Maryland CC Project Sonti – Acute Respiratory Distress Syndrome
Oct 20, 2021
Dr. Rajiv Sonti, Assistant Professor and Pulmonary Critical Care leader at MedStar Georgetown, discusses ARDS research and guideline updates. He covers oxygen targets and major trials. He explains when and how to use neuromuscular blockade and how to titrate paralytics. He highlights driving pressure–focused ventilation, inhaled pulmonary vasodilators, and nuanced approaches to extubation and weaning.
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ARDS Oxygen Targets Are Pragmatic Not Definitive
- ARDSNet PO2 target of 55–80 is pragmatic but not strongly evidence-based, chosen to limit oxygen toxicity while preserving oxygen content.
- Trials (LOCO2, ICU-ROX, HOT-ICU) show mixed results; LOCO2 suggested harm with conservative oxygen but was small and stopped early, so higher targets remain acceptable.
Reserve Paralysis For Refractory Hypoxemia Or Severe Dysynchrony
- Use neuromuscular blockade selectively for refractory gas-exchange problems or severe patient–ventilator dyssynchrony rather than routinely in all moderate ARDS.
- Consider sedation depth, prior paralysis, proning rate, and that ROSE found no mortality benefit compared with modern lighter sedation.
Minimize Sedatives Before Starting Paralytics
- If you intend to paralyze for dysynchrony, avoid excessive sedative escalation; aim to minimize total sedative exposure by pausing and reassessing before starting paralytics.
- Titrate paralytic to observable dyssynchrony or gas exchange, not strictly to train-of-four readings.