Tidal volume
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6 to 8 mL/kg PBW may be beneficial
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Recommended 4–8 mL/kg PBW (Grade 1B) [123, 124]
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6 to 8 mL/kg PBW may be beneficial
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4–8 mL/kg PBW may be beneficial
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Inspiratory plateau pressure
|
< 20 cmH2O
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Recommended < 30 cmH2O to reduce risk of alveolar over-distension (Grade 1B) [123]
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Higher airway pressures may be acceptable and may arise due to reduced chest wall compliance. Corrected target plateau pressure = target plateau pressure − 7 + IAP (mmHg) * 0.7
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Higher airway pressures may be acceptable and may arise due to reduced chest wall compliance. Corrected target plateau pressure = target plateau pressure − 7 + (mmHg) * 0.7
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Driving pressure
|
< 14 cmH2O
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< 14 cmH2O (Grade 2B) [84]
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< 14 cmH2O
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< 14 cmH2O
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Inspiratory plateau trans-pulmonary pressure
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< 15 cmH2O is reasonable
|
< 25 cmH2O is reasonable [29]
|
< 25 cmH2O is reasonable
|
< 25 cmH2O may be a reasonable target
|
PEEP
|
5 in cmH2O
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Higher PEEP levels in moderate to severe ARDS improves survival rate (Grade 2B) [123]. We suggest 5–10 cmH2O in mild to moderate ARDS and 10–15 in moderate to severe ARDS
|
Higher PEEP levels may reduce atelectasis and atelectrauma. We suggest not to exceed 15 cmH2O
|
Higher than usual PEEP levels may be required to improve oxygenation and respiratory mechanics. We suggest not to exceed 15 cmH2O
|
PEEP titration
|
We suggest avoidance of excessive driving pressure
|
Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. Oesophageal pressure guided is a reasonable alternative
|
Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. We suggest PEEP in cmH2O = IAP in mmHg
|
Optimal respiratory compliance, i.e. lowest driving pressure during constant protective tidal volume. Oesophageal pressure guided is a reasonable alternative
|
Recruitment manoeuvre (RM)
|
RM not routinely recommended
|
RM improves oxygenation, but outcome may be worsened with RM. Best RM method is unknown [65, 123]
|
RM not routinely recommended
|
Higher airway pressures might be required for RM to be effective
|
Prone
|
Not recommended
|
Recommended as it improves oxygenation and survival rate in patients with ARDS (Grade 1B) [108, 123]
|
Not recommended
|
May reduce IAP and improve oxygenation Important to assure free hanging abdomen and absent IAP increase [29]
|
NMBA
|
Not recommended
|
Short term NMBA may be beneficial [125]
|
May reduce IAP [121]
|
May reduce IAP and/or improve oxygenation
|
Adjunctive therapy
| |
Nitric oxide
|
Negative fluid balance
|
Negative fluid balance
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ECCO2R
|
Ascites drainage
|
Ascites drainage
|
ECMO
|
Laparostoma [26, 121]
|
Laparostoma
|
| |
Nitric oxide, ECCO2R, ECMO
|