Commentary: Spontaneous Ventilation in the Setting of Early Severe Stabilized ARDS: Heresy?

After 50 years of research in the field of severe Acute Respiratory Distress Syndrome (ARDS) (PaO2/FiO2<100), according to Villar, et al., only 3 interventions stand out: low tidal volume (Vt), muscle relaxants and prone positioning. Nevertheless, some authors have proposed various modalities of spontaneous ventilation in the setting of early severe ARDS. We surmise that immediately after stabilization of acute cardio-ventilatory distress, an “analytical” management of early severe ARDS should include the following: reduced ventilatory demands (i.e. minimized O2 consumption: normothermia, etc.); improved cardiac output; upright positioning; minimized work of breathing, defined by a normalized tidal volume and respiratory rate; normalized acidosis; minimal hypercapnia; high positive end-expiratory pressure (PEEP: 10-24 cm H2O); low-level pressure support; and sedation without respiratory depression or cognitive side effects evoked by alpha-2 agonists. Such an analytical bundle requires evidence-based demonstration.