Airway pressure release ventilation [edit]

No particular ventilator mode is known to improve mortality in acute respiratory distress syndrome
(ARDS).[19]
Some practitioners favor airway pressure release ventilation when treating ARDS. Well documented
advantages to APRV ventilation[20] include decreased airway pressures, decreased minute
ventilation, decreased dead-space ventilation, promotion of spontaneous breathing, almost 24-hour-
a-day alveolar recruitment, decreased use of sedation, near elimination of neuromuscular blockade,
optimized arterial blood gas results, mechanical restoration of FRC (functional residual capacity), a
positive effect on cardiac output[21] (due to the negative inflection from the elevated baseline with
each spontaneous breath), increased organ and tissue perfusion and potential for increased urine
output secondary to increased kidney perfusion. [citation needed]
A patient with ARDS, on average, spends between 8 and 11 days on a mechanical ventilator; APRV
may reduce this time significantly and thus may conserve valuable resources. [22]
Positive end-expiratory pressure[edit]
Positive end-expiratory pressure (PEEP) is used in mechanically ventilated people with ARDS to
improve oxygenation. In ARDS, three populations of alveoli can be distinguished. There are normal
alveoli that are always inflated and engaging in gas exchange, flooded alveoli which can never,
under any ventilatory regime, be used for gas exchange, and atelectatic or partially flooded alveoli
that can be "recruited" to participate in gas exchange under certain ventilatory regimens. The
recruitable alveoli represent a continuous population, some of which can be recruited with minimal
PEEP, and others can only be recruited with high levels of PEEP. An additional complication is that
some alveoli can only be opened with higher airway pressures than are needed to keep them open,
hence the justification for maneuvers where PEEP is increased to very high levels for seconds to
minutes before dropping the PEEP to a lower level. PEEP can be harmful; high PEEP necessarily
increases mean airway pressure and alveolar pressure, which can damage normal alveoli by
overdistension resulting in DAD. A compromise between the beneficial and adverse effects of PEEP
is inevitable.[citation needed]
The 'best PEEP' used to be defined as 'some' cmH
2O above the lower inflection point (LIP) in the sigmoidal pressure-volume relationship curve of the

lung. Recent research has shown that the LIP-point pressure is no better than any pressure above it,
as recruitment of collapsed alveoli—and, more importantly, the overdistension of aerated units—
occur throughout the whole inflation. Despite the awkwardness of most procedures used to trace the
pressure-volume curve, it is still used by some[who?] to define the minimum PEEP to be applied to their
patients. Some new ventilators can automatically plot a pressure-volume curve. [citation needed]
PEEP may also be set empirically. Some authors [who?] suggest performing a 'recruiting maneuver'—a
short time at a very high continuous positive airway pressure, such as 50 cmH
2O (4.9 kPa)—to recruit or open collapsed units with a high distending pressure before restoring

previous ventilation. The final PEEP level should be the one just before the drop in PaO
2 or peripheral blood oxygen saturation during a step-down trial. A large randomized controlled trial

of patients with ARDS found that lung recruitment maneuvers and PEEP titration was associated
with high rates of barotrauma and pneumothorax and increased mortality. [23]
Intrinsic PEEP (iPEEP) or auto-PEEP—first described by John Marini of St. Paul Regions Hospital—
is a potentially unrecognized contributor to PEEP in intubated individuals. When ventilating at high
frequencies, its contribution can be substantial, particularly in people with obstructive lung disease
such as asthma or chronic obstructive pulmonary disease (COPD). iPEEP has been measured in
very few formal studies on ventilation in ARDS, and its contribution is largely unknown. Its
measurement is recommended in the treatment of people who have ARDS, especially when
using high-frequency (oscillatory/jet) ventilation.[citation needed]
Prone position[edit]
Main article: Proning

The position of lung infiltrates in acute respiratory distress syndrome is non-uniform. Repositioning
into the prone position (face down) might improve oxygenation by relieving atelectasis and improving
perfusion. If this is done early in the treatment of severe ARDS, it confers a mortality benefit of 26%
compared to supine ventilation.[24][25] However, attention should be paid to avoid the SIDS in the
management of the respiratory distressed infants by continuous careful monitoring of their
cardiovascular system.[25]

Fluid management[edit]
Several studies have shown that pulmonary function and outcome are better in people with ARDS
who lost weight or whose pulmonary wedge pressure was lowered by diuresis or fluid restriction.[10]

Medications[edit]
As of 2019, it is uncertain whether or not treatment with corticosteroids improves overall survival.
Corticosteroids may increase the number of ventilator-free days during the first 28 days of
hospitalization.[26] One study found that dexamethasone may help. [27] The combination of
hydrocortisone, ascorbic acid, and thiamine also requires further study as of 2018. [28]
Inhaled nitric oxide (NO) selectively widens the lung's arteries which allows for more blood flow to
open alveoli for gas exchange. Despite evidence of increased oxygenation status, there is no
evidence that inhaled nitric oxide decreases morbidity and mortality in people with ARDS.
[29]
 Furthermore, nitric oxide may cause kidney damage and is not recommended as therapy for
ARDS regardless of severity.[30]
Alvelestat (AZD 9668) had been quoted according to one review article. [31]

Extracorporeal membrane oxygenation[edit]

Extracorporeal membrane oxygenation (ECMO) is mechanically applied prolonged cardiopulmonary
support. There are two types of ECMO: Venovenous which provides respiratory support and
venoarterial which provides respiratory and hemodynamic support. People with ARDS who do not
require cardiac support typically undergo venovenous ECMO. Multiple studies have shown the
effectiveness of ECMO in acute respiratory failure. [32][33][34] Specifically, the CESAR (Conventional
ventilatory support versus Extracorporeal membrane oxygenation for Severe Acute Respiratory
failure) trial[35] demonstrated that a group referred to an ECMO center demonstrated significantly
increased survival compared to conventional management (63% to 47%). [36]

Ineffective treatments[edit]
As of 2019, there is no evidence showing that treatments with exogenous surfactants, statins, beta-
blockers or n-acetylcysteine decreases early mortality, late all-cause mortality, duration of
mechanical ventilation, or number of ventilator-free days.