Acute Respiratory Distress Syndrome (ARDS) is one of the most demanding conditions in an Intensive Care Unit (ICU). Management of
analgesia and sedation in ARDS is particularly challenging. An expert panel was convened to produce a "state-of-the-art" article to support clinicians in the optimal management of
analgesia/sedation in mechanically ventilated adults with ARDS, including those with
COVID-19. Current ICU
analgesia/sedation guidelines promote
analgesia first and minimization of sedation, wakefulness,
delirium prevention and early rehabilitation to facilitate
ventilator and ICU liberation. However, these strategies cannot always be applied to patients with ARDS who sometimes require
deep sedation and/or
paralysis. Patients with severe ARDS may be under-represented in
analgesia/sedation studies and currently recommended strategies may not be feasible. With lightened sedation, distress-related symptoms (e.g.,
pain and discomfort, anxiety,
dyspnea) and
patient-ventilator asynchrony should be systematically assessed and managed through interprofessional collaboration, prioritizing
analgesia and anxiolysis. Adaptation of
ventilator settings (e.g., use of a pressure-set mode, spontaneous breathing, sensitive inspiratory trigger) should be systematically considered before additional medications are administered. Managing the
mechanical ventilator is of paramount importance to avoid the unnecessary use of
deep sedation and/or
paralysis. Therefore, applying an "ABCDEF-R" bundle (R = Respiratory-drive-control) may be beneficial in ARDS patients. Further studies are needed, especially regarding the use and long-term effects of fast-offset drugs (e.g.,
remifentanil, volatile
anesthetics) and the electrophysiological assessment of
analgesia/sedation (e.g., electroencephalogram devices, heart-rate variability, and video pupillometry). This review is particularly relevant during the
COVID-19 pandemic given drug shortages and limited ICU-bed capacity.