Approaches to Refractory Hypoxemia in Acute Respiratory Distress Syndrome: Current Understanding, Evidence, and Debate

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Abstract:

Acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) cause substantial morbidity and mortality despite our improved understanding of lung injury, advancements in the application of lung-protective ventilation, and strategies to prevent ventilator-induced lung injury. Severe refractory hypoxemia may develop in a subset of patients with severe ARDS. We review several approaches referred to as “rescue” therapies for severe hypoxemia, including lung-recruitment maneuvers, ventilation modes, prone positioning, inhaled vasodilator therapy, and the use of extracorporeal membrane oxygenation. Each shows evidence for improving oxygenation, though each has associated risks, and no single therapy has proven superior in the management of severe hypoxemia. Importantly, increased survival with these strategies has not been clearly established.

Keywords: ALI; APRV; ARDS; HFOV; acute lung injury; acute respiratory distress syndrome; airway pressure release ventilation; extracorporeal membrane oxygenation; high-frequency oscillatory ventilation; inhaled vasodilators; prone positioning; recruitment maneuvers; refractory hypoxemia

Document Type: Research Article

DOI: http://dx.doi.org/10.4187/respcare.01366

Affiliations: Department of Anesthesiology, University of Virginia School of Medicine, Charlottesville, Virginia, USA

Publication date: October 1, 2011

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