Académique Documents
Professionnel Documents
Culture Documents
Ashley Williams
Abstract
ARDS is a lung condition that causes fluid to leak into the lungs and prevents oxygen
from being delivered to the vital organs in the body. It affects over 190,000 people in the United
States alone each year which results in > 40% morbidity and mortality rates (Grawe, Bennett, &
Hurford, 2016) The syndrome was first described by Ashbaugh in 1967, when there was
mortality rate of approximately 65% (Natt, et al., 2016) Since that time, there have been a variety
of successful treatment strategies used for patients with ARDS. Among those treatments are: (1)
prone positioning; (2) lung protective strategies; (3) early paralysis; (4) extracorporeal membrane
oxygenation (ECMO). Prone positioning has been studied extensively, and data shows that prone
positioning improves oxygenation and lung recruitment when acute lung injuries are present
(Kallet, 2015). Lung protective strategies such as low tidal volume ventilation reduce the risk of
harming lung tissue and alveoli (Mechanical Ventilation, 2016). Another lung protective
strategy is positive end expiratory pressure (PEEP). Studies show a significant decline in
mortality in people who receive higher PEEP levels versus lower PEEP levels (Hess, 2015). The
outcomes of Neuromuscular Blocking Agents (NMBAs) are that they can decrease
inflammation, improve oxygenation, and improve patient ventilator asynchrony in patients with
ARDS (Grawe, Bennett, & Hurford, 2016). ECMO is a rescue strategy for patients with severe
ARDS. After controlled studies, it has become a very common therapeutic strategy for ARDS.
Also, due to technological improvements making it safer and easier to use, physicians are very
favorable to its treatment. The mortality rate of 40% is still considered to be high which requires
more research and studies to be conducted in the treatment of ARDS (Natt, et al., 2016).
TREATMENT STRATEGIES 3
There are a variety of successful treatment strategies for patients with Acute Respiratory
Distress Syndrome (ARDS). ARDS is a lung condition that causes fluid to leak into the lungs
and prevents oxygen from being delivered to the vital organs in the body. ARDS affects over
190,000 people in the United States each year which results in > 40% morbidity and mortality
rates (Grawe, Bennett, & Hurford, 2016). The syndrome was first described by Ashbaugh and his
associates in 1967, when mortality rates were approximately 65% (Natt, et al., 2016). Research
and studies since that time have shown a continued decrease in mortality from ARDS to the
current 40% estimate (Natt, et al., 2016). A 40% mortality rate is still considered very high,
therefore, there has been and will continue to be a great deal of research on the strategies used in
the treatment of severe ARDS. The more severe forms of ARDS have a higher rate of mortality
verses more moderate forms of ARDS (Natt, et al., 2016). Therefore, emphasis of these
therapeutic strategies will be placed on patients with severe ARDS. The major causes of death
in patients with ARDS are severe hypoxemia and multi-system organ failure, secondary to
infection, sepsis, hemodynamic instability, and ventilator induced lung injury (Grawe, Bennett,
& Hurford, 2016, p. 831). The treatment of patients with severe ARDS using the following
strategies: (1) prone positioning; (2) lung protective strategies; (3) early paralysis; (4)
More explanation is necessary regarding the history and definitions of ARDS. Prior to
Ashbaughs research in 1967, von Neergaard in 1929 intimated that, surface tension plays a role
in lung elasticity (Haitsma & Lachmann, p. 117). Then his work showed, the pressure
necessary to fill the lung with liquid was less than half the pressure needed to fill the lung with
air (Haitsma & Lachmann, p. 117). In other words, when the surfactant production is reduced or
impaired, it allows for an increase in surface tension which can further lead to: atelectasis
TREATMENT STRATEGIES 4
formation, impaired gas exchange, pulmonary edema, or hypoxemia (Haitsma & Lachmann).
