Ariel L. Clark
Since the COVID-19 pandemic, the world has seen the extent of harm caused by lung disease and infection. Acute respiratory distress syndrome (ARDS) is one that results in significant inflammation that reduces the lungs’ ability to exchange oxygen for carbon dioxide and leaves patients at high risk for hypoxia, which can lead to severe impairment and death.
Patients with ARDS are at risk for severe complications, and according to Yale Medicine, up to 40% of patients do not recover from the condition. In a clinical practice guideline update published in the American Journal of Respiratory and Critical Care Medicine in January 2024, experts in ARDS treatment compiled and summarized their recommendations, including treatment updates and supportive care measures, to aid clinicians in treating their patients.
Systemic corticosteroids recommendations
Corticosteroids have been used successfully in the treatment of other respiratory conditions, including COVID-19 and community-acquired pneumonia, due to their ability to reduce inflammatory markers and inflammation in the lungs. In previous treatment guidelines, they were not mentioned. But in the current update, experts recommend using systemic corticosteroids in patients with ARDS, with certain caveats.
First, clinicians should use their best judgment when deciding the dosing regimen and duration of treatment, as that was not decided by the panel of experts. Second, treatment should be initiated within 2 weeks of symptom onset. Finally, clinicians should closely monitor for adverse effects, especially in those patients who are immunocompromised, are diagnosed with metabolic syndrome, or are at high risk for systemic infections, such as tuberculosis.
VV-ECMO recommendations
Experts included venovenous extracorporeal membrane oxygenation (VV-ECMO) as another treatment option in the update. VV-ECMO is an external gas exchange system that removes carbon dioxide and reoxygenates blood in an external chamber before returning blood to the patient.
Guideline authors recommend the use of VV-ECMO in patients with severe ARDS who have been unsuccessfully managed with other therapies and supportive measures.
Compared to the other recommendations in this update, experts noted that ECMO can be cost- and resource-prohibitive for many patients and health systems, leading to its conditional recommendation and use only after other measures have been exhausted.
Neuromuscular blockade
Patients with lung injury have successfully been treated with neuromuscular blocking agents (NMBAs) in several randomized controlled clinical trials in recent years. Despite their exact mechanism remaining unknown, panelists agreed to include their use in this guideline update given the multitude of data supporting their use.
However, the recommendation to use NMBAs comes with “low certainty of evidence,” as the literature reviewed included variable sedation strategies that were not directly comparable.
Overall, the pool of data showed that NMBAs reduced mortality and increased off-ventilator days, but clinicians should be wary unless patients are in early (<48 hours), severe ARDS and should balance the decision to administer NMBAs with the risk of ICU-acquired weakness. And for patients with late and severe ARDS, experts did not make a recommendation, stating that further research should be done on appropriate timing of initiation, dosing, and duration.
Ventilator settings
Intubated patients require intricate ventilator settings to minimize risk of further lung injury and to improve patient outcomes. The guideline update includes a recommendation from experts to use higher positive end-expiratory pressure (PEEP) versus lower PEEP in patients with moderate to severe ARDS, while no recommendation could be made for mild ARDS.
Along with higher PEEP, the panelists recommended against the use of lung recruitment maneuvers, or when intermittent increases in PEEP settings are used for roughly 60 seconds, because studies have shown the potential for harm with these techniques.
While the updated ARDS guideline represents a significant step forward in helping clinicians improve patient care, guideline authors acknowledged the ongoing need for further research to strengthen their recommendations. They emphasized the importance of collaboration among health care professionals in deciding the best treatment strategies for individual patients.
As clinicians continue to treat patients with ARDS, they should continue collaboration, further research, and commit to evidence-based practice to further refine ARDS management and treatment. ■