Role of IVIG in Acute Respiratory Distress Syndrome (ARDS)

Current Evidence and Recommendations

The American Thoracic Society recommends lung-protective ventilation strategies, higher PEEP in moderate-to-severe ARDS, prone positioning in severe ARDS, consideration of VV-ECMO in selected severe cases, and corticosteroids for patients with poor oxygenation as standard therapies for ARDS 1
The American College of Rheumatology conditionally recommends IVIG as a treatment option for rapidly progressive interstitial lung disease (RP-ILD) in systemic autoimmune rheumatic diseases, which can present as ARDS 2, 3

IVIG is typically administered with pulse methylprednisolone in the context of RP-ILD in systemic autoimmune rheumatic diseases 2, 3
The primary advantage of IVIG in this setting is its lower infection risk, which is particularly important in critically ill or intubated patients 2, 3
IVIG is conditionally ranked below rituximab and cyclophosphamide in the treatment hierarchy for RP-ILD 2, 3

Early administration of IVIG appears to be more beneficial if considered for RP-ILD in systemic autoimmune conditions 2, 3
IVIG should not be used long-term without clear clinical need due to limited supply and high cost 2, 3
The American Thoracic Society notes that IVIG carries risks of complications, including renal failure 1

The treatment algorithm for ARDS involves first implementing standard ARDS management strategies, including lung-protective ventilation, prone positioning, and consideration of neuromuscular blockade and corticosteroids 1
IVIG should only be considered in specific circumstances, such as ARDS due to rapidly progressive interstitial lung disease in systemic autoimmune rheumatic diseases, as part of combination therapy with pulse methylprednisolone, or when infection risk is a particular concern 2, 3

The American College of Rheumatology conditionally recommends adding IVIG as a treatment option for people with idiopathic inflammatory myopathy-associated ILD (IIM-ILD) and mixed connective tissue disease-associated ILD (MCTD-ILD) progression despite first-line ILD treatment 4, 5
IVIG may be considered in ARDS specifically associated with rapidly progressive interstitial lung disease (RP-ILD) in systemic autoimmune rheumatic diseases 4
IVIG is particularly useful when rapid onset of action is desired, such as in the presence of severe respiratory muscle weakness in IIM-ILD 4