Adjunctive Therapies May Be Underutilized in ARDS

Approaching adjunctive therapy use in a more consistent and evidence-driven manner may improve outcomes among patients with moderate to severe acute respiratory distress syndrome (ARDS), according to a new study analysis. 

“Adjunctive strategies are an important part of the management of ARDS. However, their application in clinical practice remains inconsistent,” the researchers wrote. 

To determine the frequency and patterns of use of adjunctive strategies among patients with moderate to severe ARDS (defined as Pao2/Fio2 < 150), the researchers analyzed data from the Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure (LUNG SAFE).

Conducted in 2014, LUNG SAFE was a prospective cohort study that comprised patients with severe respiratory failure from 459 intensive care units across 50 countries. 

Using LUNG SAFE data, the researchers compared the frequency of use of widely available adjuncts (neuromuscular blockade, prone position) vs adjuncts requiring specialized equipment (extracorporeal membrane oxygenation, inhaled vasodilators, high-frequency ventilation) among patients in the first 48 hours of moderate to severe ARDS.

In all, 1146 patients had been on invasive ventilation with moderate to severe ARDS. Of these, 811 patients (71%) had received no adjunct within 48 hours of ARDS onset. And of the 335 patients (29%) who did receive adjunctive therapies, 252 (75%) had received a single strategy, and 83 (25%) had received more than 1 strategy.

Among those with ARDS who died, 67% had received no adjunctive strategy in the first 48 hours.

In all, 67% of the patients who had received specialized adjuncts did not receive prone positioning or neuromuscular blockade.

“Three in 10 patients with moderate to severe ARDS, and only one-third of nonsurvivors, received adjunctive strategies over the first 48 [hours] of ARDS,” the researchers wrote.

“Patients that received adjuncts were more likely to have their ARDS recognized, be younger and sicker, have pneumonia, be more difficult to ventilate, and be in a European high-income country than those that did not receive adjuncts,” the researchers concluded.

In addition to yielding improved outcomes among patients, a more consistent and evidence-driven approach may also reduce costs, according to the researchers. 

—Colleen Murphy


Duggal A, Rezoagli E, Pham T, et al; LUNG SAFE Investigators and the ESICM Trials Group. Patterns of use of adjunctive therapies in patients with early moderate to severe ARDS: insights from the LUNG SAFE study. Chest. 2020;157(6):1497-1505.