Key Points
➤ The acute respiratory distress syndrome (ARDS) is a life-threatening
form of respiratory failure characterized by acute hypoxemia and bilateral
radiographic infiltrates.
➤ ARDS management remains largely supportive, high mortality rates
persist, with those who survive often facing long-term impairments.
➤ Since 2017, new data have emerged addressing multiple ARDS therapies
and supportive care interventions that include corticosteroids,
venovenous extracorporeal membrane oxygenation (VV-ECMO)
neuromuscular blocking agents (NMBAs), and positive end expiratory
pressure (PEEP), prompting an update to the guidelines.
➤ This guideline updates and adds to recommendations for the management
of patients with ARDS (Figure 1).
New Recommendations in This Guideline
➤ We suggest using corticosteroids for patients with ARDS (conditional
recommendation, moderate certainty of evidence).
➤ We suggest using venovenous extracorporeal membrane oxygenation in
selected patients with severe ARDS (conditional recommendation, low
certainty of evidence).
➤ We suggest using neuromuscular blockers in patients with early severe
ARDS (conditional recommendation, low certainty of evidence).
➤ With regard to positive end-expiratory pressure (PEEP):
• We suggest using higher PEEP without lung recruitment maneuvers as compared to
lower PEEP in patients with moderate-severe ARDS (conditional recommendation,
low-moderate certainty).
• We recommend against using prolonged lung recruitment maneuvers in patients with
moderate-severe ARDS (strong recommendation, moderate certainty).
Recommendations From the 2017 Guideline That Remain in Place
➤ We recommend using mechanical ventilation strategies that limit
tidal volume (4–8 ml/kg predicted body weight) and inspiratory
pressures (plateau pressure <30 cm H
2
O) in patients with ARDS (strong
recommendation, moderate quality evidence).
➤ We recommend prone positioning for >12 hours per day in patients with
severe ARDS (strong recommendation, moderate certainty of evidence).
➤ We recommend against the routine use of high-frequency oscillatory
ventilation in patients with moderate or severe ARDS (strong
recommendation, high certainty of evidence).
Treatment
