly comparing oxygenation and clinical outcomes between iNO and iEPO exclusively in an adult ARDS patient population utilized a weight-based dosing strategy.…”

“…1 Several therapeutic options including prone positioning, neuromuscular blocking agents (NMBA), extracorporeal life support, corticosteroids, and inhaled pulmonary vasodilating agents are currently available. [4][5][6] A standard of care for the optimal role of these adjunctive therapies is lacking leading to significant variability in clinical practice. 7 Nonetheless, inhaled pulmonary vasodilating agents are commonly employed in managing ARDS.…”

Uninterrupted Continuous and Intermittent Nebulizer Therapy in a COVID-19 Patient Using Sequential Vibratory Mesh Nebulizers: A Case Report

“…(2)(3)(4) Although without a proven mortality benefit, in some circumstances, pulmonary vasodilators such as inhaled nitric oxide or prostacyclin analogues may be considered to enhance oxygenation or serve as a bridge to extracorporeal membrane oxygenation. (5,6) The most severe cases may become ventilator dependent for a prolonged period of time that is associated with further complications including nosocomial infections. In this study, we describe a patient with ARDS due to COVID-19 pneumonia and multidrug-resistant bacterial pneumonia requiring both intermittent and continuous nebulization of inhaled therapies while avoiding frequent circuit disconnections.…”

Contemporary Topics in Critical Care With Evolving Medication Management Considerations

“…Two reviews highlight literature on the clinical evidence for management strategies of adult patients with ARDS and ICU patients presenting with acute decompensated pulmonary hypertension. 7,8 Effective medication management is completed with cost conscious considerations; this critical care themed issue includes a cost assessment associated with acute kidney injury (AKI) to emphasize the financial impact of preventing an episode of AKI. 9 Treatment for AKI is lacking but application of prevention strategies that includes the early identification of high-risk patients may have a substantial influence on patient outcomes and resources.…”