Ventilatory support in ARDS: Our approach

The competing needs to maintain lung volume for oxygen exchange while avoiding lung-damaging alveolar distending pressures define the key choices for ventilatory support of patients with the acute respiratory distress syndrome (ARDS). These choices include the maximum pressure to be applied to the alveolus during the tidal cycle, the minimum acceptable alveolar pressure, and the pattern and frequency of tidal volume delivery. To avoid injury from high transalveolar stretching forces in the heterogeneous lung in ARDS, we recommend small tidal volumes, relatively high positive end- expiratory pressure levels, and prone positioning. We also minimize oxygen demand, accept permissive hypercapnia and, in some patients, encourage spontaneous breathing.