What is the standard care for the initial ventilator settings in patients with acute respiratory distress syndrome (ARDS)?

Updated: Apr 07, 2020
  • Author: Allon Amitai, MD; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Answer

Answer

ARDS lungs are typically irregularly inflamed and highly vulnerable to atelectasis as well as barotrauma and volutrauma. Their compliance is typically reduced, and their dead space increased. The standard of care for the ventilatory management of patients with ARDS changed dramatically in 2000 with the publication of a large multicenter, randomized trial comparing patients with ARDS initially ventilated with either the traditional tidal volume of 12 mL/kg or a lower TV of 6 mL/kg. This trial was stopped early because the lower tidal volume was found to reduce mortality by an absolute 8.8% (P=0.007). Intriguingly, plasma interleukin 6 concentrations decreased in the low TV group relative to the high TV group (P< 0.001), suggesting a decrease in lung inflammation. [13, 14, 15, 16]

The authors recommend initiating ventilation of patients with ARDS with A/C ventilation at a tidal volume of 6 mL/kg, with a PEEP of 5 and initial ventilatory rate of 12, titrated up to maintain a pH greater than 7.25. There is not yet adequate evidence to routinely recommend PEEP greater than 5 cm water, but, in appropriately monitored circumstances, it may be attempted. [17]  Intrinsic PEEP may occur in patients with ARDS at high ventilatory rates and should be watched for and treated by reducing the rate of ventilation under direct observation until plateau pressures decrease. The authors recommend a target plateau pressure of less than 30 cm water. Once a patient has been stabilized with adequate tidal volumes at a plateau pressure of less than 30 cm water, considering a trial of pressure-cycled ventilation is reasonable.


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