What are the guidelines for Acute Respiratory Distress Syndrome (ARDS)?

From the Guidelines

The guidelines for Acute Respiratory Distress Syndrome (ARDS) recommend the use of corticosteroids, venovenous extracorporeal membrane oxygenation (VV-ECMO), neuromuscular blockers, and higher positive end-expiratory pressure (PEEP) without lung recruitment maneuvers in selected patients with moderate to severe ARDS.

Key Recommendations

• The use of corticosteroids is suggested for patients with ARDS, with a conditional recommendation and moderate certainty of evidence 1.
• VV-ECMO is suggested for selected patients with severe ARDS, with a conditional recommendation and low certainty of evidence 1.
• Neuromuscular blockers are suggested for patients with early severe ARDS, with a conditional recommendation and low certainty of evidence 1.
• Higher PEEP without lung recruitment maneuvers is suggested for patients with moderate to severe ARDS, with a conditional recommendation and low to moderate certainty of evidence 1.
• Prolonged lung recruitment maneuvers are not recommended for patients with moderate to severe ARDS, with a strong recommendation and moderate certainty of evidence 1.

Ventilator Management

• Mechanical ventilation strategies that limit tidal volume (4–8 mL/kg predicted body weight) and inspiratory pressures are recommended 1.
• Prone positioning for > 12 hours per day is recommended for patients with severe ARDS 1.

Important Considerations

• Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations 1.
• The evidence base for supportive modalities for ARDS continues to evolve, and these guidelines will be revisited as new information is available 1.

From the Research

Diagnosis and Definition of ARDS

• Acute respiratory distress syndrome (ARDS) is characterized by acute hypoxaemic respiratory failure with bilateral infiltrates on chest imaging, which is not fully explained by cardiac failure or fluid overload 2.
• ARDS is defined by the Berlin criteria 2, 3.

Management of ARDS

• Guideline recommendations for ARDS management include the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) 4.
• Prone positioning is recommended for at least 12 hours per day for patients with moderate/severe ARDS (PF ratio<20 kPa) 4, 5.
• A conservative fluid management strategy is suggested for all patients 4.
• High-flow nasal cannula oxygenation is weakly recommended for the respiratory management of ARF in general and even for initial management of ARDS 6.
• Noninvasive positive pressure ventilation is also weakly recommended for the management of certain ARF conditions and as initial management of ARDS 6.
• Low tidal volume ventilation is now weakly recommended for all patients with ARF and strongly recommended for patients with ARDS 6.
• Limiting plateau pressure and high-level PEEP are weakly recommended for moderate-to-severe ARDS 6.
• Prone position ventilation with prolonged hours is weakly to strongly recommended for moderate-to-severe ARDS 6, 5.
• Extracorporeal membrane oxygenation (ECMO) is suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS 4, 3.

Respiratory Support Strategies

• The European Society of Intensive Care Medicine (ESICM) guidelines address 21 questions and formulate 21 recommendations on the following domains: definition, phenotyping, and respiratory support strategies including high-flow nasal cannula oxygen, non-invasive ventilation, tidal volume setting, positive end-expiratory pressure, and recruitment maneuvers 5.
• The guidelines also include expert opinion on clinical practice and identify areas of future research 5.