The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia

Bein, Thomas; Grasso, Salvatore; Moerer, Onnen; Quintel, Michael; Guerin, Claude; Deja, Maria; Brondani, Anita; Mehta, Sangeeta

In the early phase of ARDS, at the time of admission to an ARDS center a lung and whole body computed tomography (CT) may be performed especially in the combination of sepsis and ARDS-if the indication is supported by careful anamnesis, clinical history, and examination-to diagnose (a) focus of infection as the major cause of ARDS; (b) typical complications of ARDS; (c) concomitant disorders requiring therapeutic interventions; and (d) risk factors for extracorporeal lung support. CT is performed for detection of several causal agents of infection (pulmonary infiltrates, ground glass opacities, pleural effusions, pleural empyema, lung abscess, lymphadenopathy, cerebral abscess, cerebral septic embolus, intra-abdominal abscess or infection). Transesophageal echocardiography is useful to exclude endocarditis and pericardial effusion and to assess right and left ventricular function. Flexible bronchoscopy is used as a diagnostic/therapeutic procedure but hypoxemia and hypercapnia may occur during bronchoscopy, and severe hypoxemia (PaO 2 /FiO 2 < 100) might be seen as a contraindication for bronchoalveolar lavage (BAL). Protected specimen brush is used rarely, as it is costly and disposable.