able burden of ARDS to patients and health care
Lung protective mechanical ventilation remains
the only therapy with established survival benefit
for the treatment of ARDS. While various modes
of mechanical ventilation have been shown to
be equivalent in multicenter clinical trials, consistent tenets of lung protective ventilation include
targeting a tidal volume of 6 mL/kg of predicted
body weight to reduce alveolar overdistention and
barotrauma and higher levels of PEEP to reduce
alveolar de-recruitment at end-expiratory volumes
and atelectrauma. Insufficient clinical evidence
exists to make strong recommendations regarding alternative modes of mechanical ventilation
as rescue therapies. However, current clinical trial
experience supports a trial of a high PEEP protocol
and neuromuscular blockade for at least 48 hours
in patients failing standard modes of mechanical
ventilation before switching to less conventional
modes. If available, transition of appropriately
selected patients to ECMO is currently the most
evidence-based rescue maneuver.
Current data do not support the routine use of
pharmacologic agents other than neuromuscular
blockade in the treatment of ARDS. However,
given the marked heterogeneity among patients
with ARDS, existing clinical trials have likely been
underpowered to rule out a survival benefit in cer-
tain subgroups. Still, in an era of improved compli-
ance with lung protective ventilation, the majority of
patients who die with ARDS will likely die from their
underlying conditions leading to ARDS, and efforts
targeting improved supportive care should be pri-
oritized over unsubstantiated treatments. Rescue
therapy with pulmonary artery vasodilator therapy,
if used at all, should be reserved for patients with
critical levels of hypoxemia or right ventricular
dysfunction. Corticosteroids are not indicated in
the majority of patients who have a known infec-
tious etiology of their ARDS. However, sufficient
equipoise exists to warrant use in patients with
suspected underlying autoimmune conditions or
Institution-wide efforts to improve early recogni-
tion of high-risk patients and improved standard-
ization of care to prevent exposures to secondary
risk factors are likely low-cost, high-impact strate-
gies to reduce the incidence of hospital-acquired
ARDS. Multicenter collaborations like the PETAL
Network may further identify effective strategies
for the prevention of ARDS and novel therapies for
treatment of early acute lung injury prior to progres-
sion to ARDS.
1. Bernard GR, Artigas A, Brigham KL, et al. Report of the
American-European Consensus conference on acute respiratory distress syndrome: definitions, mechanisms, relevant outcomes, and clinical trial coordination. Consensus
Committee. J Crit Care 1994;9:72–81.
2. Rubenfeld GD, Cooper C, Carter G, et al. Barriers to providing lung-protective ventilation to patients with acute lung
injury. Crit Care Med 2004;32:1289–93.
3. Herasevich V, Yilmaz M, Khan H, et al. Validation of an
electronic surveillance system for acute lung injury. Intensive Care Med 2009;35:1018–23.
4. Herasevich V, Tsapenko M, Kojicic M, et al. Limiting
ventilator-induced lung injury through individual electronic
medical record surveillance. Crit Care Med 2011;39:34–9.
5. Rubenfeld GD, Caldwell E, Peabody E, et al. Incidence
and outcomes of acute lung injury. N Engl J Med
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