HARD DECISIONS IN INTENSIVE CARE UNIT

Intensivecareunitkapak

NON-ECMO APPROACHES FOR ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS)

Gamze Kılıçarslan

Ümrani̇ye Training and Research Hospital, Department of Anesthesia and Intensive Care, İstanbul, Türkiye

Kılıçarslan G. NonEcmo Approaches for Acute Respiratory Distress Syndrome (ARDS). In: Turan S, editor. Hard Decisions in Intensive Care Unit. 1st ed. Ankara: Türkiye Klinikleri; 2025. p.11-21.

ABSTRACT

Acute Respiratory Distress Syndrome (ARDS) is a severe form of acute lung injury characterized by pulmonary inflammation, edema, and hypoxemic respiratory failure. It affects 10% of the patients admitted to the intensive care unit (ICU) and is associated with high mortality rates, particularly in severe cases. The management of ARDS primarily focuses on supportive care and minimizing ventila torinduced lung injury (VILI) through lungprotective ventilation strategies, including low tidal vol ume ventilation, optimal positive endexpiratory pressure (PEEP) adjustments, and prone positioning. Despite advancements in the field, given the lack of targeted therapies for ARDS, the need for ongoing research remains.

Ventilation strategies are the cornerstone of ARDS management. Lungprotective ventilation has been shown to reduce mortality and improve outcomes, though underuse remains a challenge. High PEEP strategies demonstrate potential benefits in specific subgroups, while recruitment maneuvers and highfrequency oscillatory ventilation have limited efficacy and may increase risks. Driving pressure (ΔP) has emerged as a critical metric, with lower ΔP associated with improved survival. Noninvasive respiratory support, such as highflow nasal oxygen (HFNO) and noninvasive ventilation (NIV), is effective in selected cases. However, if intubation is delayed, noninvasive respiratory support carries risks of patient selfinduced lung injury (PSILI).

Pharmacological interventions including corticosteroids and neuromuscular blocking agents (NMBAs) have shown mixed results. Corticosteroids, particularly dexamethasone, are effective in COVID19re lated ARDS, reducing mortality in severe cases. However, the timing and dosage remain critical to avoid adverse effects. NMBAs may benefit patients with moderatetosevere ARDS by reducing baro trauma and improving oxygenation, although routine use is not recommended outside specific con texts. Adjunct therapies, such as inhaled pulmonary vasodilators, provide temporary improvements in oxygenation but lack significant survival benefits.

Prone positioning significantly improves outcomes, especially in severe ARDS, by enhancing oxy genation and reducing VILI. Awakeprone positioning (APP) has gained prominence during the COVID19 pandemic, showing efficacy in reducing intubation rates. However, logistical challenges and inconsistent adherence limit its widespread utility.

This review highlights the importance of evidencebased, individualized management strategies for ARDS. It emphasizes the need for further research to optimize treatments and address gaps in knowl edge, particularly in COVID19associated ARDS. Noninvasive respiratory support, adjunct thera pies, and pharmacological interventions should be tailored to patientspecific needs, guided by clinical judgment and evolving evidence.

Keywords: Acute respiratory distress syndrome; Mechanical ventilation; Ventilatorinduced lung injury; Prone position

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