ARDS

The clinician managing ARDS prescribes ventilator strategies, determines the need for rescue therapies, and makes ECMO referral decisions. Advanced ventilator concepts include stress index analysis (pressure-time curve during constant-flow volume ventilation: upward concavity indicates tidal overdistension, downward concavity indicates tidal recruitment, linear shape indicates optimal ventilation), transpulmonary pressure monitoring using esophageal manometry (estimates pleural pressure to calculate true alveolar distending pressure, particularly useful in obesity and abdominal compartment syndrome where elevated pleural pressure makes airway pressures unreliable), and optimal PEEP selection strategies (FiO2/PEEP table vs best compliance PEEP vs transpulmonary pressure-guided PEEP vs electrical impedance tomography EIT-guided PEEP). The EPVent-2 trial compared transpulmonary pressure-guided PEEP to empiric high PEEP and found no mortality difference but improved oxygenation. ECMO referral criteria include: P/F below 60-80 for 6 or more hours despite optimized ventilator settings, prone positioning, and NMB; pH below 7.25 with PaCO2 above 60 for 6 or more hours despite maximal RR (35) and permissive hypercapnia; uncompensated respiratory acidosis despite optimal management. The EOLIA trial showed a trend toward survival benefit with VV-ECMO, and the Bayesian post-hoc analysis suggested a...