ARDS Mechanical Ventilation Management

Algorithm Steps

1. ▶

   Start

   ARDS Diagnosed

   Berlin criteria: acute onset, bilateral opacities, P/F ≤300 on PEEP ≥5, not fully explained by cardiac failure

   1. ◆

      Decision

      Classify ARDS Severity

      Based on P/F ratio on PEEP ≥5 cmH2O

      • Mild: 200 < P/F ≤ 300
      • Moderate: 100 < P/F ≤ 200
      • Severe: P/F ≤ 100
      1. ●

         Action

         Initiate Lung Protective Ventilation

         Core strategy for ALL ARDS patients (Strong recommendation)

         • Tidal volume: 4-8 mL/kg PBW (target 6 mL/kg)
         • Plateau pressure: <30 cmH2O
         • Driving pressure: <15 cmH2O (Pplat - PEEP)
         • PBW Male: 50 + 2.3 × (height in inches - 60)
         • PBW Female: 45.5 + 2.3 × (height in inches - 60)
         1. ◆

            Decision

            Assess Oxygenation Response

            Check P/F ratio after initial stabilization

            1. ●

               Action

               Mild ARDS Management

               P/F 200-300

               • PEEP 5-10 cmH2O per ARDSNet table
               • FiO2 to maintain SpO2 88-95%
               • Conservative fluid strategy
               • Daily SBT screening
               1. ●

                  Action

                  Daily Reassessment

                  Continuous optimization

                  • Daily P/F ratio
                  • Reassess PEEP needs
                  • SBT screening when appropriate
                  • Weaning protocol when improved
                  1. ✓

                     Outcome

                     ARDS Resolving

                     Proceed with liberation protocol

                  2. ✓

                     Outcome

                     Persistent ARDS

                     Continue optimization, consider rescue therapies

            2. ●

               Action

               Moderate ARDS Management

               P/F 100-200

               • Higher PEEP strategy (ARDSNet high PEEP table)
               • Consider prone positioning >12h/day
               • Consider neuromuscular blockade
               • Recruitment maneuvers (conditional)
               • Corticosteroids (conditional recommendation)
               1. ◆

                  Decision

                  Prone Positioning Candidate?

                  Severe ARDS (P/F <150) within 36h of intubation

                  • Contraindications: spinal instability, open abdomen
                  • Relative: facial trauma, recent sternotomy
                  • Strong recommendation for severe ARDS
                  1. ●

                     Action

                     Prone Position >12-16h/day

                     Continue until P/F >150 on PEEP ≤10, FiO2 ≤0.6 supine for 4h

                     • Turn prone for 16h sessions
                     • Monitor pressure points
                     • Secure ETT and lines
                     • Continue proning until sustained improvement
                  2. ◆

                     Decision

                     Refractory Hypoxemia?

                     Persistent P/F <80 despite optimal management

                     1. ⚠

                        Warning

                        ⚠️ VV-ECMO Evaluation

                        Consider for severe refractory ARDS

                        • Contact ECMO center early
                        • RESP score for mortality risk
                        • Age typically <65, reversible etiology
                        • ATS 2024: Conditional recommendation
            3. ●

               Action

               Severe ARDS Management

               P/F ≤100

               • Prone positioning >12h/day (Strong)
               • Higher PEEP per protocol
               • Neuromuscular blockade (conditional)
               • Corticosteroids (conditional)
               • ECMO evaluation if refractory