Acute respiratory distress syndrome Management Noninvasive ventilation Insufficient evidence to recommend noninvasive ventilation in adult patients with sepsis- induced hypoxemic respiratory failure. I Mechanical ventilation, tidal volume targets Use a lower target tidal volume (6 mL/kg predicted body weight) routinely in patients with ARDS. A Mechanical ventilation, plateau pressure targets Use low plateau pressures (upper limit goal of 30 cmH O) over higher plateau pressures in adult patients with sepsis-induced severe ARDS. B Mechanical ventilation, high-frequency oscillatory ventilation Do not use high-frequency oscillatory ventilation in patients with ARDS. D Pulmonary artery catheterization Do not perform pulmonary artery catheterization routinely in patients with sepsis- induced ARDS. D Corticosteroids Consider administering corticosteroids in patients with sepsis-induced early moderate- to-severe ARDS (PaO /FiO of < 200 and within 14 days of onset). C Inhaled nitric oxide Avoid using inhaled nitric oxide in patients with ARDS. D Mechanical ventilation PEEP targets Q Is the PaO /FiO ratio < 200 mmHg? No No recommendation on specific PEEP targets in patients with PaO /FiO ratio 200 mmHg. Yes No Consider using a high PEEP strategy in patients with ARDS and a PaO /FiO ratio < 200 mmHg (< 27 kPa). C Neuromuscular blocking agents BTS Q Is the PaO /FiO ratio < 150 mmHg? Yes Do not initiate ECMO routinely in all patients with ARDS. D Consider initiating ECMO with lung-protective mechanical ventilation in selected patients with severe ARDS (Lung Injury Score 3 or pH < 7.20 due to uncompensated hypercapnia). C No to all Consider avoiding the routine use of ECMO in patients with ARDS . D Mechanical ventilation, weaning Attempt spontaneous breathing trials in mechanically ventilated patients with sepsis ready for weaning. A Use a weaning protocol to assist in weaning patients with sepsis-induced respiratory failure from mechanical ventilation. B