Adjunctive drug treatment in severe hypoxic respiratory failure

This article reviews the pharmacological treatment of severely hypoxaemic c ritically ill patients, notably those with acute respiratory distress syndr ome (ARDS), acute lung injury or the sepsis syndrome, Haemodynamic support in hypotensive patients often initially requires aggre ssive fluid resuscitation with crystalloids or colloids, combined with vaso pressors to maintain adequate end-organ perfusion. The catecholamine of cho ice in severe hypotension with low systemic resistance is norepinephrine (n oradrenaline); dopamine is often used in mild hypotension. Once haemodynami c stabilisation is achieved, loop diuretics such as furosemide (frusemide) are used to obtain the lowest volaemia that guarantees adequate perfusion, If the fraction of inspired oxygen necessary to achieve the satisfactory ha emoglobin oxygen saturation of 90% approaches 1, a trial of nitric oxide wi th or without almitrine is justified. Oxygen consumption can be lowered by treating fever with paracetamol (acetaminophen) and physical cooling, Occas ionally, deep sedation using a combination of an opioid (most often morphin e or fentanyl) and a benzodiazepine (lorazepam or midazolam) is necessary; in the presence of renal or hepatic insufficiency, propofol is a valid, alt hough expensive, alternative, Paralysis with pancuronium or vecuronium has been associated with critical illness polyneuropathy and is used only as a last resort. Corticosteroids may be indicated in the subacute (fibroproliferative) phase of ARDS. Other anti-inflammatory treatments (such as cytokine antagonists, cyclooxygenase inhibitors, antioxidants or monoclonal anti-endotoxin antib odies), as well as surfactant supplementation, have failed to improve progn osis in randomised trials.