Prior to 1992, the definition of ARDS pertained mainly to adults. It is interesting to note that in
1994, the American-European Consensus Committee on ARDS expanded the definition to all
Prone positioning (PP) has been in effect since the 1970s when it was observed that
children with cystic fibrosis would position themselves on their hands and knees to improve
ventilation (Kallet, 2015). Concurrently, a study showed that passive mechanical ventilation in
the supine position (SP) resulted in ventilation distributed primarily to nondependent lung
regions where profusion was reduced (Kallet, 2015, p. 1661). Based on further findings, it was
suggested that PP could recruit dependent lung areas. In the recent PROSEVA study and
numerous other meta-analyses randomized control trials, the outcomes showed a reduction in
mortality rates when PP was used as an early and prolonged intervention in patients with severe
ARDS (Kallet, 2015). Experimental studies with moderate PEEP levels (10 cmH2O) have been
conducted on patients with ARDS. The results of these studies showed significant recruitment of
the alveoli in both SP and PP. However, when the patient was placed in SP, recruitment was
limited to the dorsal lung. Whereas, when a patient was placed in PP recruitment was distributed
Since 1974, the use of PP in ARDS has been studied extensively, both clinically and at
the bedside (Marini, Josephs, Mechlin, & Hurford, 2016). In over 40 observational studies, data
shows that PP improves oxygen and lung recruitment when there are acute lung injuries (Kallet,
2015). One clinical study of PP effects on gas exchange in ARDS reported a decrease in V/Q
mismatching when patients were placed in the PP. Although V/Q mismatch decreased from 44%
to 34% in PP, when the patient was placed back into SP, all improvements that had been made
TREATMENT STRATEGIES 5
were reversed (Kallet, 2015). Initiation of PP in early stages of ARDS shows to be most effective
in improving oxygenation, but numerous studies have also resulted in significant improvement in
oxygenation levels when PP was initiated > 5 days after the onset of ARDS. The following graph
positive oxygenation response when placed in PP (Kallet, 2015). The studies conducted used
criteria of a minimum of 10-20 mmHg increase in PaO2 or PaO2/FiO2 ratio in order to show
The magnitude of oxygenation response from the studies mentioned above reads as follows: the
increase in ranges is greater than that of the average ranges for the minimum cut off values
(Kallet, 2015). From the studies that showed results of an increase in PaO2, the average
improvement was between 23 to 78 mmHg. The observational studies that reported results of
PaO2/FiO2 showed an improvement between 21 to 161 mmHg (Kallet, 2015). The intensity and
time course using PP in patients with ARDS may vary in improving oxygenation. Therefore,
patients may respond differently. The following chart is derived from studies conducted by
Papazlan and Lim on the percentage of improvement shown in PaO2/FiO2 levels over prolong
TREATMENT STRATEGIES 6
6 hours
2 hours
Lim
1 hour Papazlan
30 mins
0 10 20 30 40 50 60 70 80
Based on all of these positive results of using prone positioning, it could be recommended as
Nearly all people with severe ARDS are in need of invasive mechanical ventilation. Lung
protective strategies are needed when this intervention is used. It has been shown that lung
protective mechanical ventilation is a well-established therapy for ARDS (Grawe, Bennett, &
Hurford, 2016). There are a couple different lung protective strategies used during mechanical
ventilation in order to protect the lungs of ARDS patients. The first is low tidal volume
ventilation. This reduces the risk of harming lung tissue and alveoli (Mechanical Ventilation,
2016). It is also standard procedure for people requiring mechanical ventilation. After ten
randomized trials, physicians were convinced that this strategy reduced the mortality rate. The
following chart is derived from the ARDSNet protocol and serves as guideline to initial
The second lung protective strategy is high positive end expiratory pressure (PEEP)
versus low PEEP. PEEP is the amount of pressure maintained in the lungs after exhalation that
allows for improvement in gas exchange. It has been stated that a PEEP level should be selected
that balances alveolar recruitment against overdistention (Hess, 2015, p. 1688). During ARDS,
only a fraction of the alveoli are relatively normal: some are collapsed, fluid-filled, or
consolidated (Hess, 2015). When a patient is being mechanically ventilated, the alveoli that are
not affected by ARDS are at risk for overdistention. PEEP coupled with recruitment maneuvers
pressure with the goal to open collapsed alveoli after which sufficient PEEP is applied to keep
the lungs open (Hess, 2015, p.1690). The goal of a recruitment maneuver is to improve
oxygenation. Gattinoni tested the possibility for recruitment in 68 subjects with ARDS. A
computed tomography (CT) was used to take images of the lungs while performing breath holds
at airway pressures of 5, 15, and 45 cmH20 (Hess, 2015). The results of the study showed that
patients at a PEEP of 5 cm H20 with a PaO2/FiO2 of <150, a decrease in dead space, and an
increase in compliance had an increased chance for recruitment, and therefore could benefit from
TREATMENT STRATEGIES 8
the use of recruitment maneuvers or increased levels of PEEP (Hess, 2015). There are various
recruitment maneuvers that can be used, however, for a recruitment maneuver to be effective
there must be sufficient PEEP in order to maintain the recruitment. Patients with severe ARDS
are better candidates for recruitment than patients with mild ARDS (Hess, 2015).
