ARDS

Noncardiogenic pulmonary edema.

How to confirm “Noncardiogenic”?

Gold standard would be RHC, but typically defined clinically

Berlin Criteria

P/F ratio.

Severity ratings (for prognostication, do not influence tx)

• <300 mild
• 100-200 moderate
• <100 severe

PEEP >= 5.

Acute: onset w/in 1wk of insult

Etiologies

Two major branches: Pulmonary vs extrapulmonary.

Extrapulmonary: anything inflammatory (pancreatitis, sepsis)

Mgmt

Low-tidal volume ventilation: 6mL/kg of ideal body weight

NEJM 2000

Finer points from this article:

• 6 vs 12
• plateau pressure targets differed
• allowances for adjusting tidal volume based on ventilation needs
• used pressure control, which has led to wider use of this mode

Conservative fluid mgmt

NEJM 2006

• no mortality difference
• improvements in ventilator-days and ICU days
• CVP endpoint less than 4, almost never reached == never cease to diurese

Proning

NEJM 2013

• large reported mortality benefit
• results called into question

Paralysis

NEJM 2019

• no mortality benefit
• still will paralyse patients, but not early as part of routine practice

Steroids (all-comers)

Lancet 2020

• done just prior to COVID-19
• long enrollment period, very strict enrollment criteria
• possible improvement in ventilator-days and mortality

VV Ecmo

NEJM 2018

• trial ended early for futility, but KM curves did diverge