Therapeutic strategies for severe acute lung injury

Objective: In the management of patients with severe acute lung injury and acute respiratory distress syndrome, clinicians are sometimes challenged to maintain acceptable gas exchange while avoiding harmful mechanical ventilation practices. In some of these patients, physicians may consider the use of "rescue therapies" to sustain life. Our goal is to provide a practical, evidence-based review to assist critical care physicians' care for patients with severe acute lung injury and acute respiratory distress syndrome. Data Sources: We searched the PubMed database for clinical trials that examined the use of the following therapies in severe acute lung injury and acute respiratory distress syndrome: recruitment maneuvers, high positive end-expiratory pressure, prone position, high-frequency oscillatory ventilation, glucocorticoids, inhaled nitric oxide, buffer therapy, and extracorporeal life support. Study Selection: All clinical trials that included patients with severe acute lung injury and acute respiratory distress syndrome were included in the review. Data Synthesis: The primary author reviewed the aforementioned trials in depth and then disputed findings and conclusions with the other authors until consensus was achieved. Conclusions: This article is designed to provide clinicians with a simple bedside definition for the diagnosis of severe acute respiratory distress syndrome; to describe several therapies that can be used for severe acute respiratory distress syndrome with an emphasis on the potential risks and the indications and benefits; and to offer practical guidelines for implementation of these therapies. (Crit Care Med 2010; 38: 1644-1650)