ICU · Respiratory
ARDS and lung-protective ventilation
Also known as Acute respiratory distress syndrome (ARDS) · Lung-protective ventilation · Non-cardiogenic pulmonary oedema · Berlin definition · Low tidal volume ventilation · Prone positioning
ARDS is a syndrome of acute, diffuse, inflammatory lung injury causing increased pulmonary vascular permeability and loss of aerated lung tissue, presenting as refractory hypoxaemia and bilateral opacities not explained by cardiac failure. The ARDSNet trial (2000) established lung-protective ventilation (Vt 6 mL/kg PBW, plateau pressure <30) as the standard of care, reducing mortality from 39.8% to 31.0%. Driving pressure is the ventilation variable most strongly associated with survival (Amato 2015). Adjunctive therapies include prone positioning (PROSEVA: 28-day mortality 16.0% vs 32.8%), early dexamethasone (DEXA-ARDS: 60-day mortality 21% vs 36%), neuromuscular blockade (ROSE: no benefit), and VV-ECMO for refractory cases (EOLIA: no significant benefit but high crossover). Two biologic subphenotypes exist (Calfee 2014, Sinha 2020): hyperinflammatory (day-90 mortality 39% vs 23% hypoinflammatory in SAILS validation) — the basis of precision-medicine approaches.
Checked against its sources on 2 Oct 2026
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Red flags
- Higher driving pressure is the ventilation variable most strongly associated with mortality (Amato 2015) — keep Vt low and minimise ΔP
- Plateau pressure >30 cmH2O causes volutrauma — reduce Vt immediately
- PaO2/FiO2 <80 for >6 h (or <50 for >3 h) despite optimised ventilation and proning — consider VV-ECMO referral (EOLIA criteria)
- ROSE trial (2019): routine cisatracurium does NOT improve survival in moderate-severe ARDS — do not routinely paralyse
- EOLIA trial: early routine VV-ECMO did not significantly reduce mortality — use selectively for refractory cases
- ART trial (2017): aggressive staircase recruitment + titrated high PEEP INCREASED mortality — do not use routine recruitment manoeuvres
- DEXA-ARDS: dexamethasone benefits early (randomised ~24 h after onset) moderate-severe ARDS (P/F <=200) — evidence for late unresolving ARDS is lacking
- Higher PEEP benefits only moderate-severe ARDS (P/F <200) — can harm mild ARDS (Briel 2010 meta-analysis)
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References27ShowHide
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