clinical studies of ARDS done by Ashbaugh and Downs reported that the use of PEEP was a
therapeutic of apparent value (Hess, 2015, p. 1693). A later study by Kirby suggested the use
of high levels of PEEP resulted in a great reduction in shunt fraction (Hess, 2015). Gas exchange
is a method for setting optimal PEEP that targets oxygenation. Goligher conducted a study
showing that when an increase in PEEP levels is applied and an improvement in oxygenation
results then the risk of death is decreased (Hess, 2015). The following chart is derived from the
ARDSnet protocol which shows the combinations associated with levels of FiO2 and PEEP that
LOWER PEEP associated with HIGHER HIGHER PEEP associated with LOWER
FiO2 FiO2
5 0.3/0.4 5 0.3
8 0.4/0.5 8 0.3
10 0.5/0.6/0.7 10 0.3
12 0.7 12 0.3
14 0.7/0.8/0.9 14 0.3/0.4
16 0.9 16 0.4/0.5
18 0.9 18 0.5
20 0.5/0.6/0.7/0.8
22 0.8/0.9/1.0
24 1.0
Patients with a PaO2/FiO2 <150 that showed an increase of 25 when PEEP levels were
increased were associated with a decrease in the risk of mortality (Hess, 2015).
TREATMENT STRATEGIES 9
incremental or decremental PEEP titration and selecting the level of PEEP with the highest
compliance (Hess, 2015, p.1695). This setting was first studied by Suter in 1975. The outcome
showed that PEEP corresponding to maximum oxygen delivery corresponded to the lowest
VD/VT and highest compliance (Hess, 2015, p.1695). Recent data from 9 randomized controlled
trials indicates that if there is an increase in PEEP that results in recruitment and improved
compliance, the driving pressure will decrease and lower mortality. The driving pressure is the
There are other approaches to setting PEEP levels, but current evidence is not conclusive as to
There have been clinical trials providing evidence regarding higher versus lower PEEP
levels. In 2 studies, there was a significant decline in mortality in the group who received higher
PEEP levels (Hess, 2015). In a meta-analysis studied by Briel patients with severe ARDS who
received higher levels of PEEP showed a mortality of 34.1%. Those patients who received a
lower PEEP level had a mortality rate of 39.1% (Hess, 2015). A PEEP level of <5 cmH2O is
considered to be harmful to patients with mild ARDS. A balance between alveolar recruitment
and overdistenion should be taken into consideration when determining the appropriate levels of
Blocking Agents (NMBA) are used to aid in comfort and safety in mechanically ventilated
patients (Grawe, Bennett, & Hurford, 2016). Sedatives and opioids are some of the more
common neuromuscular blocking agents that can increase oxygenation and possibly decrease
becomes asynchronies with the mechanical ventilator, it can cause an increase in patient
discomfort, dyspnea, work of breathing, increase respiratory fatigue, and produce measurement
errors in the assessment of breathing frequency and readiness to wean (Grawe, Bennett, &
Hurford, 2016, p. 830). If a NMBA is administered to patients who have become asynchronous
with the mechanical ventilator; it alleviates the patients effort and allows the mechanical
ventilator to control the triggering and cycling of breaths. Along with controlling the patients
breaths, NMBA allows for tidal volumes to be closely regulated. This may result in the decrease
in risk for volutrauma or barotrauma that is caused by high levels of tidal volumes or pressure
causing overdistension to the alveoli (Grawe, Bennett, & Hurford, 2016). Blanch conducted an
mechanical ventilation modes. The subjects asynchrony index was measured based on the
number of asynchronous events that occurred within a one hour time period. The results showed
that an index of <10% was related to a decreased time in ICU, mortality, and less time spent on
they can contribute to lowering the mortality rate for people with severe hypoxemia (Grawe,
Bennett, & Hurford, 2016). Gainnier conducted a randomized control trail using 56 subjects with
ARDS. The purpose of the study was to examine the effects of NMBAs on oxygenation
parameters. The results showed that the NMBA group showed significant improvement over
subjects who received a placebo. After a 48 hour time period, the patients who received NMBAs
demonstrated a significant increase in PaO2/FiO2 ratio. The study continued into a 5 day trail,
and the results further indicated the NMBA group having improved lung compliance and quicker
weaning times with PEEP levels. Another randomized trial by Ford also reported improvements
TREATMENT STRATEGIES 11
in oxygenation when NMBAs were administered to patients with ARDS (Grawe, Bennett, &
Hurford, 2016).
