ARDS

Question 1

Mechanical Ventilation Strategies

Answer 1

• ARMA Trial, 2000: Lower tidal volumes (6 mL/kg of predicted body weight) led to lower mortality and fewer ventilator days compared with traditional tidal volumes (12 mL/kg).
• ExPress Trial (2008): Higher PEEP didn’t affect mortality but reduced other complications including the need for rescue therapies and the duration of mechanical ventilation.

Question 2

Prone Positioning

Answer 2

• PROSEVA Trial (2013): Early application of prolonged prone positioning sessions significantly decreased 28-day and 90-day mortality in severe ARDS.

Question 3

Use of Paralytics

Answer 3

• ACURASYS Trial (2010): Early administration of cisatracurium besylate improved adjusted 90-day survival in severe ARDS patients, with no increase in muscle weakness.
• ROSE Trial (2019): Early neuromuscular blockade with cisatracurium did not result in better outcomes than a usual-care approach with lighter sedation targets.

Question 4

Fluid Management

Answer 4

• FACTT Trial (2006): Conservative fluid strategy resulted in better lung function and shorter duration of mechanical ventilation and ICU stay.

Question 5

ECMO for ARDS

Answer 5

• CESAR Trial (2009): Patients with severe but potentially reversible respiratory failure have a significantly increased survival without severe disability if they are transferred to an ECMO center.
• EOLIA Trial (2018): This study showed a non-statistically significant decrease in 60-day mortality with early use of ECMO in severe ARDS patients. However, the trial did show significant improvement in several secondary outcomes such as fewer days of mechanical ventilation and organ failure, which has led to continued debate about the role of ECMO in ARDS.

Question 6

Inhaled Nitric Oxide

Answer 6

• INO in ARDS Study (1998): While inhaled nitric oxide can improve oxygenation in patients with ARDS, it does not improve survival rates.
• Inhaled Nitric Oxide in ARDS (2016): Inhaled nitric oxide did not reduce mortality in patients with ARDS but was associated with improvements in oxygenation.

Question 7

Steroids in ARDS

Answer 7

• ARDSnet Steroids in Late ARDS (2006): Late administration of methylprednisolone (after 14 days) in ARDS was associated with increased mortality.
• Dexamethasone in ARDS (2020): Early administration of dexamethasone in moderate-to-severe ARDS was associated with an increased number of ventilator-free days.

Question 8

High-Frequency Oscillatory Ventilation (HFOV)

Answer 8

• OSCAR Trial (2013): HFOV did not significantly reduce mortality rates in adults with moderate-to-severe ARDS.
• OLIVE Trial (2012): HFOV was not found to be superior to conventional mechanical ventilation and was associated with more adverse events.

Question 9

Recruitment Maneuvers

Answer 9

• Alveolar Recruitment for ARDS Trial (ART, 2017): Use of lung recruitment maneuver and titrated PEEP compared with low PEEP increased 28-day all-cause mortality.

Question 10

Alternative Strategies

Answer 10

• Beta Agonists in ARDS (BALTI-2, 2012): Intravenous infusion of salbutamol in ARDS patients did not lead to improvement and may have contributed to increased mortality.
• ALTA Trial (2014): Aerosolized albuterol did not improve survival or other clinical outcomes in ARDS.
• SAILS Trial (2014): Rosuvastatin did not reduce mortality in sepsis-associated ARDS.
• HARP-2 Trial (2014): Simvastatin did not affect clinical outcomes in ARDS.

Question 11

Driving Pressure

Answer 11

• ARDSnet Driving Pressure Study (2015): Lower driving pressure (plateau pressure - PEEP) was associated with improved survival in ARDS. This introduced the concept of driving pressure as a primary variable of interest in mechanical ventilation.

Question 12

Permissive Hypercapnia

Answer 12

• Laffey and Kavanagh (1999): Described the approach of ‘permissive hypercapnia’ where lower tidal volumes are used even though they may result in elevated CO2 levels. The study showed that it can reduce ventilator-induced lung injury in ARDS, improving patient outcomes.

Question 13

High-Flow Nasal Cannula in ARDS

Answer 13

• FLORALI Trial (2015): Found that in patients with acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or non-invasive ventilation did not result in significantly different intubation rates. However, among patients with ARDS, those in the high-flow-oxygen group had significantly lower intubation rates than those in the standard-oxygen group.