Current and Evolving

Standard of care for patient

with ARDS
Presenter: Dr Rozita
Supervisor: Dr See
Learning Objectives
• Defining ARDS
• Ventilatory management
• Ventilation adjuncts
• Pharmacotherapy
• Conclusion
Defining ARDS
• ARDS is characterized by the following
-characterized by the acute onset (within 1 week) of bilateral chest radiograph opacities,
respiratory failure not fully explained by cardiac failure/ fluid overload
• ARDS divided into mild, moderate and severe subgroups according to degree of
hypoxemia
 mild ARDS: 201 – 300 mmHg
 moderate ARDS: 101 – 200 mmHg
 severe ARDS: ≤ 100 mmHg
• The Berlin definition requires a minimum positive end expiratory pressure (PEEP) of
5 cmH2O for consideration of the PaO2/FiO2 ratio
• The Berlin definition remains the current standard for ARDS diagnosis in 2020, but we
anticipate ongoing evolution of the ARDS definition in the future
Ventilatory management
• Current standards for ventilatory management
-limitation of tidal volume and airway pressure
-standard approaches to setting PEEP
• Evolving standards focus on
-limitation of driving pressure or mechanical power
-individual titration of PEEP
-monitoring efforts during spontaneous breathing
PEEP Titration
Individual
titration of
PEEP
Spontaneous breathing in ARDS
• It is help to improve oxygenation, and to minimize diaphragm atrophy; therefore,
it may confer advantage in ventilated patients
• Partially assisted breathing is commonly employed even in moderate-severe ARDS
patients and is associated with improved outcomes
• There are concerns of treatment where spontaneous breathing with or without
assistance may lead to further lung injury ie self-inflicted lung injury (P-SILI)
• APRV use in ARDS treatment shows improvements in oxygenation but no difference
in ICU stay and mortality between groups
• NIV and HFNO are increasingly being considered for use in the early phase of ARDS
• HFNO was better than facemask NIV in preventing intubation and even reducing
mortality in more severe hypoxemia
• In ARDS, the FRC and lung compliance are reduced thus elastic work
of breathing is elevated
• By applying CPAP, the FRC restored and inspiration starts from more
favorable P/V relationship, facilitate spontaneous ventilation and
improve oxygenation
• Spontaneous breathing plays a very important role in APRV allowing
patient to control their respiratory frequency without being confined
to a preset I:E ratio
• Thus, improve patient comfort, patient-ventilator synchrony with
reduction in the sedation necessary
ARDS due to Covid-19
• COVID 19 pandemic has swept across the world and has resulted in
thousands of patients with severe respiratory failure and ARDS
• several reports suggesting that ARDS due to COVID-19 was different than
non-COVID ARDS and that different ventilatory strategies should be used
• As more info emerged, it appears that ARDS due to COVID-19 often looks
like and behaves similarly to ARDS from other causes
• COVID-19 ARDS is still an area of uncertainty
• It is reasonable to us to apply the same ventilatory approach to patients
with COVID-19 ARDS, taking into account the specific physiology/biology
of the individual patient.
Ventilation adjuncts
• Current standards in ventilation adjuncts include
-prone positioning in moderate-severe ARDS and
veno-venous extracorporeal life support after prone
positioning in patients with severe hypoxemia or who
are difficult to ventilate
Prone ventilation
• technique used to help patients with acute respiratory distress syndrome (ARDS) breathe
better
• Prone position means patients lie on their abdomen in a monitored setting
• It is generally used for patients who require a ventilator
• Advantages
i) Reduce lung compression thus improve the gas exchange process in areas of collapsed
lung
ii) Redistribute V/Q gradient more evenly and improve the gas exchanges
iii) Reduce risk of VALI
iv) Improve oxygen delivery to the body (increase VR, reduce constriction pulmonary
vessel)
v) Help to drain the secretions
Preparation for prone position
• A trained staff and the resources to move/monitor patients is important and
needed for the necessary to safely reposition a patient
• Most hospital maintain patients in a prone position for at least 12 hours per day,
though practices vary
• Prone positioning should be applied as a first-line therapy in moderate and severe
ARDS and generally be continued daily until PaO2/FiO2 is stable above 150 mmHg
in the supine position
• In patients with ARDS due to COVID-19, use of prone positioning for a prolonged
period of time (36 h) was safe and associated with a more pronounced impact on
oxygenation compared to 16 h of prone positioning
Challenges of prone positioning
• The clinical responses may varies depend on individual basis
• ETT, medical devices and drain can dislodge while repositioning
• Performing procedures or cardiopulmonary resuscitation (CPR) is also
challenging in the prone position and may require immediate
repositioning
• Pressure is placed on the shoulders, chest, knee, and face when
reposition thus predisposing these areas to pressure ulcers. This may
also result in nerve injury
Neuromuscular blockade
• high respiratory drive and subsequent strong spontaneous respiratory effort in
ventilated patients with ARDS may result in severe patient–ventilator
dyssynchrony and increased lung injury.
• Early neuromuscular blockade might prevent these effects and improve outcomes
• Some reluctance to use paralysis may arise because of concerns about long-term
effects on muscle strength, or about the need for concomitant deep sedation
• It should be reserved for those patients, where there is specific indication, e.g.,
those in whom lung protective ventilation is not possible because of severe
patient-ventilator asynchrony or markedly increased respiratory drive, those with
persistent high driving pressure, or who are difficult to oxygenate or ventilate
Veno-venous extracorporeal membrane
oxygenation(vvECMO)

