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

Prone position ventilation consists of delivering mechanical ventilation to the patient turned face-down. This method frequently and sometimes markedly improves oxygenation in patients with ARDS [45] . As a treatment, prone position ventilation results in significantly better oxygenation than mechanical ventilation applied in the supine position in ARDS patients [46] . As such prone positioning is used as an important strategy in life-threatening hypoxemia to avoid serious adverse events or death due to severe hypoxemia. In an individual patient-data Fibroproliferative response of the lung parenchyma Up to 50 % in the "lung-protective era" Decrements in lung function (vital capacity, forced expiratory volume) up to 5 years after discharge meta-analysis of four large RCTs, prone position was associated with a significantly better survival rate in ARDS patients with PaO 2 /FiO 2 < 100 mmHg [47] . However, in a recent trial that showed significantly better survival in the prone position group compared to the supine position [48] in patients with moderate to severe ARDS, the benefit of proning was observed at any level of hypoxemia at the time of randomization and no correlation was found between the magnitude of oxygenation response of the first session and patient survival [49] . Therefore, the beneficial effect of proning is likely explained by factors other than improvement in oxygenation. Among them the prevention of VALI [50, 51] is likely a major contributing factor to the benefit of proning. As such, it should be applied as first-line therapy to any patient with moderate or severe ARDS.