ARDS Management (ATS 2024)

Algorithm Steps

1. ▶

   Start

   Suspected ARDS

   Acute hypoxemic respiratory failure with bilateral infiltrates

   1. ◆

      Decision

      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
      1. ◆

         Decision

         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
         1. ●

            Action

            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
            1. ◆

               Decision

               Adequate Response?

               After 12-24h of lung-protective ventilation

               • Improving: P/F ratio increasing, FiO2 weaning
               • Refractory: Persistent severe hypoxemia (P/F <150)
               1. ●

                  Action

                  Continue & Wean

                  Gradual liberation from ventilator

                  • Continue lung-protective settings
                  • Daily SBT when improving
                  • Wean FiO2 and PEEP as tolerated
                  • Early mobilization when stable
                  1. ✓

                     Outcome

                     Recovery & Extubation

                     Successful liberation from ventilator

                     • Daily spontaneous awakening trial
                     • Daily spontaneous breathing trial
                     • Post-ICU rehabilitation
                     • Screen for PICS
               2. ●

                  Action

                  Rescue Therapies

                  For moderate-severe ARDS not responding

                  • Prone positioning (strong evidence)
                  • Neuromuscular blockade (conditional)
                  • Corticosteroids (conditional)
                  • Higher PEEP strategy
                  1. ●

                     Action

                     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
                     1. ◆

                        Decision

                        Still Refractory?

                        Despite prone + NMB + steroids

                        1. ●

                           Action

                           Optimized Supportive Care

                           Conservative management

                           • Conservative fluid strategy
                           • Nutrition: Enteral preferred
                           • DVT prophylaxis
                           • Stress ulcer prophylaxis
                           • Minimize sedation
                        2. ◆

                           Decision

                           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
                           1. ●

                              Action

                              VV-ECMO

                              Transfer to ECMO center

                              • Venovenous ECMO preferred
                              • Ultra-protective ventilation on ECMO
                              • Specialized center required
                              • ATS 2024: Conditional recommendation
                              1. ✓

                                 Outcome

                                 Goals of Care Discussion

                                 If not improving despite all measures

                                 • Family meeting
                                 • Palliative care consultation
                                 • Discuss prognosis honestly
                  2. ●

                     Action

                     Neuromuscular Blockade

                     For early severe ARDS

                     • Cisatracurium infusion for 48h
                     • With deep sedation
                     • For P/F <150 in first 48h
                     • ATS 2024: Conditional recommendation
                  3. ●

                     Action

                     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