title: [Therapy of acute respiratory distress syndrome : Survey of German ARDS centers and scientific evidence].
abstract: BACKGROUND
  In addition to specific treatment of the underlying cause, the therapy of acute respiratory distress syndrome (ARDS) consists of lung protective ventilation and a range of adjuvant and supportive measures.
  
  
  OBJECTIVE
  A survey was conducted to determine the current treatment strategies for ARDS in German ARDS centers.
  
  
  METHODS
  The 39 centers listed in the German ARDS network in 2011 were asked to complete a questionnaire collecting data on the clinic, epidemiology as well as diagnostic and therapeutic measures regarding ARDS treatment.
  
  
  RESULTS
  Of the centers 25 completed the questionnaire. In 2010 each of these centers treated an median of 31 (25-75 percentile range 20-59) patients. Diagnostic measures at admission were computed tomography of the thorax (60 % of the centers), whole body computed tomography (56 %), chest x-ray (52 %), abdominal computed tomography (32 %) and cranial computed tomography (24 %). Transesophageal echocardiography was performed in 64 %, pulmonary artery pressure was measured in 56 % and cerebral oximetry in 12 %. Sedation was regularly interrupted in 92 % of the centers and in 68 % this was attempted at least once a day. A median minimum tidal volume of 4 ml/kg (range 2-6) and a maximum tidal volume of 6 ml/kg (4-8) were used. Methods to determine the optimal positive end-expiratory pressure (PEEP) were the best PEEP method (60 %), ARDS network table (48 %), empirical (28 %), pressure volume curve (16 %), computed tomography (8 %), electrical impedance tomography (8 %) and others (8 %). Median minimum and maximum PEEPs were 10 cmH2O (range 5-15) and 21 cmH2O (15-25), respectively. Median plateau pressure was limited to 30 cmH2O (range 26-45). The respiratory rate was set below 20/min in 20 % and below 30/min in 44 %. Controlled ventilator modes were generally preferred with 80 % using biphasic positive airway pressure (BIPAP/BiLevel), 20 % pressure controlled ventilation (PCV) and 4 % airway pressure release ventilation (APRV). Assisted modes were only utilized by 8 % of the centers. Recruitment maneuvers were used by 28 %, particularly during the early phase of the ARDS. Muscle relaxants were administered by 32 % during the early phase of the ARDS. Complete prone positioning was used by 60 % of the centers, whereas 88 % utilized incomplete (135°) prone positioning. Continuous axial rotation was utilized by 16 %. Spontaneous breathing tests were used in 88 % of the centers with 60 % performing these at least once a day. Supportive therapies were frequently applied and mainly consisted of nitrous oxide (44 %), prostacycline (48 %) and corticosteroids (52 %). A restrictive fluid therapy was used in 48 % and a special nutrition regimen in 28 % of the centers. Of the participating centers 22 were able to offer extracorporeal membrane oxygenation (ECMO). In this case, respiratory therapy was modified by further reducing tidal volumes (91 %), inspiratory pressures (96 %) as well as using lower respiratory rates (≤ 8/min in 31 %). Only 9 % reduced PEEP during ECMO. Regular recruitment maneuvers were used by 14 %. Positioning maneuvers during ECMO were used by 82 %.
  
