Ventilating ARDS patients : the updates

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 cause of hypoxemia, shunt vs. VA/Q maldistribution and PaO2. 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 as a possible error due to inappropriate intubation is preferable to a possible error of delayed intubation. In moderate and severe ARDS intubation with heavy sedation/muscle relaxation allows to fully characterize the patient. A tidal volume of 6 ml/Kg predicted body weight is suggested, either in pressure or volume control but tailoring tidal volume on residual functional capacity 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 deteriorations to moderate/severe (PaO2/FiO2<150) or severe ARDS a referral center should be contacted.