{"id":19963,"date":"2024-08-23T22:08:10","date_gmt":"2024-08-24T03:08:10","guid":{"rendered":"https:\/\/turnmedical.com\/?p=19963"},"modified":"2024-08-23T22:10:06","modified_gmt":"2024-08-24T03:10:06","slug":"acute-repiratory-distress-syndrome-care","status":"publish","type":"post","link":"https:\/\/turnmedical.com\/acute-repiratory-distress-syndrome-care\/","title":{"rendered":"Acute Respiratory Distress Syndrome: Standards of Care and Salvage Therapies"},"content":{"rendered":"\t\t
\n\t\t\t\t
\n\t\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t

Acute Respiratory Distress Syndrome: Standards of Care and Salvage Therapies\n\n\n<\/h2>\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t\t\t

\"Healthy<\/p>

By Allison Varnum<\/span><\/em><\/p>

In 2019, a study by Papazian outlined the standards of care for ARDS which includes lung protective ventilation, initiating neuromuscular blockade, and prone positioning1<\/span>\u00a0<\/span>.<\/span><\/p>

Because of the decreased lung compliance due to inflammation, atelectasis, and alveolar flooding, mechanical ventilation strategies should limit tidal volumes to 4-8 ml\/kg of predicted body weight (PBW) with plateau pressure < 30 cmH2O3 to prevent hyperinflation and barotrauma1<\/span><\/span>. Patients with moderate to severe ARDS should receive higher positive end expiratory pressure (PEEP) to improve hypoxemia and prevent atelectrauma1<\/span><\/span>.PEEP should be greater than 5 cmH2O when ARDS is confirmed and increased as ARDS becomes more severe but remain an individualized parameter as every patient is different1<\/span><\/span>.<\/span><\/p>

Once a patient with moderate to severe ARDS is intubated and placed on mechanical ventilation, a neuromuscular blocking agent (NMB) via continuous intravenous infusion should be initiated within 48 hours to prevent asynchrony with the ventilator. In one study, NMBs were shown to decrease 90-day mortality and a meta-analysis of 3 randomized control trials showed similar findings1<\/span><\/span>.<\/span><\/p>

Prone positioning in patients with ARDS became a standard of care in 2013 with the publication of the PROSEVA study. Early prone positioning was found to decrease mortality by 50% in patients at 28 days and 42% at 90 days. There was a 50% reduction in cardiac arrest incidence in patients who were proned. Proned patients had an average of 4 less ventilator days and 2 less ICU days3<\/span><\/span>. Physiologically there are many benefits of prone positioning. When a patient is placed in the prone position, the dorsal regions of the lungs (where there is the greatest perfusion) are now independent of gravity. Therefore, shunting is reduced, and V\/Q match is improved4<\/span><\/span>. Additionally, there is more efficient gas exchange and increased lung compliance which reduces the need for high FiO2 and high PEEP5<\/span><\/span>. Placing a patient in the prone position also reduces the weight of the heart pressing on the lungs in turn allowing for greater lung expansion6<\/span><\/span>.<\/span><\/p>

Venovenous (VV) extracorporeal membrane oxygenation (ECMO) is known as a salvage therapy for ARDS1<\/span><\/span>. VV ECMO allows the lungs to rest by reducing tidal volume and intrathoracic pressures. This in turn reduces the risk of ventilator-induced lung injury7<\/span><\/span>. Because both ECMO and prone positioning improve oxygenation, lung compliance, and protective mechanical ventilation, theoretically combining these treatments should lead to reduction in duration of ECMO, mechanical ventilation, and ICU length of stay8<\/span><\/span>.<\/span><\/p>

Also included as a salvage therapy is inhaled nitric oxide (iNO) which is considered an off-label use in ARDS patients. Inhaled nitric oxide facilitates vasodilation in the lungs which reduces shunt and helps decrease pulmonary hypertension. Unfortunately, there is an increased risk of renal failure in adults with the use of iNO and the oxygenation improvement is transient. There is not sufficient evidence to suggest that iNO significantly improves mortality1<\/span><\/span>.<\/span><\/p>

Corticosteroid usage in ARDS has been debated for years. Research has shown that when corticosteroids are administered in the early stage of ARDS when inflammation is occurring the outcome is favorable. However, there is no evidence for improved mortality with the administration of corticosteroids in late-stage ARDS9<\/span><\/span>.<\/span><\/p>