  
  CONCLUSIONS
  Lung protective ventilation with reduced tidal volumes as well as inspiratory pressures represents the current standard of care and was utilized in all network centers. Prone positioning was widely used. Promising adjuvant therapies such as the muscle relaxation during the early phase of the ARDS, fluid restriction and corticosteroids were used less frequently. During ECMO respirator therapy was generally continued with ultraprotective ventilator settings.
authors.affiliation: Klinik und Poliklinik für Anästhesiologie, Oberdürrbacherstr. 6, 97080, Würzburg, Deutschland, Muellenbac_R@ukw.de.
authors.forename: M
authors.initials: M
authors.lastname: Kredel
authors.forename: D
authors.initials: D
authors.lastname: Bierbaum
authors.forename: C
authors.initials: C
authors.lastname: Lotz
authors.forename: J
authors.initials: J
authors.lastname: Küstermann
authors.forename: N
authors.initials: N
authors.lastname: Roewer
authors.forename: R M
authors.initials: RM
authors.lastname: Muellenbach
mesh_terms: D015199:Extracorporeal Membrane Oxygenation; D005858:Germany / Q000453:epidemiology; D019538:Health Care Surveys; D006760:Hospitalization / Q000706:statistics & numerical data; D006801:Humans; D010366:Peak Expiratory Flow Rate; D012121:Respiration, Artificial; D012128:Respiratory Distress Syndrome / Q000175:diagnosis / Q000453:epidemiology / Q000628:therapy*; D012129:Respiratory Function Tests; D013990:Tidal Volume
references.citation: Intensive Care Med. 2014 Mar;40(3):388-96
references.pmid: 24435201
references.citation: Intensive Care Med. 2010 Apr;36(4):585-99
references.pmid: 20130832
references.citation: Chest. 2000 Jun;117(6):1690-6
references.pmid: 10858404
references.citation: N Engl J Med. 2006 Jun 15;354(24):2564-75
references.pmid: 16714767
references.citation: Am J Respir Crit Care Med. 2002 Dec 1;166(11):1510-4
references.pmid: 12406836
references.citation: Anesthesiology. 2009 Oct;111(4):826-35
references.pmid: 19741487
references.citation: Perfusion. 2014 Mar;29(2):171-7
references.pmid: 23985422
references.citation: JAMA. 2012 Jun 20;307(23):2526-33
references.pmid: 22797452
references.citation: N Engl J Med. 2010 Sep 16;363(12):1107-16
references.pmid: 20843245
references.citation: N Engl J Med. 2013 Jun 6;368(23):2159-68
references.pmid: 23688302
references.citation: Crit Care Med. 2009 May;37(5):1594-603
references.pmid: 19325471
references.citation: JAMA. 2010 Mar 3;303(9):865-73
references.pmid: 20197533
references.citation: Anaesthesist. 2004 Nov;53(11):1054-60
references.pmid: 15372177
references.citation: N Engl J Med. 1998 Feb 5;338(6):347-54
references.pmid: 9449727
references.citation: Intensive Care Med. 2013 May;39(5):847-56
references.pmid: 23306584
references.citation: N Engl J Med. 2000 May 18;342(20):1471-7
references.pmid: 10816184
references.citation: Acta Radiol. 1999 Sep;40(5):552-5
references.pmid: 10485247
references.citation: N Engl J Med. 2000 May 4;342(18):1301-8
references.pmid: 10793162
references.citation: N Engl J Med. 2006 May 25;354(21):2213-24
references.pmid: 16714768
references.citation: Am J Respir Crit Care Med. 2001 Jul 1;164(1):43-9
references.pmid: 11435237
references.citation: JAMA. 2003 Jun 11;289(22):2983-91
references.pmid: 12799407
references.citation: Am J Respir Crit Care Med. 2012 Apr 1;185(7):763-8
references.pmid: 22268135
references.citation: Intensive Care Med. 2014 Jan;40(1):74-83
references.pmid: 24170143
references.citation: Anesth Analg. 2011 Jun;112(6):1411-21
references.pmid: 21372277
references.citation: Curr Opin Crit Care. 2014 Feb;20(1):98-103
references.pmid: 24247614
references.citation: Anaesthesist. 2012 Apr;61(4):344-53
references.pmid: 22526745
references.citation: Crit Care. 2014 Jun 30;18(3):442
references.pmid: 25041935
references.citation: Lancet. 2009 Oct 17;374(9698):1351-63
references.pmid: 19762075
references.citation: JPEN J Parenter Enteral Nutr. 2008 Nov-Dec;32(6):596-605
references.pmid: 18974237