Current and evolving standards of care for patients with ARDS
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NARRATIVE REVIEW
Current and evolving standards of care for patients with ARDS Mario Menk1,2, Elisa Estenssoro3,4, Sarina K. Sahetya5, Ary Serpa Neto6,7,8, Pratik Sinha9, Arthur S. Slutsky10, Charlotte Summers11, Takeshi Yoshida12, Thomas Bein13 and Niall D. Ferguson14,15* © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Abstract Care for patients with acute respiratory distress syndrome (ARDS) has changed considerably over the 50 years since its original description. Indeed, standards of care continue to evolve as does how this clinical entity is defined and how patients are grouped and treated in clinical practice. In this narrative review we discuss current standards – treatments that have a solid evidence base and are well established as targets for usual care – and also evolving standards – treatments that have promise and may become widely adopted in the future. We focus on three broad domains of ventilatory management, ventilation adjuncts, and pharmacotherapy. Current standards for ventilatory management include limitation of tidal volume and airway pressure and standard approaches to setting PEEP, while evolving standards might focus on limitation of driving pressure or mechanical power, individual titration of PEEP, and monitoring efforts during spontaneous breathing. 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. Pharmacotherapy current standards include corticosteroids for patients with ARDS due to COVID-19 and employing a conservative fluid strategy for patients not in shock; evolving standards may include steroids for ARDS not related to COVID-19, or specific biological agents being tested in appropriate subphenotypes of ARDS. While much progress has been made, certainly significant work remains to be done and we look forward to these future developments. Keywords: Acute respiratory distress syndrome, Mechanical ventilation, Prone position, Extra-corporeal life support, Acute respiratory failure Introduction
*Correspondence: [email protected] 14 Interdepartmental Division of Critical Care Medicine, Departments of Medicine and Physiology, Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada Full author information is available at the end of the article
In the more than 50 years, since the modern advent of acute respiratory distress syndrome (ARDS), clinical management has progressed significantly—both in ventilatory management, the mainstay of supportive care, and in ventilatory adjuncts. Progress has also been made in the realm of pharmacotherapy, though this too remains largely as general supportive care rather than specific disease modifying drugs. In this state-of-the-art review we provide updates on the treatment standards for the clinical care of adults with ARDS across these 3 domains and categorize these as Current standards—those for which there is
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