Key Principles
- Prompt resuscitation and treatment of the underlying cause
- Consider early intubation and mechanical ventilation in moderate to severe ARDS
- Ventilation with a lung-protective strategy
- Use of prone positioning, NMBs and APRV as required
Initial Resuscitation & Supportive Care
- ABCDE approach treating abnormalities as found
- Consider early intubation if severe hypoxia or respiratory distress
- Insertion of arterial line to monitor gas exchange
- Titrate PEEP and oxygen for saturations 88-95% or PaO2 >8.0
- May require deep sedation for ventilator synchrony or administration of neuromuscular blockade
- Catheterisation and monitoring of fluid balance to help manage conservative fluid strategy
- Assess early for underlying cause and implement appropriate management – may need careful infectious screen if not apparent
- Meticulous approach to DVT and stress ulcer prophylaxis
Specific Managment
Ventilatory Strategies
- Lung protective strategy used in ARDSnet trial (See document)
- Low tidal volumes: 6-8ml/kg of ideal body weight
- Avoidance of plateau pressures >30cm H2O
- High PEEP (10 - 12cm H2O) - Titrate according to the PEEP ladder
- Titration of FiO2 aiming for PaO2 >8.0
- Titration of respiratory rate to maintain pH >7.25 and acceptable PaCO2
- Open Lung Strategy and Recruitment manoeuvres
- Prone Positioning and Ventilation
- Airway Pressure Release Ventilation (APRV)
- Oscillatory Ventilation
Non-Ventilatory Strategies
- Chest physiotherapy
- Restrictive fluid status
- Neuromuscular blockade
- Steroid therapy
- Pulmonary Vasodilators
- ECMO / Extracorporeal CO2 removal
- Other experimental pharmacological therapies
Monitoring, Referral & Deposition
- Consider the early involvement of specialist respiratory failure / ECMO centre