Management of Acute Respiratory Distress Syndrome (ARDS)

Core Ventilation Strategy: Lung-Protective Ventilation

The American Thoracic Society recommends implementing lung-protective ventilation with tidal volumes of 4-8 mL/kg predicted body weight and plateau pressures <30 cmH2O for critically ill patients with ARDS 1, 2
Set tidal volume at 6 mL/kg predicted body weight (range 4-8 mL/kg PBW) for ARDS patients, with males' predicted body weight calculated as 50 + 0.91 × [height (cm) - 152.4] kg and females' as 45.5 + 0.91 × [height (cm) - 152.4] kg 2, 3, 4
Maintain plateau pressure <30 cmH2O for ARDS patients 1, 2, 3, 4
Accept permissive hypercapnia as a consequence of lung protection, maintaining pH >7.20 5

For moderate-to-severe ARDS (PaO₂/FiO₂ <200 mmHg), use higher PEEP (typically >10 cmH2O); for mild ARDS (PaO₂/FiO₂ 200-300 mmHg), lower PEEP may be appropriate 1, 3, 5
Higher PEEP strategy is suggested for moderate-to-severe ARDS 1, 3, 5
Monitor for barotrauma when using PEEP >10 cmH2O 6
In patients with cirrhosis or hemodynamic instability, use lower PEEP (<10 cmH2O) for mild ARDS to avoid impairing venous return 7, 8

For severe ARDS with PaO₂/FiO₂ <150 mmHg, implement prone positioning for at least 12-16 hours daily 1, 2, 3, 6
Prone positioning reduces mortality in severe ARDS (RR 0.74) 2
Duration matters: trials with >12 hours/day proning showed mortality benefit, while shorter durations did not 2

For early severe ARDS with PaO₂/FiO₂ <150 mmHg, use neuromuscular blocking agents for up to 48 hours 1, 3
Administer as intermittent boluses rather than continuous infusion when possible 6
Use continuous infusion only for persistent ventilator dyssynchrony, need for deep sedation, prone positioning, or persistently high plateau pressures 6

Administer systemic corticosteroids to mechanically ventilated patients with ARDS 1
This is a conditional recommendation with moderate certainty of evidence 1
The American Thoracic Society represents the most recent high-quality recommendation supporting corticosteroid use 1

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

For severe refractory ARDS despite optimized ventilation, proning, and rescue therapies, consider VV-ECMO in carefully selected patients at experienced centers 1, 6
ECMO should only be considered in carefully selected patients due to resource-intensive nature 6

Do not use high-frequency oscillatory ventilation—this is strongly recommended against 1, 3
Do not routinely use pulmonary artery catheters for ARDS management 3
Do not use β-2 agonists for ARDS treatment without bronchospasm 3

Target SpO₂ of 88-95% to avoid hyperoxia while maintaining adequate oxygenation 4, 6
Start supplemental oxygen if SpO₂ <92%, and definitely if <90% 6
Maintain SpO₂ no higher than 96% in acute hypoxemic respiratory failure 6

Minimize continuous or intermittent sedation, targeting specific titration endpoints 3
Use spontaneous breathing trials in patients ready for weaning 3
Implement a weaning protocol for patients who can tolerate weaning 3

Do not prioritize normocapnia over lung-protective ventilation—accept permissive hypercapnia as necessary 5
Do not use tidal volumes >8 mL/kg PBW even if plateau pressures are acceptable—both parameters must be optimized 2, 4
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 1, 7, 8