›Tolerate elevated PaCO2
›Maintain pH generally > 7.20
›Prioritize low tidal volume
›Cautions
›Avoid with raised intracranial pressure
›Avoid with severe pulmonary hypertension
›Prone positioning protocol
›Indication
›Moderate-to-severe ARDS PaO2/FiO2 < 150 mmHg
›Strong recommendation for severe ARDS
›Duration
›>= 12 to 16 hours per day
›Daily sessions until improvement
›Combined strategy benefit
›Low tidal volume plus prone positioning
›Greatest mortality reduction
›Monitoring during proning
›Pressure injury surveillance
›Endotracheal tube and line security
›Corticosteroids
›Moderate-to-severe ARDS within 14 days
›Dexamethasone 20 mg IV daily for 5 days
›Then dexamethasone 10 mg IV daily for 5 days
›Avoid initiation past 14 days as may worsen outcomes
›Monitoring
›Glycemic control
›Secondary infection surveillance
›Neuromuscular blockade
›Early severe ARDS with refractory hypoxemia
›Cisatracurium intermittent boluses preferred over continuous infusion
›Limit to <= 48 hours
›Indication specifics
›Ventilator dyssynchrony
›Deep sedation prerequisite
›Treat the underlying cause
›Infection source
›Broad-spectrum antibiotics for suspected infection
›De-escalate with culture data
›Source control
›Drainage of intra-abdominal sepsis
›Surgical intervention when indicated
Fluid management and supportive care
›Conservative fluid strategy
›Net balance target
›Net neutral-to-negative once off vasopressors
›Aggressive diuresis improves ventilator-free days
›Cautions
›Avoid hypoperfusion
›Monitor renal function during diuresis
›Supportive bundle
›VTE prophylaxis
›Subcutaneous heparin or LMWH unless contraindicated
›Mechanical prophylaxis if bleeding risk
›Stress ulcer prophylaxis
›PPI or H2 blocker
›Reassess need with enteral feeding
›Nutrition and sedation
›Early enteral nutrition within 24 to 48 hours
›Sedation titrated to ventilator synchrony
›Daily spontaneous breathing trials when FiO2 <= 0.5 and PEEP <= 8 cm H2O
Rescue therapies for refractory hypoxemia
›Inhaled pulmonary vasodilators
›Inhaled nitric oxide
›Transient oxygenation improvement
›No proven mortality benefit
›Inhaled epoprostenol
›Rescue oxygenation adjunct
›Monitor for hypotension
›VV-ECMO
›Selected severe refractory ARDS
›Refractory to conventional therapy
›Transfer to ECMO center
›Candidate considerations
›Reversible underlying process
›Absence of major contraindications