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Pulmonary

ARDS

Berlin: ≤7 days, bilateral opacities, not fully explained by HF, PEEP ≥5, P/F ≤300 (mild 200–300, moderate 100–200, severe ≤100).

Tarun Ramesh5 min6 questions5 trials

Berlin, then the 6 Ps

ARDS is acute (≤1 week) hypoxemic respiratory failure with bilateral opacities not fully explained by effusion, collapse, nodules, or heart failure, on PEEP ≥5 (Berlin, ). Mild P/F 200–300, moderate 100–200, severe ≤100.

The 6 Ps of hypoxemia — and of ARDS care
  1. P

    PEEP / recruitment

    After is gone, open the lung. Optimal PEEP is a trial, not a religion.

  2. P

    Pipes (PE)

    Always on the mimic list, especially if the plateau is not that high.

  3. P

    Pump (heart)

    Echo. Cardiogenic edema is not ARDS even if the CXR looks white.

  4. P

    Parenchyma

    Pneumonia, aspiration, DAH, acute eosinophilic pneumonia, AIP, AE-IPF.

  5. P

    Pee (fluid)

    : a conservative fluid strategy after resuscitation shortens ventilator days ().

  6. P

    Prone / paralysis / pipes of the vent

    Low VT, prone if P/F <150, paralysis only for dyssynchrony (, ).

Direct hits: pneumonia, aspiration, inhalation, drowning, contusion. Indirect: sepsis, trauma, pancreatitis, burns, bypass, TRALI. Exudative week 1 → proliferative week 2 → fibrotic later ().

Ventilator and rescue

ATS/ESICM/SCCM 2024 (AJRCCM 2024;209:24).

MoveHowWhy
Low tidal volume ( / ARDSNet)VT 4–8 mL/kg predicted body weight, Pplat ≤30, driving pressure ≤15. Permissive hypercapnia to pH ≥7.20–7.25Mortality 31% vs 40% versus 12 mL/kg (). Skip permissive CO2 if ↑ICP, RV failure, TCA/ASA overdose, pregnancy.
Prone ()Within 36 h if P/F <150 on FiO2 ≥0.6 and PEEP ≥5, 16+ hoursMortality win in moderate–severe disease (). Avoid if crashing hemodynamics, unstable C-spine, late pregnancy, fresh sternotomy.
NM blockadeCisatracurium for ventilator dyssynchrony or refractory hypoxemia — not as a default () found no benefit of routine early paralysis in the light-sedation era.
FluidsDry-ish after . Dynamic measures (PPV, passive leg raise): more ventilator-free days, not more dialysis.
SteroidsConsider in selected non-infectious or persistent ARDS per 2024 ATS guidanceNot a substitute for source control. Watch superinfection.