Guidelines on the management of acute respiratory distress syndrome

Mark J D Griffiths, Danny Francis McAuley, Gavin D Perkins, Nicholas Barrett, Bronagh Blackwood, Andrew Boyle, Nigel Chee, Bronwen Connolly, Paul Dark, Simon Finney, Aemun Salam, Jonathan Silversides, Nick Tarmey, Matt P Wise, Simon V Baudouin, Mark J D Griffiths, Danny Francis McAuley, Gavin D Perkins, Nicholas Barrett, Bronagh Blackwood, Andrew Boyle, Nigel Chee, Bronwen Connolly, Paul Dark, Simon Finney, Aemun Salam, Jonathan Silversides, Nick Tarmey, Matt P Wise, Simon V Baudouin

Abstract

The Faculty of Intensive Care Medicine and Intensive Care Society Guideline Development Group have used GRADE methodology to make the following recommendations for the management of adult patients with acute respiratory distress syndrome (ARDS). The British Thoracic Society supports the recommendations in this guideline. Where mechanical ventilation is required, the use of low tidal volumes (<6 ml/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For patients with moderate/severe ARDS (PF ratio<20 kPa), prone positioning was recommended for at least 12 hours per day. By contrast, high frequency oscillation was not recommended and it was suggested that inhaled nitric oxide is not used. The use of a conservative fluid management strategy was suggested for all patients, whereas mechanical ventilation with high positive end-expiratory pressure and the use of the neuromuscular blocking agent cisatracurium for 48 hours was suggested for patients with ARDS with ratio of arterial oxygen partial pressure to fractional inspired oxygen (PF) ratios less than or equal to 27 and 20 kPa, respectively. Extracorporeal membrane oxygenation was suggested as an adjunct to protective mechanical ventilation for patients with very severe ARDS. In the absence of adequate evidence, research recommendations were made for the use of corticosteroids and extracorporeal carbon dioxide removal.

Keywords: ARDS.

Conflict of interest statement

Competing interests: Each author contributed elements to the final text.

Figures

Figure 1
Figure 1
Sixty-day and hospital mortality comparing LTV and HTV mechanical ventilation in adult patients with ARDS. ARDS, acute respiratory distress syndrome; HTV, higher tidal volume; LTV, lower tidal volume.
Figure 2
Figure 2
ICU length of stay comparing LTV and HTV mechanical ventilation in adult patients with ARDS. ARDS, acute respiratory distress syndrome; HTV, higher tidal volume; ICU, intensive care unit; LTV, lower tidal volume.
Figure 3
Figure 3
Analysis of evidence relating to the topics selected in this figure. ARDS, acute respiratory distress syndrome; CPAP, continuous positive airway pressure; ECMO, extracorporeal membrane oxygenation; PEEP, positive end-expiratory pressure.

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