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