Management of Acute Respiratory

Distress Syndrome (ATS update 2024)

PRESENTER: Anas V P
MODERATOR: Prof Dr Subrata Podder

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Am J Respir Crit Care Med Vol 209, Iss 1, pp 24–36, Jan 1, 2024 2 OF 35
 2023 New Global
definition for non-
intubated patients
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2024 update by
ATS on the
management of
ARDS

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Overview of management

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•Recommendations from the 2017 guideline that remain in
place include
•Mechanical ventilation strategies that limit TV (4–8 mL/kg
PBW) and inspiratory pressures (plateau pressure 30 cm
H2O) in patients with ARDS
•Prone positioning for >12 hours per day in patients with
severe ARDS
• We recommend against the routine use of high-frequency
oscillatory ventilation in patients with moderate or severe
ARDS 6 OF 35
 JAN 1 2024

•1) Corticosteroids for patients with ARDS

•2) Venovenous extracorporeal membrane oxygenation
in selected patients with severe ARDS
•3)Neuromuscular blockers in patients with early severe
ARDS
•4) higher PEEP without lung recruitment manoeuvres
Vs lower PEEP in patients with moderate to severe
ARDS
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•Q1: Should Patients with ARDS Receive Systemic
Corticosteroids?

•Recommendation. We suggest using corticosteroids for

patients with ARDS (conditional recommendation,
moderate certainty of evidence).

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 •POSSIBLE MECHANISM:
• Corticosteroids are anti-inflammatory medications that
inhibit the synthesis of proinflammatory mediators present in
ARDS.

①•ARDS with septic shock

① •COVID-19–related ARDS
• severe community-acquired pneumonia
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Corticosteroids Vs placebo or no corticosteroids in patients
with ARDS. Grouped by COVID-19 Status. 28 day Mortality

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Corticosteroids versus placebo or no corticosteroids in all
patients with ARDS (COVID-19 and non-COVID-19).
Duration of mechanical ventilation.

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Effect of corticosteroids on mortality. Studies are grouped by steroid subtype.

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 Corticosteroids Vs placebo or no corticosteroids in all patients with ARDS
(COVID-19 and non-COVID-19). Rates of neuromuscular weakness

• Corticosteroids versus placebo or no corticosteroids in all patients with ARDS (COVID-19 and non-
COVID-19). Rates of gastrointestinal bleeding

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Corticosteroids Vs placebo or no corticosteroids in all patients with ARDS (COVID-19 and non-COVID-19).
Rates of hyperglycemia.

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DENQUIN et al NEJM 2023

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VV ECMO in ARDS??
•They suggest the use of VV-ECMO in selected patients with
severe ARDS (conditional recommendation, low certainty of
evidence

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•SELECTION CRITERIA OF VV-ECMO
•Patients with reversible etiologies of respiratory failure and
very severe hypoxemia
•PaO2/FIO2 ratio,50mmHg more than 3 hrs
•PaO2/FIO2 ratio,80mmHg more than 6 hrs or
•Hypercapnia (pH,7.25 with PaCO2 >60mmHg for more than
6hrs ) despite optimal conventional management
• who are early (7 d) in their ARDS course and have few risk
factors for the futility of treatment
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PRECAUTIONS

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PRACTICAL CONSIDERATIONS

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CESAR Trial 2010
EOLIA Trial 2019

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Forest plot of 90-day mortality in the intention-to-treat population
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•Q3: Should Patients with ARDS Receive Neuromuscular
Blockade?
•Recommendation. We suggest using neuromuscular blockade
in patients with early severe ARDS (conditional
recommendation, low certainty)
•No recommendation for specific agent, although 2 major trial
used CISATRACURIUM ACURASY Trial
ROSE PETAL trial

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•POSSIBLE MECHANISM
•Decreasing ventilator-induced lung injury via a reduction in
patient-ventilator dyssynchrony
•Reduction in oxygen consumption, inflammation
•EARLY-within 48hrs ,SEVERE-P/F ratio less than 100

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 MORTALITY

Tarazan et al. Intensive Care Medicine (2020)

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 A:barotrauma
B:icu-acquired weakness
C :adverse events

Tarazan et al. Intensive Care Medicine (2020)

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•Q4: Should Patients with ARDS Receive Higher Compared
with Lower PEEP, with or without LRMs?
• We suggest using higher PEEP without LRMs rather than
lower PEEP in patients with moderate to severe ARDS
(conditional recommendation, low-moderate certainty).
•We recommend against using prolonged (PEEP>35 cm
H2O for.60 s) LRMs in patients with moderate to severe
ARDS (strong recommendation, moderate certainty).

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•Higher PEEP can facilitate alveolar recruitment and prevent
cyclic opening/closing injury, which improve gas exchange
by decreasing intrapulmonary shunting and reduce lung stress
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•PEEP can also cause injurious overdistension in aerated lung
and hemodynamic compromise

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Dianti et al American journal of respiratory and ccm 2022

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•In patients with moderate to severe ARDS, higher PEEP
without LRM is associated with a lower risk of death than
lower PEEP.

•A higher PEEP with prolonged LRM strategy is associated

with an increased risk of death when compared with higher
PEEP without LRM

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•The optimal strategy for setting PEEP in Patients with ARDS
remains uncertain.
• Bedside techniques such as the
•Use of oxygenation response
•Driving pressure change
•Stress index
•Electrical impedance tomography

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 all
gi

in wate

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CONCLUSIONS
• Conditional recommendations supporting the use of corticosteroids in
ARDS,
• VV-ECMO in selected patients with severe ARDS,
• Neuromuscular blockers in early severe ARDS
• Higher PEEP without LRMs in moderate to severe ARDS.
• Low tidal volume ventilation
• Proning

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• THANK YOU

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