Acute Respiratory Distress Syndrome (ARDS)
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Acute respiratory distress syndrome is underrecognized and has a >40% mortality in moderate-to-severe disease. Recognition utilizing the Berlin definition clarifies the mortality risk and drives treatment efforts maximizing survival. Lung protective strategies as well as neuromuscular blockade and prone positioning have been shown to have a survival advantage. Measurement of driving pressure and trans-pulmonary pressure may impede injury to the lung. Recruitment maneuvers and directed fluid management strategy may benefit certain ARDS patients. Optimal care of the ARDS patient includes the ABCDEF bundle.
KeywordsAcute respiratory distress syndrome (ARDS) Berlin definition Positive end-expiratory pressure (PEEP) Plateau pressure Neuromuscular blockade agents Prone positioning Driving pressure Trans-pulmonary pressure Recruitment maneuvers Subphenotypes of ARDS ABCDEF bundle
If one should have a patient developing new-onset or worsening respiratory compromise within 1 week of exposure to relevant risk factors, one should be aware that the patient could be developing ARDS . This syndrome is underrecognized in 40% of all cases  and has a mortality rate of greater than 40% in moderate-to-severe disease .
Once you suspect ARDS, apply the criteria cited in the Berlin definition of ARDS . Recognition of a patient with ARDS and staging (mild, moderate, severe) of the syndrome clarifies the mortality risk and drives treatment efforts maximizing survival. (see table in Algorithm 173.1)
Patients meeting ARDS criteria must have lung protective strategies initiated. These strategies include low tidal volume ventilation, elevated positive end-expiratory pressure (PEEP), and diminished plateau pressures . PEEP strategy should be determined by the ARDS stage [5, 6].
To optimize care of the ARDS patient, the ABCDEF  bundle must be employed.
Presently, there is no compelling evidence to support the routine use of extracorporeal membrane oxygenation , high-frequency oscillatory ventilation , inhaled nitric oxide , or glucocorticoids  in the treatment of ARDS patients.
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