Guideline sources The following summarized guidelines for the management of acute respiratory distress syndrome are prepared by our editorial team based on guidelines from the British Thoracic Society (BTS 2019), the Surviving Sepsis Campaign (SSC 2017), and the European Society of Intensive Care Medicine (ESICM/SCCM/ATS 2017). 1 2 3 4 5 5 6 6 Definition ARDS is an acute inflammatory disease of the lungs that develops secondary to pulmonary or extrapulmonary damage to the alveolar-capillary membrane, leading to interstitial and alveolar edema. Clinically, ARDS is characterized by acute hypoxemic respiratory failure, decreased lung compliance, and bilateral radiographic infiltrates in the absence of cardiogenic pulmonary edema. 4 Epidemiology An acute injury to the lungs (direct or indirect) is the most common cause of ARDS, with pneumonia, aspiration of gastric contents, and sepsis accounting for > 85% of all cases. 6 Pathophysiology In the United States, the incidence of ARDS is estimated at 64.2-78.9 cases per 100,000 person- years. 5 https://web.pathway.md/diseases/recNTWckOcmQM1veT 1/8 6/23/23, 2:03 AM Acute respiratory distress syndrome Pathway Disease course Classically, an initial exudative phase with interstitial and alveolar edema is followed by a proliferative phase, which may further progress to a fibrotic phase. The latter is associated with collagen deposition, along with interstitial and alveolar fibrosis, causing decreased lung compliance, respiratory dysfunction, multisystem organ failure, and death. 6 Prognosis and risk of recurrence ARDS is associated with an in-hospital mortality of 27%, 32%, and 45% for mild, moderate, and severe disease, respectively. 5 Pathway Calculator Acute respiratory distress syndr Murray lung injury score Management Guidelines 1. Respiratory support Noninvasive ventilation: insufficient evidence to assess the risks and benefits of noninvasive ventilation for patients with sepsis-induced ARDS. Head of the bed elevation: maintain the head of the bed elevated to 30-45 degrees in mechanically ventilated patients with sepsis to limit aspiration risk and the development of ventilator-associated pneumonia. B Tidal volume targets: As per BTS 2019 guidelines, use a lower target tidal volume (6 mL/kg predicted body weight) routinely in patients with ARDS. A Landmark trials: ARDSNet In patients with ARDS and acute lung injury, ventilation with lower tidal volumes were superior to traditional tidal volume with respect to hospital death. Brower RG et al. N Engl J Med. 2000 May 4. As per ATS 2017 guidelines, use limiting tidal volumes (4-8 mL/kg predicted body weight) and inspiratory pressures (plateau pressure < 30 cmH O) in adult patients with ARDS. B As per SSC 2017 guidelines: https://web.pathway.md/diseases/recNTWckOcmQM1veT 2/8 6/23/23, 2:03 AM Acute respiratory distress syndrome Pathway Use a target tidal volume of 6 mL/kg predicted body weight in adult patients with sepsis- induced ARDS. A Consider using low tidal volumes over higher tidal volumes in adult patients with sepsis- induced respiratory failure without ARDS. C Plateau pressure targets: target plateau pressures < 30 cm H O in adult patients with sepsis- induced severe acute respiratoire distress syndrome. B PEEP targets: As per BTS 2019 guidelines, consider using a high PEEP strategy in patients with ARDS and a PaO /FiO ratio < 200 mmHg (< 27 kPa). C As per ATS 2017 guidelines, consider using higher rather than lower levels of PEEP strategy in adult patients with moderate or severe ARDS. C As per SSC 2017 guidelines, consider using a high PEEP strategy in adult patients with sepsis- induced moderate-to-severe ARDS. C Prone positioning: As per BTS 2019 guidelines: Use prone positioning for 12 hours/day in patients with ARDS and a PaO /FiO ratio < 150 mmHg (< 20 kPa). A Avoid the routine use of prone positioning for patients with ARDS. D As per ATS 2017 guidelines, use prone positioning for > 12 hours/day in adult patients with severe ARDS. B As per SSC 2017 guidelines, use prone positioning in adult patients with sepsis-induced ARDS and a PaO /FiO ratio < 150 mmHg (< 20 kPa). B Landmark trials: PROSEVA In patients undergoing mechanical ventilation for severe ARDS, performing prone-positioning sessions were superior to standard supine positioning with respect to death at 28 days. Guerin C et al. N Engl J Med. 2013 Jun 6. Recruitment maneuvers: As per ATS 2017 guidelines, consider using recruitment maneuvers in adult patients with ARDS. C As per SSC 2017 guidelines, consider using recruitment maneuvers in patients with sepsis- induced severe ARDS. C High-frequency oscillatory ventilation: As per BTS 2019 guidelines, do not use high-frequency oscillatory ventilation in patients with ARDS. D https://web.pathway.md/diseases/recNTWckOcmQM1veT 3/8 6/23/23, 2:03 AM Acute respiratory distress syndrome Pathway As per ATS 2017 guidelines, do not use high-frequency oscillatory ventilation routinely in patients with moderate or severe ARDS. D As per SSC 2017 guidelines, do not use high-frequency oscillatory ventilation in adult patients with sepsis-induced ARDS. D Landmark trials: OSCILLATE In adults with new-onset, moderate-to-severe ARDS, high-frequency oscillatory ventilation was inferior to low tidal volume ventilation with respect to a in-hospital death. Ferguson ND et al. N Engl J Med. 2013 Feb 28. 2. Medical management Fluid strategy: use a conservative fluid strategy in patients with established sepsis-induced ARDS who do not have evidence of tissue hypoperfusion. B Landmark trials: FACTT In patients with acute lung injury, conservative fluid use was superior to liberal fluid use with respect to death at 60 days. National Heart et al. N Engl J Med. 2006 Jun 15. Neuromuscular blocking agents: As per BTS 2019 guidelines: Consider administering cisatracurium besylate for 48 hours in patients with ARDS and a PaO /FiO ratio < 150 mmHg (< 20 kPa). C Consider avoiding routine use of neuromuscular blocking agents for the treatment of ARDS. D Landmark trials: PETAL In patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets (42.5% vs. 42.8%, p=0.930). While in the hospital, patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group. National Heart et al. N Engl J Med. 2019 May 23. https://web.pathway.md/diseases/recNTWckOcmQM1veT 4/8 6/23/23, 2:03 AM Acute respiratory distress syndrome Pathway As per SSC 2017 guidelines, consider administering neuromuscular blocking agents for 48 hours in adult patients with sepsis-induced ARDS and a PaO /FiO ratio < 150 mmHg (< 20 kPa). C Updated evidence: PETAL In patients with moderate-to-severe ARDS who were treated with a strategy involving a high PEEP, there was no significant difference in mortality at 90 days between patients who received an early and continuous cisatracurium infusion and those who were treated with a usual-care approach with lighter sedation targets (42.5% vs. 42.8%, p=0.930). While in the hospital, patients in the intervention group were less physically active and had more adverse cardiovascular events than patients in the control group. National Heart et al. N Engl J Med. 2019 May 23. Intravenous corticosteroids: insufficient evidence of sufficient quality to assess the risks and benefits of corticosteroids for the treatment of established ARDS. I Inhaled nitric oxide: consider avoiding the use of inhaled nitric oxide in patients with ARDS. D Inhaled bronchodilators: avoid the use of -2 agonists for the treatment of patients with sepsis- induced ARDS without bronchospasm. D 3. Inpatient care Pulmonary artery catheters: avoid the routine use of pulmonary artery catheters in patients with sepsis-induced ARDS. D Landmark trials: Pulmonary artery catheters for acute lung injury In patients with established acute lung injury, pulmonary artery catheter-guided resuscitation was not superior to central venous catheter-guided resuscitation with respect to survival at 60 days. National Heart et al. N Engl J Med. 2006 May 25. 4. Therapeutic procedures Extracorporeal membrane oxygenation: Consider using ECMO with lung-protective mechanical ventilation in selected patients with severe ARDS (defined as a Lung Injury Score of 3 or more, or pH < 7.20 due to uncompensated hypercapnia). C https://web.pathway.md/diseases/recNTWckOcmQM1veT 5/8 6/23/23, 2:03 AM Acute respiratory distress syndrome Pathway Consider avoiding the routine use of ECMO in patients with ARDS . D Extracorporeal carbon dioxide removal: insufficient evidence to assess the risks and benefits of extracorporeal CO removal in patients with ARDS. I 5. Follow-up and surveillance Weaning from mechanical ventilation: Use spontaneous breathing trials in mechanically ventilated patients with sepsis who are ready for weaning. A Use a weaning protocol to assist in weaning patients with sepsis-induced respiratory failure from mechanical ventilation. B References 1. Rhodes A, Evans LE, Alhazzani W et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016. Intensive Care Med. 2017 Mar;43 3 304 377. Open 2. Griffiths MJD, McAuley DF, Perkins GD et al. Guidelines on the management of acute respiratory distress syndrome. BMJ Open Respir Res. 2019 May 24;6 1):e000420. Open 3. Eddy Fan, Lorenzo Del Sorbo, Ewan C Goligher et al. 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