What is the best guideline for managing Acute Respiratory Distress Syndrome (ARDS)?

Best Guideline for ARDS Management

The 2024 American Thoracic Society (ATS) Clinical Practice Guideline represents the most current and authoritative evidence-based recommendations for managing adult patients with ARDS, building upon and updating the foundational 2017 ATS/ERS/SCCM guideline. 1

Core Ventilation Strategy: Universal for All ARDS Patients

Implement lung-protective ventilation immediately upon ARDS diagnosis with tidal volumes of 4-8 mL/kg predicted body weight (target 6 mL/kg) and plateau pressures <30 cmH₂O. 1, 2 This is a strong recommendation with moderate certainty of evidence and remains the only intervention consistently proven to reduce mortality across all ARDS severity levels. 1

• Calculate predicted body weight precisely: Males = 50 + 0.91 × [height (cm) - 152.4] kg; Females = 45.5 + 0.91 × [height (cm) - 152.4] kg 2
• Accept permissive hypercapnia (pH >7.20) as a necessary consequence of lung protection—do not prioritize normocapnia over tidal volume limitation 2
• Meta-regression demonstrates that larger tidal volume gradients (greater difference between protective and traditional ventilation) correlate with greater mortality reduction 1

PEEP Strategy: Titrate to Disease Severity

For moderate-to-severe ARDS (PaO₂/FiO₂ <200 mmHg), use higher PEEP (typically >10 cmH₂O) without prolonged recruitment maneuvers; for mild ARDS (PaO₂/FiO₂ 200-300 mmHg), lower PEEP may be appropriate. 1, 2

• The 2024 guideline provides a conditional recommendation for higher PEEP in moderate-to-severe ARDS with low-to-moderate certainty of evidence 1
• Strongly recommend against prolonged lung recruitment maneuvers in moderate-to-severe ARDS (strong recommendation, moderate certainty) 1
• Monitor for barotrauma when PEEP exceeds 10 cmH₂O 2
• In hemodynamically unstable patients or those with cirrhosis, use lower PEEP (<10 cmH₂O) for mild ARDS to avoid impairing venous return 2

Prone Positioning: Essential for Severe ARDS

For severe ARDS (PaO₂/FiO₂ <150 mmHg), implement prone positioning for at least 12-16 hours daily. 1, 2 This is a strong recommendation with moderate certainty of evidence. 1

• Duration is critical: trials demonstrating mortality benefit used >12 hours/day proning (RR 0.74; 95% CI 0.56-0.99), while shorter durations showed no benefit 1
• The PROSEVA trial confirmed mortality reduction in severe ARDS with mean baseline PaO₂/FiO₂ of 100 ± 30 mmHg 1
• Accept higher rates of endotracheal tube obstruction (RR 1.76) as a manageable complication 1

Pharmacologic Interventions: New Evidence

Administer systemic corticosteroids to mechanically ventilated patients with ARDS (conditional recommendation, moderate certainty of evidence). 1, 2 This represents new guidance from the 2024 update.

Use neuromuscular blocking agents for up to 48 hours in early severe ARDS (PaO₂/FiO₂ <150 mmHg) (conditional recommendation, low certainty of evidence). 1, 2

• Administer as intermittent boluses rather than continuous infusion when possible 2
• Reserve continuous infusion for persistent ventilator dyssynchrony, need for deep sedation, prone positioning, or persistently high plateau pressures 2

Fluid Management

Use a conservative fluid strategy in established ARDS without tissue hypoperfusion. 2, 3 Conservative fluid management improves ventilator-free days without increasing non-pulmonary organ failures. 2

Rescue Therapy for Refractory Hypoxemia

Consider venovenous extracorporeal membrane oxygenation (VV-ECMO) in carefully selected patients with severe ARDS (PaO₂/FiO₂ <150 mmHg) at experienced centers when conventional therapies fail (conditional recommendation, low certainty of evidence). 1, 2

• ECMO should only be implemented after optimizing ventilation, prone positioning, and other rescue therapies 2
• This intervention is resource-intensive and requires careful patient selection 2

Interventions to Avoid

Strongly recommend against routine use of high-frequency oscillatory ventilation (HFOV) in moderate-to-severe ARDS (strong recommendation, high certainty of evidence). 1

• Do not use β-2 agonists for ARDS treatment without bronchospasm 2
• Do not routinely use pulmonary artery catheters for ARDS management 2

Oxygenation Targets

Target SpO₂ of 88-95% to avoid hyperoxia while maintaining adequate oxygenation. 2 Start supplemental oxygen if SpO₂ <92%, and maintain SpO₂ no higher than 96% in acute hypoxemic respiratory failure. 2

Critical Pitfalls to Avoid

• Do not use tidal volumes >8 mL/kg PBW even if plateau pressures are acceptable—both parameters must be optimized simultaneously 2
• Do not delay prone positioning in severe ARDS—early implementation (within 48 hours) improves outcomes 2
• Do not use prolonged recruitment maneuvers—the 2024 guideline provides a strong recommendation against this practice based on moderate certainty evidence showing potential harm 1
• Do not apply higher PEEP indiscriminately—tailor to ARDS severity (mild vs. moderate-to-severe) and hemodynamic tolerance 1, 2
• Do not prioritize normocapnia over lung-protective ventilation—accept permissive hypercapnia as necessary for lung protection 2

Guideline Evolution and Strength of Evidence

The 2024 ATS guideline 1 represents the most recent high-quality evidence, updating the 2017 ATS/ERS/SCCM guideline 1 with new recommendations on corticosteroids, VV-ECMO, neuromuscular blockade, and refined PEEP/recruitment maneuver guidance. The 2017 guideline's strong recommendations for low tidal volume ventilation and prone positioning in severe ARDS remain unchanged and form the foundation of ARDS management. 1