Over the last decade, the management of
acute respiratory distress syndrome (ARDS) has made considerable progress both regarding supportive and pharmacologic
therapies. Lung protective
mechanical ventilation is the cornerstone of ARDS management. Current recommendations on
mechanical ventilation in ARDS include the use of low tidal volume (VT) 4-6 mL/kg of predicted
body weight, plateau pressure (PPLAT) < 30 cmH2O, and driving pressure (∆P) < 14 cmH2O. Moreover,
positive end-expiratory pressure should be individualized. Recently, variables such as mechanical power and transpulmonary pressure seem promising for limiting
ventilator-induced lung injury and optimizing
ventilator settings. Rescue
therapies such as recruitment maneuvers,
vasodilators, prone positioning,
extracorporeal membrane oxygenation, and extracorporeal
carbon dioxide removal have been considered for patients with severe ARDS. Regarding
pharmacotherapies, despite more than 50 years of research, no effective treatment has yet been found. However, the identification of ARDS sub-phenotypes has revealed that some pharmacologic
therapies that have failed to provide benefits when considering all patients with ARDS can show beneficial effects when these patients were stratified into specific sub-populations; for example, those with hyperinflammation/hypoinflammation. The aim of this narrative review is to provide an overview on current advances in the management of ARDS from
mechanical ventilation to pharmacological treatments, including personalized
therapy.