Table 3 Suggested ventilation strategies depending on the presence of ARDS and IAH

Tidal volume

6 to 8 mL/kg PBW may be beneficial

Recommended 4–8 mL/kg PBW (Grade 1B) [123, 124]

6 to 8 mL/kg PBW may be beneficial

4–8 mL/kg PBW may be beneficial

Inspiratory plateau pressure

< 20 cmH₂O

Recommended < 30 cmH₂O to reduce risk of alveolar over-distension (Grade 1B) [123]

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

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

Driving pressure

< 14 cmH₂O

< 14 cmH₂O (Grade 2B) [84]

< 14 cmH₂O

< 14 cmH₂O

Inspiratory plateau trans-pulmonary pressure

< 15 cmH₂O is reasonable

< 25 cmH₂O is reasonable [29]

< 25 cmH₂O is reasonable

< 25 cmH₂O may be a reasonable target

PEEP

5 in cmH₂O

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

ECCO₂R

Ascites drainage

Ascites drainage

ECMO

Laparostoma [26, 121]

Laparostoma

Nitric oxide, ECCO₂R, ECMO