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Table 2 Summary of guidelines

From: Formal guidelines: management of acute respiratory distress syndrome

  Recommendation Level of proof
Evaluation of ARDS management
R1.1 The experts suggest that the efficacy and safety of all ventilation parameters and therapeutics associated with ARDS management should be evaluated at least every 24 h Expert opinion
Tidal volume adjustment
R2.1.1 A tidal volume around 6 mL/kg of predicted body weight (PBW) should be used as a first approach in patients with recognized ARDS, in the absence of severe metabolic acidosis, including those with mild ARDS, to reduce mortality Grade 1 +
R2.1.2 The experts suggest a similar approach for all patients on invasive mechanical ventilation and under sedation in ICU, given the high rate of failure to recognize ARDS and the importance of rapidly implementing pulmonary protection Expert opinion
Plateau pressure
R2.2.1 Once tidal volume is set to around 6 mL/kg predicted body weight, plateau pressure should be monitored continuously and should not exceed 30 cmH2O to reduce mortality Grade 1 +
R2.2.2 The experts suggest that tidal volume should not be increased when the plateau pressure is well below 30 cmH2O, except in cases of marked, persistent hypercapnia despite reduction in instrumental dead space and increase of respiratory rate Expert opinion
Driving pressure
R2.3 Available data do not allow a recommendation to be made regarding respirator settings based solely on limitation of driving pressure. This limitation can be envisaged as a complement to limitation of plateau pressure in some special instances No recommendation
Positive end-expiratory pressure
R3.1.1 PEEP is an essential component of the management of ARDS and the experts suggest using a value above 5 cmH2O in all patients presenting with ARDS Expert opinion
R3.1.2 High PEEP should probably be used in patients with moderate or severe ARDS, but not in patients with mild ARDS Grade 2 +
R3.1.3 The experts suggest reserving high PEEP for patients in whom it improves oxygenation without marked deterioration of respiratory system compliance or hemodynamic status. PEEP settings should be individualized Expert opinion
High-frequency oscillation ventilation
R3.2 High-frequency oscillation ventilation should not be used in ARDS patients Grade 1 −
Recruitment maneuvers
R3.3 Recruitment maneuvers should probably not be used routinely in ARDS patients Grade 2 −
Early and short neuromuscular blockade
R4.1 A neuromuscular blocking agent should probably be considered in ARDS patients with a PaO2/FiO2 ratio < 150 mmHg to reduce mortality. The neuromuscular blocking agent should be administered by continuous infusion early (within 48 h after the start of ARDS), for no more than 48 h, with at least daily evaluation Grade 2 +
Early spontaneous ventilation
R4.2.1 Available data do not allow a recommendation to be made regarding a strategy of routine spontaneous ventilation in the acute phase of ARDS No recommendation
R4.2.2 After the acute phase of ARDS, the experts suggest that ventilation with a pressure mode allowing spontaneous ventilation can be used when ensuring that the tidal volume generated is close to 6 mL/kg PBW and does not exceed 8 mL/kg PBW Expert opinion
Prone positioning
R5.1 Prone positioning should be used in ARDS patients with PaO2/FIO2 ratio < 150 mmHg to reduce mortality. Sessions of at least 16 consecutive hours should be performed Grade 1 +
Venovenous extracorporeal membrane oxygenation
R6.1 Venovenous extracorporeal membrane oxygenation (ECMO) should probably be considered in cases of severe ARDS with PaO2/FiO2 < 80 mmHg and/or when mechanical ventilation becomes dangerous because of the increase in plateau pressure and despite optimization of ARDS management including high PEEP, neuromuscular blocking agents, and prone positioning. The decision to use ECMO should be evaluated early by means of contact with an expert center Grade 2 +
Low-flow extracorporeal CO2 removal
R6.2 Available data do not allow a recommendation to be made concerning the use of low-flow extracorporeal CO2 removal during ARDS No recommendation
Inhaled nitrogen monoxide
R7.1 The experts suggest that inhaled nitric oxide can be used in cases of ARDS with deep hypoxemia, despite the implementation of a protective ventilation strategy and prone positioning and before envisaging use of venovenous ECMO Expert opinion