The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

Abstract

Purpose: Severe ARDS is often associated with refractory hypoxemia, and early identification and treatment of hypoxemia is mandatory. For the management of severe ARDS ventilator settings, positioning therapy, infection control, and supportive measures are essential to improve survival. Methods and results:A precise definition of life-threating hypoxemia is not identified. Typical clinical determinations are: arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO 2 /FIO 2 < 100. For mechanical ventilation specific settings are recommended: limitation of tidal volume (6 ml/ kg predicted body weight), adequate high PEEP (>12 cmH 2 O), a recruitment manoeuvre in special situations, and a 'balanced' respiratory rate (20-30/min). Individual bedside methods to guide PEEP/recruitment (e.g., transpulmonary pressure) are not (yet) available. Prone positioning [early (≤ 48 hrs after onset of severe ARDS) and prolonged (repetition of 16-hr-sessions)] improves survival. An advanced infection management/control includes early diagnosis of bacterial, atypical, viral and fungal specimen (blood culture, bronchoalveolar lavage), and of infection sources by CT scan, followed by administration of broad-spectrum anti-infectives. Neuromuscular blockage (Cisatracurium ≤ 48 hrs after onset of ARDS), as well as an adequate sedation strategy (score guided) is an important supportive therapy. A negative fluid balance is associated with improved lung function and the use of hemofiltration might be indicated for specific indications. Conclusions:A specific standard of care is required for the management of severe ARDS with refractory hypoxemia.

Effects of inflammatory factors including plasma tumor necrosis factor-α in the clinical treatment of acute respiratory distress syndrome

“…Ordinary infection, burns and septicemia are factors with a high risk of inducing ARDS, and this disease may be fatal if patients are not treated with highly effective therapy (11). A survey indicated that the mortality rate of ARDS may be up to 50% (12) and therefore, the timely administration of effective treatment is important to reduce ARDS-associated fatalities.…”

Characteristics and provision of care of patients with the acute respiratory distress syndrome: descriptive findings from the DACAPO cohort baseline and comparison with international findings

“…Additionally, the length of stay at ICU until death or discharge, the occurrence of critical events [hypoxemia (SpO 2 <85% for at least 5 min), hypoglycemia (defined as blood glucose measurement <70 mg/dL), accidental extubation, re-intubation] was assessed. In the clinical intensive care setting, an arterial SpO 2 <85%, corresponding to a PaO 2 ≤50 mmHg with a time span of a few minutes, is accepted as a valuable marker for hypoxemia (16,17). The advocated measures in these situations are the control of artificial airways and ventilator function/modes/settings, the suction of endotracheal secretions, the acute use of open lung approaches, and/or acute imaging diagnostics (Chest X-ray, ultrasound).…”

Non-invasive mechanical ventilation in hypoxemic respiratory failure: Just a matter of the interface?

“…As the intensive care community gains more and more knowledge of what measures induce and worsen ventilator induced lung injury (VILI), lung-protective ventilation strategies become a conditio sine qua non (26). On the same lines, non-invasive ventilation has advanced to be an easy to use and effective way to bridge a phase of respiratory failure for many patients.…”