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 ARDS patients with a PaO 2 /FiO 2 ratio lower than 150 mmHg early treatment with continuous infusion of cisatracurium for 48 h reduces 90-day mortality and barotrauma and increases the number of ventilator-free days and the number of days outside the ICU without increasing the risk of ICU-acquired weakness [74] . The precise mechanism resulting in improved outcomes is not clear. In terms of lung mechanics, better synchrony may lead to more-uniform lung recruitment and improved compliance, gas exchange, and systemic oxygenation. With respect to lung inflammation, it is plausible that improved control of inspiratory volumes and pressures reduces volutrauma, while better control of expiratory volumes and pressures reduces atelectrauma; the result is less pulmonary and systemic inflammation [75] . According to the study protocol, clinicians did not monitor the depth of paralysis with peripheral nerve stimulation, but rather when plateau pressures exceeded 32 cmH 2 O (for more than 10 min, despite increased sedation) an intravenous bolus of cisatracurium was administered. The outcome benefit for rescue therapy with neuromuscular blockade is applicable only to cisatracurium besylate and not to all neuromuscular blocking agents. Optimal dosing and monitoring strategies will need to be further studied.