ARDSICU / resuscitation

Bilateral infiltrates, PaO₂/FiO₂ 110 on PEEP 5, 3 days into pneumonia — this is ARDS; the ventilator itself can injure, so set it like a lung-protective protocol.

• P/F falling despite proning
• New subcutaneous emphysema (barotrauma)
• SpO₂ 88% on FiO₂ 100%
• Right heart strain on echo (PEEP/CO₂ effect)

• Cardiogenic pulmonary oedema
• Diffuse alveolar haemorrhage
• Cryptogenic organising pneumonia
• Severe bilateral pneumonia without ARDS

• Berlin: Bilateral infiltrates, ≤1 wk, non-cardiogenic, P/F ≤300 on PEEP ≥5
• VT: 6 mL/kg PBW (4–8) — the single biggest survival lever
• Prone: P/F <150 → ≥16 h/day

• Driving pressure (plateau − PEEP) ≤15 correlates with survival better than VT alone
• Proning works only in moderate-severe (P/F <150) — don't prone mild ARDS
• NMB reserved for severe ARDS with dyssynchrony/refractory hypoxaemia despite proning — not routine (ATS 2023)

• Increase tidal volume 'to improve oxygenation' — volutrauma kills
• Overhydrate the septic ARDS patient after resuscitation
• Withhold corticosteroids dogmatically — ATS 2023 SUGGESTS corticosteroids (e.g., dexamethasone) for ARDS, particularly early moderate-severe; individualise for infection risk

• Using actual body weight for VT
• PEEP too low in moderate-severe disease
• Deep sedation beyond 48 h paralysis (ICU weakness)
• Late ECMO referral — cannulate before multi-organ failure

ICU; wean FiO₂ then PEEP as P/F improves; tracheostomy for slow weaners; post-ICU weakness and PTSD follow-up.