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

ARDS Management Guidelines

All patients with ARDS must receive lung-protective mechanical ventilation with tidal volumes of 4-8 mL/kg predicted body weight and plateau pressures <30 cmH2O, and those with severe ARDS (PaO₂/FiO₂ <150 mmHg) should be placed in prone position for at least 12-16 hours daily. 1

Core Ventilation Strategy: Lung-Protective Ventilation (All ARDS Patients)

Strong recommendations that apply to ALL severity levels:

• Set tidal volume at 6 mL/kg predicted body weight (acceptable range 4-8 mL/kg PBW) 1, 2

  • Males: PBW = 50 + 0.91 × [height (cm) - 152.4] kg
  • Females: PBW = 45.5 + 0.91 × [height (cm) - 152.4] kg 2

• Maintain plateau pressure <30 cmH2O (measure with 0.3-0.5 second inspiratory pause) 1, 2

• Accept permissive hypercapnia with pH >7.20 as a consequence of lung protection 2, 3

• Target SpO₂ of 88-95% to avoid hyperoxia while maintaining adequate oxygenation 2

PEEP Strategy: Titrate Based on ARDS Severity

For moderate-to-severe ARDS (PaO₂/FiO₂ <200 mmHg):

• Use higher PEEP (typically >10 cmH2O) WITHOUT prolonged recruitment maneuvers 1
• This is a conditional recommendation with low-to-moderate certainty 1

For mild ARDS (PaO₂/FiO₂ 200-300 mmHg):

• Lower PEEP may be appropriate 2

Strong recommendation AGAINST:

• Do NOT use prolonged lung recruitment maneuvers in moderate-to-severe ARDS (strong recommendation, moderate certainty) 1

Prone Positioning: Mandatory for Severe ARDS

For severe ARDS (PaO₂/FiO₂ <150 mmHg):

• Implement prone positioning for at least 12-16 hours daily (strong recommendation, moderate certainty) 1, 2
• Prone positioning reduces mortality (RR 0.74) 2
• Duration matters: trials with >12 hours/day showed mortality benefit, shorter durations did not 2

Corticosteroids: Suggested for All ARDS

• Administer systemic corticosteroids to mechanically ventilated patients with ARDS 1
• This is a conditional recommendation with moderate certainty of evidence 1
• This represents NEW guidance from the 2024 American Thoracic Society update 1

Neuromuscular Blockade: Early Use in Severe ARDS

For early severe ARDS (PaO₂/FiO₂ <150 mmHg):

• Use neuromuscular blocking agents for up to 48 hours 1
• Administer as intermittent boluses rather than continuous infusion when possible 2
• Use continuous infusion only for persistent ventilator dyssynchrony, need for deep sedation, prone positioning, or persistently high plateau pressures 2

Fluid Management: Conservative Strategy

• Use a conservative fluid strategy in established ARDS without tissue hypoperfusion 2, 4
• Conservative fluid management improves ventilator-free days without increasing non-pulmonary organ failures 2

Rescue Therapy: VV-ECMO for Refractory Severe ARDS

For severe refractory ARDS despite optimized ventilation, proning, and other rescue therapies:

• Consider VV-ECMO in carefully selected patients at experienced centers 1
• This is a conditional recommendation with low certainty of evidence 1
• ECMO should only be considered in carefully selected patients due to resource-intensive nature 2

Strong Recommendations AGAINST Specific Interventions

• Do NOT use high-frequency oscillatory ventilation (strong recommendation, high certainty) 1, 2, 3, 4
• Do not routinely use pulmonary artery catheters for ARDS management 2
• Do not use β-2 agonists for ARDS treatment without bronchospasm 2

Sedation and Weaning

• Minimize continuous or intermittent sedation, targeting specific titration endpoints 2
• Use spontaneous breathing trials in patients ready for weaning 2
• Implement a weaning protocol for patients who can tolerate weaning 2

Critical Pitfalls to Avoid

• Do NOT prioritize normocapnia over lung-protective ventilation—accept permissive hypercapnia as necessary 2
• Do NOT use tidal volumes >8 mL/kg PBW even if plateau pressures are acceptable—both parameters must be optimized 2
• Do NOT delay prone positioning in severe ARDS—early implementation improves outcomes 2
• Do NOT use recruitment maneuvers routinely or for prolonged periods—these are associated with harm 1
• Do NOT apply higher PEEP indiscriminately—tailor to ARDS severity and hemodynamic tolerance 2
• Do not use excessive oxygen therapy—maintain SpO₂ no higher than 96% in acute hypoxemic respiratory failure 2