• It proposed for patients with severe ARDS based on two potential mechanisms:
-Providing adequate oxygenation to prevent or reverse tissue hypoxia, and
-Allowing for a reduction in the intensity of mechanical ventilation substantially
reducing VILI
• Outcomes in ECMO are best when used in severe ARDS patients who are younger,
with reversible etiology, few co-morbidities and when employed in experienced
centers
• Supportive care of patients with COVID-19 ARDS was still in questioned because of
the uncertainty around efficacy and potential risks
Pharmacotherapy
• Pharmacotherapy current standards
-corticosteroids for patients with ARDS due to COVID-19
-employing a conservative fluid strategy for patients not in shock
• Evolving standards
-steroids for ARDS not related to COVID-19, or specific biological
agents being tested in appropriate subphenotypes of ARDS
Corticosteriod
• Due to their anti-inflammatory and immune-modulating properties,
glucocorticoids have been considered and studied as a therapy for ARDS for
decades
• Early administration of dexamethasone (20 mg/day from days 1–5, and 10
mg/day from days 6–10) reduced duration of mechanical ventilation and
mortality
• Evaluated the role of corticosteroids in respiratory failure due to COVID-19,
-low-dose dexamethasone for 10-day reduced mortality in hospitalized patients
with COVID-19 who required oxygen or respiratory support
• Thus, in contrast to ARDS from other causes, we have a moderate degree of
certainty that corticosteroids may improve outcomes in patients
Fluid therapy
• ARDS patients who are not in shock should be treated with a conservative fluid
treatment strategy
• It has been recommended that patients with ARDS who no longer have
shock should have their overall fluid balance reduced by 500–1000 mL per day by
use of diuretics, and reducing intravenous fluids until they are euvolemic
• Evolving standard, avoidance of excess fluid administration that is of most
value, rather than diuresis
• A large RCT is ongoing in patients with septic shock, many of whom will likely
have ARDS, comparing a strategy of restrictive fluid and early vasopressors with
liberal fluids, which will likely inform future practice in this area
Conclusion
• Review of current and evolving standards of care from the definition itself and across the domains
of ventilatory management, ventilatory adjuncts and pharmacotherapy for adults with ARDS
• Recognition of the heterogeneity of ARDS led to the call for a more individualized approach to
pressure and volume limitation in ventilatory management
• Prone positioning should be applied as a first-line therapy in moderate and severe ARDS
• Early neuromuscular blockade reserved for those patients persistent high driving pressure, or
who are difficult to oxygenate or ventilate
• We have a moderate degree of certainty that corticosteroids may improve outcomes in patients
• Areas ripe for investigation are many and across all domains, including for example ultra-
protective ventilation facilitated by ECLS, stromal cell therapies, and prospective replication of
effects by hyper/hypo inflammatory sub-phenotype.
• We look to these future developments with much anticipation
Reference