ICU · Pharmacology
Acute respiratory distress syndrome: pharmacological therapies — comprehensive (neuromuscular blockade, inhaled vasodilators, corticosteroids, statins, beta-2 agonists, ECMO pharmacology, fluid management)
Also known as ARDS pharmacotherapy · Steroids in ARDS · Neuromuscular blockade in ARDS · Cisatracurium in ARDS · ACURASYS trial · ROSE trial · DEXA-ARDS trial · BALTI-2 trial · HARP-2 trial · SAILS trial · FACTT trial · Inhaled pulmonary vasodilators · Inhaled nitric oxide ARDS · Inhaled epoprostenol ARDS · Statins in ARDS · Beta-2 agonists in ARDS · ECMO pharmacology · Conservative fluid management ARDS
No specific pharmacological therapy reduces mortality in ALL ARDS patients. Foundation: lung-protective ventilation (ARMA — the proven mortality-reducing intervention), proning (PROSEVA), conservative fluids (FACTT). Selective pharmacotherapy: dexamethasone in moderate-severe ARDS within 24 h of onset (DEXA-ARDS — more ventilator-free days and lower 60-day mortality), 48-h cisatracurium only for severe ARDS (PaO2/FiO2 <150) with ventilator dyssynchrony (ACURASYS positive, ROSE negative), inhaled nitric oxide or epoprostenol as a bridge for refractory hypoxaemia (oxygenation only, no mortality benefit). Avoid: IV beta-2 agonists (BALTI-2 increased mortality), statins (HARP-2, SAILS), high-dose vitamin C (LOVIT composite harm), aspirin for ARDS prevention (LIPS-A).
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Red flags
- NO drug has been proven to reduce mortality in ALL ARDS patients
- IV salbutamol increased 28-day mortality (BALTI-2 trial) — routine beta-2 agonist use in ARDS cannot be recommended
- Statins have NO benefit (HARP-2 simvastatin, SAILS rosuvastatin) — do NOT use for ARDS
- Vitamin C: LOVIT — higher risk of death or persistent organ dysfunction at 28 days — do NOT use
- Neuromuscular blockade: ACURASYS showed benefit, ROSE did NOT — use ONLY in severe ARDS (PaO2/FiO2 <150) with ventilator dyssynchrony, NOT routinely
- Inhaled nitric oxide: transient oxygenation improvement only — NO mortality benefit; increased renal impairment (Afshari meta-analysis); not for routine use
- Corticosteroids: do NOT use in mild ARDS; DEXA-ARDS — dexamethasone in moderate-severe (PaO2/FiO2 <200) at 24 h increased ventilator-free days and reduced 60-day mortality
- ECMO: drugs are sequestered in the circuit (especially lipophilic drugs) and volume of distribution is increased — dose adjustments required
Meet the patient
A 58-year-old woman (165 cm, 70 kg) is intubated 18 h after onset of severe pneumococcal pneumonia. Vt 420 mL (6 mL/kg PBW), RR 28, PEEP 14, FiO2 0.85. ABG: pH 7.30, PaCO2 48, PaO2 68 (P/F 80). Pplat 28, driving pressure 14. Noradrenaline 0.15 for septic shock. Bilateral alveolar infiltrates, normal biventricular function. The ICU consultant asks whether to start dexamethasone.[5]
The question that decides the next 48 hours is the question that decides every ARDS: have I got the foundation right (lung-protective ventilation, proning, conservative fluid), and is this candidate receiving the one selective adjunct she actually meets criteria for, while avoiding the drugs that failed their trials? The ARDS pharmacological landscape is a long list of negative trials, a handful of selective positives, and a single foundation that has never been beaten.[1][16][9]
References25ShowHide
- [1]Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome N Engl J Med, 2000.PMID 10793162
- [2]Dzierba AL, Abel EE, Buckley MS, et al. A review of inhaled nitric oxide and aerosolized epoprostenol in acute lung injury or acute respiratory distress syndrome Pharmacotherapy, 2014.PMID 24734313
- [3]Papazian L, Forel JM, Gacouin A, et al. Neuromuscular blockers in early acute respiratory distress syndrome N Engl J Med, 2010.PMID 20843245
