Dry vs wet, FACT showed dry was better, however post hoc study of ARDS NETT showed higher rates of cognitive impairment in dry group. Do it depends which outcomes you are interested in? Vent days, lung protection, or functional and cognitive outcomes.
I agree with Fred's answer.Several studies in human have showed that using diuretics therapy and fluid restriction are beneficial in ARDS and Ali patients by reduction of the amount of EVLW. This approach is beneficial in clinical measures like lung compliance, gas exchange and length of time on the ventilator. However, the diuretic don’t reduce inflammation.
I agree with Fred and Yanick, however if the etiology is known then the use of diuretics may be useful. For example, the patient who is not septic and undergoes an abdominal surgical procedure while receiving large boluses of IV fluid causing ARDS will probably respond better to diuretics since the etiology of the ARDS is due to fluid overload.
ARDS by definition assumes normal LVFP, fluid overload and pulmonary edema with high LVFP would be a different picture. I agree some ARDS patients may have a component of fluid overload but thinking that overload lead to ARDS is a misnomer.
we know diuretics work against water...but in ARDS it is actually inflammatory exudates of which water constitute very little portion
again in an ARDS patient who is already on PEEP the addition of diuretics further decreases venous return thereby cardiac output and thus affect tissue oxygenation
So I think the use of diuretics must be judicious with continous monitoring of the patient if atal to be used.
interesting question , but usefulness of diuretic in ARDS remain unproved.
see the recent review of Roch et al: fluid management in ALI and ARDS; annals of intensive care 2011,1:16
These are also very interesting, touching the colloid and crystalloid debate.
Neamu RF, Martin GS
Curr Opin Crit Care 2013, 19:24–30
DOI:10.1097/MCC.0b013e32835c285b
Myburgh JA, Mythen MG
N Engl J Med 2013;369:1243-51.
DOI: 10.1056/NEJMra1208627
Diuretics only adress part of the question and several of the comments provided so far are exactly on target. The inflammatory response is itself triggered by the type/quantity of fluid used, and mechanical ventilation, among other things. So, by the time one thinks about diuretics, many of the inflammatory triggers have already been pulled. So, I believe FACTT's design was correct in trying to prevent fluid overload in the first place. There are probably subgroups of patients where excess fluid matters more (more FACCT data will be published in 2014).
ARDS is not collection of free water in lungs. It is collection of inflammatory exudates which may be unhomogenous as confirmed by CT scan findings. So, diuretics are not a choice for ARDS.
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