Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets (hemodynamic, neurologic, respiratory) and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Confirm ARDS by Berlin criteria; treat underlying cause and apply lung‑protective ventilation.
- Set VT 4–8 mL/kg PBW; keep plateau ≤30 and driving pressure low; titrate PEEP/FiO2 per tables.
- Early prone positioning for PaO2/FiO2 ≤150; consider sedation ± neuromuscular blockade.
- Use conservative fluid strategy once hemodynamically stable; avoid unnecessary transfusions.
- If refractory → consult ECMO center; prevent complications and plan rehab after extubation.
Clinical Synopsis & Reasoning
Use low tidal volume ventilation (4–8 mL/kg PBW) and limit plateau pressure ≤30 cm H2O; apply appropriate PEEP and early prolonged prone positioning in moderate–severe ARDS. Consider neuromuscular blockade and conservative fluid strategy; ECMO in refractory hypoxemia.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|---|---|---|
| Berlin criteria assessment | Diagnosis | Acute hypoxemia with bilateral opacities not fully explained by cardiac failure | PAO2/FiO2 ratio for severity |
| ABG and ventilator mechanics | Monitoring | Driving pressure, plateau pressure | Guide settings |
| CXR/CT and ultrasound | Etiology/complications | Diffuse opacities, pneumothorax | — |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|---|---|---|---|
| Low tidal volume ventilation (4–8 mL/kg PBW) | Vent strategy | Immediate | Reduces VILI and mortality | Requires close monitoring |
| Prone positioning ≥16 h/day (moderate–severe) | Positioning therapy | Hours | Improves oxygenation/outcomes | Need trained team |
| Neuromuscular blockade (early, selected) | Paralysis | Hours | Facilitate ventilator synchrony/proning | Risk of weakness |
| Conservative fluid strategy/diuresis | Fluid mgmt | Hours–days | Improve oxygenation | Balance with perfusion |
| ECMO (VV) | Extracorporeal support | Immediate | Rescue in refractory hypoxemia | Resource intensive |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- ARDSNet/ATS guidelines and PROSEVA trial insights — Link