title: The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia.
abstract: OBJECTIVE
  Severe ARDS is often associated with refractory hypoxemia, and early identification and treatment of hypoxemia is mandatory. For the management of severe ARDS ventilator settings, positioning therapy, infection control, and supportive measures are essential to improve survival.
  
  
  RESULTS
  A precise definition of life-threating hypoxemia is not identified. Typical clinical determinations are: arterial partial pressure of oxygen < 60 mmHg and/or arterial oxygenation < 88 % and/or the ratio of PaO2/FIO2 < 100. For mechanical ventilation specific settings are recommended: limitation of tidal volume (6 ml/kg predicted body weight), adequate high PEEP (>12 cmH2O), a recruitment manoeuvre in special situations, and a 'balanced' respiratory rate (20-30/min). Individual bedside methods to guide PEEP/recruitment (e.g., transpulmonary pressure) are not (yet) available. Prone positioning [early (≤ 48 hrs after onset of severe ARDS) and prolonged (repetition of 16-hr-sessions)] improves survival. An advanced infection management/control includes early diagnosis of bacterial, atypical, viral and fungal specimen (blood culture, bronchoalveolar lavage), and of infection sources by CT scan, followed by administration of broad-spectrum anti-infectives. Neuromuscular blockage (Cisatracurium ≤ 48 hrs after onset of ARDS), as well as an adequate sedation strategy (score guided) is an important supportive therapy. A negative fluid balance is associated with improved lung function and the use of hemofiltration might be indicated for specific indications.
  
  
  CONCLUSIONS
  A specific standard of care is required for the management of severe ARDS with refractory hypoxemia.
authors.affiliation: Department of Anesthesia, Operative Intensive Care, University Hospital Regensburg, 93042, Regensburg, Germany. thomas.bein@klinik.uni-regensburg.de.
authors.forename: Thomas
authors.identifier: http://orcid.org/0000-0002-0088-3507
authors.initials: T
authors.lastname: Bein
authors.affiliation: Dipartimento dell'Emergenza e Trapianti d'Organo (DETO), Sezione di Anestesiologia e Rianimazione, Università degli Studi di Bari "Aldo Moro", Bari, Italy.
authors.forename: Salvatore
authors.initials: S
authors.lastname: Grasso
authors.affiliation: Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medicine, Georg-August-University, Goettingen, Germany.
authors.forename: Onnen
authors.initials: O
authors.lastname: Moerer
authors.affiliation: Department of Anaesthesiology, Emergency and Intensive Care Medicine, University Medicine, Georg-August-University, Goettingen, Germany.
authors.forename: Michael
authors.initials: M
authors.lastname: Quintel
authors.affiliation: Reanimation Medicale, Hopital de la Croix Rousse, Hospices Civils de Lyon, Université de Lyon, Lyon, France.|INSERM 955 Equipe 13, Créteil, France.
authors.forename: Claude
authors.initials: C
authors.lastname: Guerin
authors.affiliation: Department of Anesthesia and Operative Intensive Care, Charitè Universitätsmedizin Berlin, Campus Virchow Klinikum and Campus Charitè Mitte, Berlin, Germany.
authors.forename: Maria
authors.initials: M
authors.lastname: Deja
authors.affiliation: Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Canada.
authors.forename: Anita
authors.initials: A
authors.lastname: Brondani
authors.affiliation: Department of Medicine and Interdepartmental Division of Critical Care Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Canada.
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mehta
mesh_terms: D006801:Humans; D017053:Infection Control / Q000592:standards*; D056888:Patient Positioning / Q000592:standards*; D011175:Positive-Pressure Respiration / Q000592:standards*; D012128:Respiratory Distress Syndrome / Q000628:therapy*; D059039:Standard of Care
keywords: Acute respiratory distress syndrome; Infection management; Neuromuscular blockade; Prone positioning; Refractory hypoxemia; Ventilatory settings