- [4]Moss M, Huang DT, Brower RG, et al. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome N Engl J Med, 2019.PMID 31112383
- [5]Villar J, Ferrando C, Martínez D, et al. Dexamethasone treatment for the acute respiratory distress syndrome: a multicentre, randomised controlled trial Lancet Respir Med, 2020.PMID 32043986
- [6]Gao Smith F, Perkins GD, Gates S, et al. Effect of intravenous β-2 agonist treatment on clinical outcomes in acute respiratory distress syndrome (BALTI-2): a multicentre, randomised controlled trial Lancet, 2012.PMID 22166903
- [7]McAuley DF, Laffey JG, O'Kane CM, et al. Simvastatin in the acute respiratory distress syndrome N Engl J Med, 2014.PMID 25268516
- [8]Truwit JD, Bernard GR, Steingrub J, et al. Rosuvastatin for sepsis-associated acute respiratory distress syndrome N Engl J Med, 2014.PMID 24835849
- [9]Wiedemann HP, Wheeler AP, Bernard GR, et al. Comparison of two fluid-management strategies in acute lung injury N Engl J Med, 2006.PMID 16714767
- [10]Lamontagne F, Masse MH, Menard J, et al. Intravenous Vitamin C in Adults with Sepsis in the Intensive Care Unit N Engl J Med, 2022.PMID 35704292
- [11]Peek GJ, Mugford M, Tiruvoipati R, et al. Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial Lancet, 2009.PMID 19762075
- [12]Kor DJ, Carter RE, Park PK, et al. Effect of Aspirin on Development of ARDS in At-Risk Patients Presenting to the Emergency Department: The LIPS-A Randomized Clinical Trial JAMA, 2016.PMID 27179988
- [13]Afshari A, Brok J, Møller AM, et al. Inhaled nitric oxide for acute respiratory distress syndrome and acute lung injury in adults and children: a systematic review with meta-analysis and trial sequential analysis Anesth Analg, 2011.PMID 21372277
- [14]Steinberg KP, Hudson LD, Goodman RB, et al. Efficacy and safety of corticosteroids for persistent acute respiratory distress syndrome N Engl J Med, 2006.PMID 16625008
- [15]Tomazini BM, Maia IS, Cavalcanti AB, et al. Effect of Dexamethasone on Days Alive and Ventilator-Free in Patients With Moderate or Severe Acute Respiratory Distress Syndrome and COVID-19: The CoDEX Randomized Clinical Trial JAMA, 2020.PMID 32876695
- [16]Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndrome N Engl J Med, 2013.PMID 23688302
- [17]Horby P, Lim WS, Emberson JR, et al. Dexamethasone in Hospitalized Patients With Covid-19 N Engl J Med, 2021.PMID 32678530
- [18]Ranieri VM, Rubenfeld GD, Thompson BT, et al. Acute respiratory distress syndrome: the Berlin Definition JAMA, 2012.PMID 22797452
- [19]Calfee CS, Delucchi K, Parsons PE, et al. Subphenotypes in acute respiratory distress syndrome: latent class analysis of data from two randomised controlled trials Lancet Respir Med, 2014.PMID 24853585
- [20]Hraiech S, Forel JM, Guervilly C, et al. How to reduce cisatracurium consumption in ARDS patients: the TOF-ARDS study Ann Intensive Care, 2017.PMID 28770545
- [21]Shekar K, Fraser JF, Smith MT, Roberts JA Pharmacokinetic changes in patients receiving extracorporeal membrane oxygenation J Crit Care, 2012.PMID 22520488
- [22]Hsu CW, Lee DL, Lin SL, et al. The initial response to inhaled nitric oxide treatment for intensive care unit patients with acute respiratory distress syndrome Respiration, 2008.PMID 17396026
- [23]Nguyen S, Chromi S, Decerbo M, et al. Impact of Inhaled Epoprostenol in Patients on COVID-19 Acute Respiratory Distress Syndrome (ARDS) HCA Healthc J Med, 2023.PMID 37424973
- [24]Kisor DF, Schmith VD Clinical pharmacokinetics of cisatracurium besilate Clin Pharmacokinet, 1999.PMID 9989341
- [25]Lim J, Cox J, Nguyen T, et al. Cisatracurium dosing in a patient with hyperthermia Am J Health Syst Pharm, 2019.PMID 31361873