Pharmacotherapy in acute respiratory distress syndrome—the long and winding road

Ashbaugh’s original case series of patients with acute respiratory distress syndrome (ARDS) had a mortality of 58% (1). Significant gains have been made in the treatment of ARDS with contemporary mortality ranging between 25% and 45% depending upon disease severity (2). In part, improvements are due to general advancements in critical care. Since 1967, new antibiotics have become available for treating pneumonia, continuous renal replacement therapies allow for improved volume management in patients with ARDS and acute renal failure, and sepsis resuscitation is more aggressive and protocolized. Changes in mechanical lung ventilation practices have also improved outcomes. The most salient of these is the widespread adoption of low tidal volume, “protective”, mechanical lung ventilation. In a landmark clinical trial, the ARDS network demonstrated a 9% mortality reduction in patients ventilated with a 6 mL per kilogram tidal volume, compared to patients ventilated with a 12 mL per kilogram tidal volume. Subsequently the practice has become widespread (3). Recently, prone positioning was also shown to lower mortality in patients with severe ARDS (4)