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HEATHER R. BREAM-ROUWENHORST, PHARMD., is Clinical Pharmacy. Specialist—Surgery/Transplant, Veterans Affairs Medical Center, Iowa City, IA, and Assistant Professor (Clinical), College of Pharmacy, University of Iowa, Iowa City; at the time of writing she was Critical Care Specialty Resident, Department of Pharmaceutical Care, University of Iowa Hospitals and Clinics (UIHC), Iowa City. ELIZABETH A. BELTZ, PHARM.D., is Clinical Pharmacy Specialist—MICU/Pulmonary/Infectious Disease, Department of Pharmaceutical Care, UIHC, and Assistant Professor (Clinical), College of Pharmacy, University of Iowa. MARY B. ROSS, B.S.PHARM., M.B.A., is Assistant Director, Department of Pharmaceutical Care, UIHC, and Adjunct Associate Professor, College of Pharmacy, University of Iowa, Iowa City. KEVIN G. MOORES, PHARM.D., is Associate Professor (Clinical) and Director, Division of Drug Information Service, College of Pharmacy, University of Iowa.

Address correspondence to Dr. Moores at the College of Pharmacy, University of Iowa, 100 Oakdale Campus N330 OH, Iowa City, IA 52242-5000 (kevin-moores{at}uiowa.edu).

Purpose. Recent developments in the management of acute respiratory distress syndrome (ARDS) in adults are reviewed. Summary. Corticosteroids have been extensively studied in ARDS; however, they have not demonstrated clear benefit in patients with ARDS. Some trials have found increased complications and mortality related to corticosteroid use. The use of conservative fluid management has been associated with significant reductions in morbidity, highlighting the need to avoid fluid overadministration in patients with ARDS. A number of ventilatory strategies have also been studied. Studies have found that higher positive end-expiratory pressure settings do not appear to be harmful in patients with ARDS. In an effort to prevent alveolar overdistention, low tidal volume and plateau pressure ventilation is increasingly being used in patients with acute lung injury (ALI). Given the increasing evidence supporting the use of lower tidal volume ventilation, this strategy has become the new standard of care in patients with suspected ALI and ARDS. No clear benefit has been shown in the treatment of ARDS with nitric oxide and surfactant. Prostaglandins and acetylcysteine are not considered useful in the treatment of ARDS, while no conclusions can be drawn regarding the benefits of albuterol on mortality in patients with ARDS. The use of prone positioning should be discouraged in the treatment of ARDS based on its associated risks. Conclusion. Early administration of moderate-dosage corticosteroids likely helps decrease the time of ventilator dependence and duration of intensive care unit stay. Conservative fluid management and low tidal volume ventilation are becoming increasingly widespread in the management of patients with ARDS. Nitric oxide, surfactant, prostaglandins, albuterol, acetylcysteine, and prone positioning have not been shown to be beneficial in the treatment of ARDS. Index terms: Acetylcysteine; Albuterol; Gases; Mortality; Mucolytic agents; Nitric oxide; Prostaglandins; Pulmonary surfactants; Respiratory distress syndrome; Steroids, cortico-; Sympathomimetic agents; Toxicity