Running head: INTERVENTIONS FOR SEVERE ARDS

Interventions to Mitigate Severe Acute Respiratory Distress Syndrome

Jassmine Bradley

University of Mary

Submitted to Mike Wahl, in partial fulfillment of requirements for

RTH 470: Research & Evidence Based Practice

April 24, 2020

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INTERVENTIONS FOR SEVERE ARDS

Interventions to Mitigate Severe Acute Respiratory Distress Syndrome

Introduction

In its most severe form, acute respiratory distress syndrome (ARDS) is a difficult illness

to treat given its high mortality rate. Multiple interventions have been used in order to mitigate

and cure the effects of this syndrome. Interventions include, but not limited to, conventional

mechanical ventilation, high frequency ventilation, low-volume lung protective ventilation, and

extracorporeal membrane oxygenation management.

ARDS is a form of respiratory failure that presents as a sudden emergence of

inflammation in the pulmonary system. Because of its high mortality rate and bleak prognosis,

this illness often requires mechanical ventilation (MV) as an effective method of treatment (Sun

et. al, 2020). This paper will analyze different interventions used to mitigate the effects of severe

ARDS.

To categorize its severity, one would use the Berlin definition of ARDS. It is categorized

as mild, moderate or severe by obtaining an arterial blood sample to determine the partial

pressure of oxygen (PaO2) and dividing it by the fraction of inspired oxygen (FiO2). Less than

300, 200, and 100mmHg determines the classification respectively (American Thoracic Society,

2018). According to the Berlin definition, ARDS is an inflammatory lung injury that leads to

increased alveolar permeability that proliferates lung weight. This, manifests in bilateral

radiographic opacities and hypoxemia that is correlated to an increase in physiological dead

space and poorer lung compliance.

Conventional Mechanical Ventilation

Conventional mechanical ventilation (CMV) signifies the practice of a positive pressure

ventilator that delivers a tidal volume (VT) with targeted and cycling parameters (Man, 2015).
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The goal of CMV is to generate a VT to help preserve appropriate gas exchange within the lung

parenchyma.

Although CMV proves to be beneficial in some instances, improper use can lead to

detrimental consequences. Ventilator induce lung injury (VILI) arises when mechanical

ventilation is the established source of lung damage (Guerin et. al, 2011). Several mechanisms of

injury can be classified as VILI. Barotrauma occurs when high alveolar pressure rupture alveoli

causing a pneumothorax. Air accumulation may also cause other injuries such as

pneumopericardium, pneumomediastinum, and subcutaneous emphysema. Volutrauma takes

place when lung tissue is damaged by alveolar distention. This injury can increase alveolar

permeability which may lead to pulmonary edema (Combes et. al, 2018). Atelectrauma occurs

when alveoli are damaged by the repetitive recruitment and derecruitment during each

ventilatory breath. Oxygen toxicity occurs when high FiO2 is inspired for a prolonged period of

time and can lead to pulmonary fibrosis (Hopkins & Li, 2017). It can also cause absorption

atelectasis, which occurs when the naturally occurring nitrogen in the alveoli is washed out by

increased FiO2 resulting in collapse. Biotrauma takes place when the preceding traumas activate

a biological reaction that initiates proinflammatory mediators that results in neutrophilic

migration, slackening of the vascular smooth muscles, and edema, which can consummate or

aggravate the effects of ARDS (Beitler et. al, 2016).

Low Volume Lung Protective Ventilation

CMV can worsen the very illness it’s trying to treat, which is why certain ventilatory

techniques are used to reduce further injury. According to Cannon, Gutsche, & Brodie (2017),

the management goal for ARDS is to cautiously support alveolar gas exchange without

additional damage to the lungs. The primary and most optimal method appears to be with a low
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volume, low pressure ventilation. This lung protective approach restrictions a patient’s VT to 4-8

mL/kg of predicted body weight (PBW) to limit plateau pressure (Pplat) ≤ 30 cmH2O. To

optimize lung parenchyma, gas exchange goals of oxygen saturations between 88%-95% and a

pH ≥ 7.30 with an acceptable lactate level (Cannon et. al, 2017). One way to achieve low VT is

by implementing permissive hypercapnia. Permissive hypercapnia is strategy that allows higher

PaCO2 levels to easily achieve low VT. Another strategy to optimize gas exchange for patients

with severe ARDS with hypoxemia is prone positioning (PP). PP alters the mechanism and

composition of gas exchange in order to increase ventilation/perfusion (V/Q) matching. PP

allows for uniform VT delivery while recruiting resting lung volume by decreasing the

superimposed weight of the abdomen and heart. This, in turn, distributes pulmonary perfusion to

the dorsal lung areas which increases alveolar V/Q matching (Guerin et. al, 2018).

