Fluid administration and monitoring in ARDS: which management?
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REVIEW
Fluid administration and monitoring in ARDS: which management? Philippe Vignon1,2,3,16* , Bruno Evrard1,2,3 , Pierre Asfar4, Mattia Busana5, Carolyn S. Calfee6, Silvia Coppola7,8,9 , Julien Demiselle4 , Guillaume Geri10,11,12 , Mathieu Jozwiak13,14 , Greg S. Martin15, Luciano Gattinoni5 and Davide Chiumello7,8,9 © 2020 Springer-Verlag GmbH Germany, part of Springer Nature
Abstract Modalities of fluid management in patients sustaining the acute respiratory distress syndrome (ARDS) are challenging and controversial. Optimal fluid management should provide adequate oxygen delivery to the body, while avoiding inadvertent increase in lung edema which further impairs gas exchange. In ARDS patients, positive fluid balance has been associated with prolonged mechanical ventilation, longer ICU and hospital stay, and higher mortality. Accordingly, a restrictive strategy has been compared to a more liberal approach in randomized controlled trials conducted in various clinical settings. Restrictive strategies included fluid restriction guided by the monitoring of extravascular lung water, pulmonary capillary wedge or central venous pressure, and furosemide targeted to diuresis and/or albumin replacement in hypoproteinemic patients. Overall, restrictive strategies improved oxygenation significantly and reduced duration of mechanical ventilation, but had no significant effect on mortality. Fluid management may require different approaches depending on the time course of ARDS (i.e., early vs. late period). The effects of fluid strategy management according to ARDS phenotypes remain to be evaluated. Since ARDS is frequently associated with sepsis-induced acute circulatory failure, the prediction of fluid responsiveness is crucial in these patients to avoid hemodynamically inefficient—hence respiratory detrimental—fluid administration. Specific hemodynamic indices of fluid responsiveness or mini-fluid challenges should be preferably used. Since the positive airway pressure contributes to positive fluid balance in ventilated ARDS patients, it should be kept as low as possible. As soon as the hemodynamic status is stabilized, correction of cumulated fluid retention may rely on diuretics administration or renal replacement therapy. Keywords: Acute respiratory distress syndrome, Pulmonary edema, Fluid therapies, Water–electrolyte balance, Prognosis
*Correspondence: [email protected] 16 Réanimation Polyvalente, CHU Dupuytren, 2 Avenue Martin Luther King, 87042 Limoges, France Full author information is available at the end of the article
Introduction Patients with the acute respiratory distress syndrome (ARDS) are characterized, to different degrees, by an alteration in pulmonary endothelial and epithelial permeability with associated lung edema. Acute circulatory failure is highly prevalent and potentially prognostic in ARDS patients [1]. Optimal fluid management in these patients remains challenging and controversial because it should provide an adequate oxygen delivery while avoiding inadvertent increase in
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