Another positive result of using NMBAs on patients with ARDS would be to limit
inflammation (Grawe, Bennett, & Hurford, 2016). Patients who have ARDS and are
mechanically ventilated are at risk for overinflating and overstretching of the lungs. When this
occurs, it produces a systemic inflammatory response that can contribute to multi-system organ
failure. In a trial conducted by Forel, he evaluated inflammatory cytokine levels in the serum
and bronchoalveolar lavage samples of subjects randomized to NMBA versus placebo (Grawe,
Bennett, & Hurford, 2016, p.832). The outcome illustrated a decrease in interleukin and serum
levels for patients who received the NMBA within 48 hours after randomization. The outcomes
of NMBAs are that they can decrease inflammation, improve oxygenation, and improve patient
ventilator asynchrony in patients with ARDS (Garwe, Bennett, & Hurford, 2016).
severe ARDS. ECMO is a machine that allows the lungs of a patient to relax by taking over the
workload of the lungs. ECMO takes the blood supply coming to the lungs out of the body and
provides oxygen to the blood before returning it to the body. ECMO was first used in 1972 in a
trauma patient with shock lung who was supported with venoarterial ECMO for 75 hours and
survived (ECMO as a Rescue Strategy). Since then its use has steadily increased. In addition
to many studies, there have been improvements in technology mostly in pumps and oxygenators
(Natt, et al., 2016). Then between 1997 and 2009 there was improvement in survival of ECMO
for respiratory failure to 50% (ECMO as a Rescue Strategy). In 2009, a randomized trial called
CESAR studied ECMO therapy vs. conventional mechanical ventilation in patients with ARDS.
The results of this trial showed a 63% survival rate for patients in the ECMO group compared to
TREATMENT STRATEGIES 12
a 47% survival rate for patients who used conventional mechanical ventilation (ECMO as a
Rescue Strategy). The following information is proof of the increase in the use of ECMO for
patients with ARDS from 2008-2012: (1) in 2008, 1 in 1,000 patients underwent ECMO; (2)
from 2008 to 2012, there was a 19% absolute increase and a 70% relative increase (Natt, et al.,
2016). The mortality rates are as follows: (1) in 2008, in patients with ARDS when ECMO was
used the mortality rate was 78%; (2) from 2008 to 2012, a 14% absolute reduction in mortality
and a 19% relative reduction (Natt, et al., 2016). In a case-controlled study presented by Tasi, it
was reported that over a 6 year time frame patients with ARDS who were in ECMO treatment
groups showed a decrease in six-month mortality and an increase in hospital survival (ECMO as
January 2017, cumulative adult respiratory ECLS cases numbered 12,346, with 57% of patients
surviving to hospital discharge (ECMO as a Rescue Strategy). The use of ECMO in a patient
with severe ARDS continues to grow. It has become a very common therapeutic strategy for
ARDS due to technological improvements making it safer and easier to use. Also, physicians are
In conclusion, the treatment strategies: (1) prone positioning; (2) lung protective
strategies; (3) early paralysis; (4) extracorporeal membrane oxygenation have been successful in
treating patient with ARDS. ARDS is a lung condition that has affected over 190,000 people just
in the United States each year (Grawe, Bennett, & Hurford, 2016). When ARDS was identified
by Ashbaugh in 1967, the mortality rates were approximately 65% (Natt, et al., 2016). Through
research and studies using the four above mentioned therapeutic treatments, there has been a
continued decrease in mortality from ARDS to the current estimated 40%. The more severe
forms of ARDS have higher mortality rates than moderate forms of ARDS. Because that
TREATMENT STRATEGIES 13
mortality rate is still considered high, there still needs to be a great deal of research regarding the
References
ECMO as a Rescue Strategy for Severe ARDS and Beyond. (n.d.). Retrieved March 30, 2017,
from http://www.ahcmedica.com/articles/140164-ecmo-as-a-rescue-strategy-for-severe-
ards-and-beyond
Grawe, E. S., Bennett, S., & Hurford, W. E. (2016). Early Paralysis for the Management of
Haitsma, J. J., & Lachmann, B. (n.d.). Minerva Anestesiol, 72, 3rd ser., 117-132. Retrieved March
30, 2017.
Hess, D. R. (2015). Recruitment Maneuvers and PEEP Titration. Respiratory Care, 60(11),
1688-1704. doi:10.4187/respcare.04409
Marini, J. J., Jospehs, S. A., Mechlin, M., & Hurford, W. E. (2016). Should Early Prone
Mechanical Ventilation in ARDS: Research Update. (2016, November 07). Retrieved March 30,
ards-2012-update/
Natt, B. S., Desai, H., Singh, N., Poongkunran, C., Parthasarathy, S., & Bime, C. (2016).
Extracorporeal Membrane Oxygenation for ARDS: National Trends in the United States
http://www.ardsnet.org/tools.shtml
TREATMENT STRATEGIES 15
Toujier, K F. (2003, January 15). Acute Respiratory Distress Syndrome. Retrieved March 30,