Mechanical ventilation in patients with acute respiratory distress syndrome: current status and future perspectives

ABSTRACTIntroduction Although there has been extensive research on mechanical ventilation for acute respiratory distress syndrome (ARDS), treatment remains mainly supportive. Recent studies and new ventilatory modes have been proposed to manage patients with ARDS; however, the clinical impact of these strategies remains uncertain and not clearly supported by guidelines. The aim of this narrative review is to provide an overview and update on ventilatory management for patients with ARDS.Areas covered This article reviews the literature regarding mechanical ventilation in ARDS. A comprehensive overview of the principal settings for the ventilator parameters involved is provided as well as a report on the differences between controlled and assisted ventilation. Additionally, new modes of assisted ventilation are presented and discussed. The evidence concerning rescue strategies, including recruitment maneuvers and extracorporeal membrane oxygenation support, is analyzed. PubMed, EBSCO, and the Cochrane Library were searched up until June 2023, for relevant literature.Expert opinion Available evidence for mechanical ventilation in cases of ARDS suggests the use of a personalized mechanical ventilation strategy. Although promising, new modes of assisted mechanical ventilation are still under investigation and guidelines do not recommend rescue strategies as the standard of care. Further research on this topic is required.KEYWORDS: Acute respiratory distress syndromemechanical ventilationventilator-induced lung injurypersonalized mechanical ventilationrescue therapy Article highlights Mechanical ventilation for patients with ARDS should focus on a personalized strategy, with individualized parameters.Current targets of mechanical ventilation include adequate oxygenation, lung protective parameters, and limited patient-ventilator asynchronies, thus mitigating ventilator-induced lung injury.Novel modes of mechanical ventilation are currently under investigation, and preliminary findings have highlighted their potential benefits for patients with ARDS.Rescue strategies are considered for patients with ARDS who are unable to achieve safe oxygenation thresholds, thus optimizing patients’ clinical response.Declaration of interestThe authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.Reviewers disclosurePeer reviewers on this manuscript have no relevant financial relationships or otherwise to disclose.AcknowledgmentsThe authors would like to express their gratitude to Moira Elizabeth Shottler and Lorna O’Brien (authorserv.com) for editing assistance.Additional informationFundingThis paper was funded by the Brazilian Council for Scientific and Technological Development (CNPq), the Rio de Janeiro State Research Foundation (FAPERJ), the Department of Science and Technology (DECIT)/Brazilian Ministry of Health, and the Coordination for the Improvement of Higher Education Personnel (CAPES).