Evidence-based care of ARDS focuses on lung protective ventilation, early administration of neuromuscular blocking agents, and early and prolonged prone therapy1<\/span><\/span>. Prone therapy can be used in conjunction with every treatment modality, even salvage therapy with no adverse effects.<\/span><\/p>

Prone positioning is indicated for many different types of respiratory disorders. The Pronova-O<\/span>2TM<\/span> <\/span>\u00a0Automated Prone Therapy System provides a safe and efficient method for placing patients in the prone position. For additional information, please visit turnmedical.com<\/strong> or call 855-ASK-TURN.\u00a0<\/strong><\/span><\/p><\/div><\/div>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t

\n\t\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t
\n\t\t\t\t\t\t\t

References<\/p>

  1. Papazian, L., Aubron, C., Brochard, L., et al. (2019). Formal guidelines: management of acute respiratory distress syndrome. Annals of intensive care, 9(69). https:\/\/doi.org\/10.1186\/s13613-019-0540-9<\/span><\/li>
  2. Brower, R. G., Ware, L. B., Berthiaume, Y., & Matthay, M. A. (2001). Treatment of ARDS. Chest, 120(4), 1347-1367.<\/span><\/li>
  3. Guerin, C., Reignier, J., Richard, J.C., Bueret, P., Gacouin, A., Boulain, T., Mercier, E., et al. (2013). Prone positioning in severe acute respiratory distress syndrome. New England Journal of Medicine, 368(23). DOI: 10.1056\/NEJMoa1214103<\/span><\/li>
  4. Scholten et al (2017). Treatment of ARDS with prone positioning. CHEST, 151(1), 215-224, https:\/\/journal.chestnet.org\/article\/S0012-3692(16)52643-9\/fulltext<\/span><\/li>
  5. Pelosi, P., Brazzi, L., and Gattinoni, L. (2002). Prone position in acute respiratory distress syndrome. European Respiratory Journal (20), 1017-1028. DOI: 10.1183\/09031936.02.00401702<\/span><\/li>
  6. Gattinoni, L., Busana, M., Giosa, L., Macr\u00ec, M. M., & Quintel, M. (2019). Prone Positioning in Acute Respiratory Distress Syndrome. Seminars in respiratory and critical care medicine, 40(1), 94\u2013100. https:\/\/doi.org\/10.1055\/s-0039-1685180<\/span><\/li>
  7. Franchineau et al. (2020). Prone positioning monitored by electrical impedence tomography in patients with severe acute respiratory distress syndrome on veno-venous ECMO. Ann. Intensive Care,10:12 https:\/\/doi.org\/10.1186\/s13613-020-0633-5<\/span><\/li>
  8. Kimmoun et al. (2015). Prolonged prone positioning under VV-ECMO is safe and improves oxygenation and lung compliance. Ann. Intensive Care 5(35) DOI 10.1186\/s13613-015-0078-4<\/span><\/li>
  9. Kuperminc, E., Heming, N., Carlos, M., and Annane, D. (2023). Corticosteroids in ARDS. Journal of clinical medicine, 12(9), 3340. https:\/\/doi.org\/10.3390\/jcm12093340<\/span><\/li><\/ol>
    1. \u00a0<\/li><\/ol>\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"

      Nulla et consectetur ligula, ut fringilla velit. Interdum et sit amet tempor. In sit amet neque non tellus interdum tincidunt eget eu odio. <\/p>\n","protected":false},"author":3,"featured_media":19965,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"content-type":"","_monsterinsights_skip_tracking":false,"_monsterinsights_sitenote_active":false,"_monsterinsights_sitenote_note":"","_monsterinsights_sitenote_category":0,"footnotes":""},"categories":[10,7,9],"tags":[],"class_list":["post-19963","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-useful-articles","category-company-news","category-industry-news"],"_links":{"self":[{"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/posts\/19963","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/comments?post=19963"}],"version-history":[{"count":9,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/posts\/19963\/revisions"}],"predecessor-version":[{"id":19973,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/posts\/19963\/revisions\/19973"}],"wp:featuredmedia":[{"embeddable":true,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/media\/19965"}],"wp:attachment":[{"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/media?parent=19963"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/categories?post=19963"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/turnmedical.com\/wp-json\/wp\/v2\/tags?post=19963"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}