ARDS Management Guidelines 2023

Overview

This episode discusses the 2023 European Society of Intensive Care Medicine guidelines for Acute Respiratory Distress Syndrome (ARDS), focusing on definitions, ventilator management, proning, ECMO, comorbidities, and challenges in standardizing care.

ARDS Definition and Diagnostic Challenges

• ARDS is defined as non-cardiogenic pulmonary edema requiring mechanical ventilation with at least 5 cm H₂O PEEP.
• The current diagnostic criteria focus on intubated patients, which may exclude patients with early or non-intubated ARDS.
• The guidelines recommend considering "acute hypoxemic respiratory failure" not explained by pre-existing lung or heart disease to broaden evidence and strategies.

Mechanical Ventilation Strategies

• Lower tidal volumes (6 mL/kg predicted body weight) reduce mortality in ARDS and are standard.
• PEEP is used to keep airways open but should be minimized to avoid hemodynamic compromise.
• Aggressive "recruitment maneuvers" are not recommended, as studies suggest potential harm.

Proning (Face-Down Positioning)

• Proning improves oxygenation by optimizing the matching of air and blood flow in the lung.
• While technically challenging, it is effective and now standard for intubated patients with severe hypoxemia.
• Some evidence suggests benefits for non-intubated patients, particularly noted during COVID-19, though high-quality trial data are limited.

Patient-Ventilator Asynchrony

• Asynchrony occurs when patient breathing effort is out of sync with the ventilator, causing discomfort and potential lung injury.
• Routine use of neuromuscular blockade to address asynchrony is not recommended.

ECMO and Disease Subtypes

• ECMO (extracorporeal membrane oxygenation) is indicated when ventilation fails to maintain adequate oxygenation.
• The benefit of ECMO likely applies to severe ARDS from any cause, not just COVID-19.
• There is ongoing research into different ARDS subtypes and tailored interventions.

Comorbidities and Outcomes

• Many ARDS patients have chronic comorbidities or develop multiple organ dysfunctions.
• Mortality is often due to multi-organ failure rather than isolated hypoxemia.

Variability and Implementation of Guidelines

• ARDS care remains highly variable across institutions and regions.
• Dissemination and adoption of evidence-based guidelines are ongoing challenges to reduce unwanted variation in care.

Recommendations / Advice

• Apply low tidal volume ventilation and only necessary PEEP for ARDS patients.
• Use prone positioning for severe hypoxemia in intubated patients.
• Avoid routine use of recruitment maneuvers and neuromuscular blockade.
• Consider ECMO for refractory hypoxemia, regardless of ARDS etiology.
• Broaden ARDS diagnostic criteria to ensure early intervention and management.