Suspected ARDS
Acute hypoxemic respiratory failure with bilateral infiltrates
All Pathways
Pulmonary MedicineManagement
ARDS Management (ATS 2024)
ARDS Management (ATS 2024): Suspected ARDS → Berlin Criteria Met? → ARDS Severity (P/F Ratio) → Lung-Protective Ventilation → Adequate Response?.
Pathway Overview
16 steps
Algorithm Steps
16 total
01Start 02Decision Berlin Criteria Met?
Confirm ARDS diagnosis
- Timing: Within 1 week of insult/worsening symptoms
- Imaging: Bilateral opacities (CXR/CT)
- Origin: Not fully explained by cardiac failure/fluid overload
- Oxygenation: P/F ratio ≤300 with PEEP ≥5
03Decision ARDS Severity (P/F Ratio)
On PEEP ≥5 cmH2O
- Mild: P/F 201-300 mmHg
- Moderate: P/F 101-200 mmHg
- Severe: P/F ≤100 mmHg
04Action Lung-Protective Ventilation
Foundation of ARDS management
- Low Tidal Volume: 4-6 mL/kg IBW (target 6)
- Plateau Pressure: ≤30 cmH2O
- Driving Pressure: <15 cmH2O
- PEEP: Use higher PEEP/FiO2 table for moderate-severe
- Target: SpO2 88-95%, pH 7.30-7.45
05Decision Adequate Response?
After 12-24h of lung-protective ventilation
- Improving: P/F ratio increasing, FiO2 weaning
- Refractory: Persistent severe hypoxemia (P/F <150)
06Action Continue & Wean
Gradual liberation from ventilator
- Continue lung-protective settings
- Daily SBT when improving
- Wean FiO2 and PEEP as tolerated
- Early mobilization when stable
07Outcome Recovery & Extubation
Successful liberation from ventilator
- Daily spontaneous awakening trial
- Daily spontaneous breathing trial
- Post-ICU rehabilitation
- Screen for PICS
08Action Rescue Therapies
For moderate-severe ARDS not responding
- Prone positioning (strong evidence)
- Neuromuscular blockade (conditional)
- Corticosteroids (conditional)
- Higher PEEP strategy
09Action Prone Positioning
For P/F <150 within 36h of intubation
- Duration: ≥16 hours per session
- Continue until P/F >150 for 4h supine
- Contraindications: Spine instability, open abdomen, facial trauma
- Team training essential
10Decision Still Refractory?
Despite prone + NMB + steroids
11Action Optimized Supportive Care
Conservative management
- Conservative fluid strategy
- Nutrition: Enteral preferred
- DVT prophylaxis
- Stress ulcer prophylaxis
- Minimize sedation
- Path rejoins step 07Shared downstream outcome
12Decision ECMO Candidate?
VV-ECMO for severe refractory ARDS
- P/F <80 for >6h OR P/F <50 for >3h
- pH <7.25 with PaCO2 >60 for >6h
- Age typically <65
- Mechanical ventilation <7 days
- No contraindications
13Action VV-ECMO
Transfer to ECMO center
- Venovenous ECMO preferred
- Ultra-protective ventilation on ECMO
- Specialized center required
- ATS 2024: Conditional recommendation
- Path rejoins step 07Shared downstream outcome
14Outcome Goals of Care Discussion
If not improving despite all measures
- Family meeting
- Palliative care consultation
- Discuss prognosis honestly
- Path rejoins step 14Shared downstream outcome
15Action Neuromuscular Blockade
For early severe ARDS
- Cisatracurium infusion for 48h
- With deep sedation
- For P/F <150 in first 48h
- ATS 2024: Conditional recommendation
- Path rejoins step 10Shared downstream outcome
16Action Corticosteroids
ATS 2024 conditional recommendation
- Dexamethasone 20mg x 5d then 10mg x 5d
- Or Methylprednisolone 1-2 mg/kg/day
- Start within 14 days of ARDS onset
- Moderate certainty of benefit
- Path rejoins step 10Shared downstream outcome
Guideline Source
An Update on Management of Adult Patients with ARDS: ATS Clinical Practice Guideline 2024
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- ECMO availability varies by center
- Specific ventilator settings require individual titration
- Does not address pediatric ARDS (PARDS)
- Neuromuscular blockade duration controversial
Contraindicated Populations
pediatric
Applicable Regions
USGlobal
Global: Berlin criteria and lung-protective ventilation universally applicable
Version 1Next review: 2027-01-01
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Frequently Asked Questions
What is the ARDS Management (ATS 2024)?
The ARDS Management (ATS 2024) is a management clinical algorithm for Pulmonary Medicine. It provides a structured decision tree to guide clinical decision-making, based on An Update on Management of Adult Patients with ARDS: ATS Clinical Practice Guideline 2024.
What guideline is the ARDS Management (ATS 2024) based on?
This algorithm is based on An Update on Management of Adult Patients with ARDS: ATS Clinical Practice Guideline 2024 (DOI: 10.1164/rccm.202311-2011ST).
What are the limitations of the ARDS Management (ATS 2024)?
Known limitations include: ECMO availability varies by center; Specific ventilator settings require individual titration; Does not address pediatric ARDS (PARDS); Neuromuscular blockade duration controversial. Individual patient factors may require deviation from these recommendations.
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