An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline

Abstract

Background: This document updates previously published Clinical Practice Guidelines for the management of patients with acute respiratory distress syndrome (ARDS), incorporating new evidence addressing the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure (PEEP). Methods: We summarized evidence addressing four "PICO questions" (patient, intervention, comparison, and outcome). A multidisciplinary panel with expertise in ARDS used the Grading of Recommendations, Assessment, Development, and Evaluation framework to develop clinical recommendations. Results: We suggest the use of: 1) corticosteroids for patients with ARDS (conditional recommendation, moderate certainty of evidence), 2) venovenous extracorporeal membrane oxygenation in selected patients with severe ARDS (conditional recommendation, low certainty of evidence), 3) neuromuscular blockers in patients with early severe ARDS (conditional recommendation, low certainty of evidence), and 4) higher PEEP without lung recruitment maneuvers as opposed to lower PEEP in patients with moderate to severe ARDS (conditional recommendation, low to moderate certainty), and 5) we recommend against using prolonged lung recruitment maneuvers in patients with moderate to severe ARDS (strong recommendation, moderate certainty). Conclusions: We provide updated evidence-based recommendations for the management of ARDS. Individual patient and illness characteristics should be factored into clinical decision making and implementation of these recommendations while additional evidence is generated from much-needed clinical trials.

Keywords: acute respiratory distress syndrome; corticosteroids; extracorporeal membrane oxygenation; neuromuscular blockade; positive end-expiratory pressure.

Figure 1.

Current American Thoracic Society guidelines for the management of acute respiratory distress syndrome. *New or updated recommendations in current guideline. ^†Recommendations addressed in 2017 guideline. ARDS = acute respiratory distress syndrome; FiO₂ = fraction of inspired oxygen; PaO₂ = partial pressure of oxygen; PBW = predicted body weight; PEEP = positive end-expiratory pressure; P_plat = plateau pressure; V_T = tidal volume; VV-ECMO = venovenous extracorporeal membrane oxygenation.

Figure 2.

Precautions and practical considerations for the use of corticosteroids, venovenous extracorporeal membrane oxygenation, neuromuscular blocking agents, and positive end-expiratory pressure. ARDS = acute respiratory distress syndrome; CNS = central nervous system; FiO₂ = fraction of inspired oxygen; MV = mechanical ventilation; NMBA = neuromuscular blocking agent; PaO₂ = partial pressure of oxygen; pCO₂ = partial pressure of CO₂; PEEP = positive end-expiratory pressure; RCT = randomized controlled trial; VV-ECMO = venovenous extracorporeal membrane oxygenation.