ARDS: the “friday night ventilation”

We wish to report here a practical approach to an ARDS patient as devised by a group of intensivists with different expertise. The referral scenario is an intensive care unit of a Community Hospital with limited technology, where a young doctor, alone, must deal with this complicate syndrome during the night. The knowledge of pulse oximetry at room air and at 100% oxygen allows to estimate the PaO2 and the cause of hypoxemia, shunt vs. VA/Q maldistribution. The ARDS severity (mild (200<PaO2/FiO2≤300), moderate (100<PaO2/FiO2≤200) and severe (PaO2/FiO2≤100)) must be immediately assessed. Noninvasive ventilation should be attempted in mild ARDS only. Possible errors due to inappropriate premature intubation are preferable to a delayed intubation. In moderate and severe ARDS tracheal intubation associated with heavy sedation/muscle relaxation allows to fully characterize the patient. A tidal volume of 6 ml/Kg predicted body weight is recommended, either in pressure or volume control ventilation. Tailoring tidal volume on residual functional capacity, however, is preferable. Plateau pressure greater than 30 cmH2O is acceptable only if chest wall compliance is decreased. In this case maximal attention must be devoted to the hemodynamics. PEEP from 5 to 10, from 10 to 15 and greater than 15 cmH2O should be set in mild, moderate and severe ARDS, respectively. Prone position should be applied in severe ARDS, if experience is available. In case of unchanged conditions or increased ARDS severity a referral center should be contacted.