High Frequency Oscillatory Ventilation

High frequency oscillatory ventilation (HFVO) is an alternative mode of mechanical

ventilation that uses high frequencies with very low VT (Sklar, Fan, & Goligher, 2017). Its

properties seem like an ideal mode of ventilation to prevent VILI in patients with ARDS,

however, many randomized controlled trials have proved it to provide little to no improvement in

mortality in the adult population.

Airway Pressure Release Ventilation

Airway pressure release ventilation (APRV) is another form of mechanical ventilation

that uses two stages of positive airway pressure that allows spontaneous respirations during the

ventilatory phase (Henzler, 2011). APRV has a high level of positive pressure, that patients

spend the majority of the time on, and a brief expiratory release phase to enable ventilation. A

study done by Mireles-Cabodevila (2018), suggests patients with severe ARDS on APRV
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showed improvement in gas exchange and lung compliance, however, it does not acknowledge

any improvement in morbidity and mortality. Therefore, more research needs to be concluded in

order to suggest that APRV improves mortality outcomes in patients with severe ARDS.

Extracorporeal Membrane Oxygenation

Extracorporeal membrane oxygenation (ECMO) is an invasive machine that replaced the role

of the lungs (venovenous) or heart and lungs (venoarterial). ECMO does not provide direct

therapy for patients with ARDS, however, it does permit safe alveolar gas exchange by

permitting lung protective ventilatory settings (Cannon, Gutsche, & Brodie, 2017). According to

a randomized controlled trial done by Combes and his colleagues (2018), early application of

ECMO did not show significant mortality benefit compared to the control group. Lung protective

mechanical ventilatory settings remain controversial while on ECMO, therefore, more research

must be done in order to prove the optimality of ECMO for patients with severe ARDS.

Inhaled Nitric Oxide

Nitric oxide (NO) is a naturally occurring element in the body that acts as a vasodilator.

Inhaled nitric oxide is used as a discriminatory pulmonary vasodilator to manage pulmonary

hypertension. Pulmonary circulation may be altered by ARDS; therefore, it is known to be the

cause of pulmonary hypertension (Calcaianu et. al, 2018). In a meta-analysis done by Calcaianu

(2018), the application of NO may not statistically improve mortality, however, it significantly

improves hypoxemia with patients with ARDS which may help ease the course of the illness.

Neuromuscular Blockades

Neuromuscular blockages have been widely used in patients with moderate to severe

ARDS. It allows for a total paralysis of a patient for a duration of time. Although neuromuscular

blockade has been linked to intensive care unit (ICU) acquired weakness, a short course of it
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may ease the facilitation of lung protective ventilator settings (Cannon, Gutsche, & Brodie,

2017). Neuromuscular blockades inhibit spontaneous ventilation by relaxing the skeletal muscles

of a patient. This proves to be useful in order to alleviate ventilator desynchrony and allow for

optimal alveolar gas exchange. One randomized control study done by Cannon, Gutsche, &

Brodie (2017), showed that an early application of a neuromuscular blockade was beneficial for

patients with severe ARDS when displaying ventilator desynchrony.

Conclusion

ARDS is a complicated injury that includes many components of the body. Because of its

complicated nature, standardized interventions prove to be difficult to combat this involving

syndrome. Many interventions have proven to be useful to mitigate the effects of ARDS. The

most common intervention is low volume low pressure lung protective ventilation, as it provides

safe ventilation by reducing the risk of further injury to the lungs. Another seemingly beneficial

intervention is the application of ECMO for patients with refractory hypoxemia and severe

ARDS along with neuromuscular blockades to improve ventilator asynchrony. Research show

that combining multiple interventions can mitigate the effects of ARDS thus, decreasing

ventilator days and reducing mortality. Additional studies are crucial in order to determine the

efficacy of each intervention when combined with another in order to facilitate a reduction in

mortality.
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