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ARDS Mechanical Ventilation Management

ARDS Mechanical Ventilation Management: Adult ARDS on invasive ventilation → All ARDS: lung protective ventilation → All ARDS: corticosteroids and conse...

Pathway Overview

15 steps

Algorithm Steps

15 total

  1. 01Start

    Adult ARDS on invasive ventilation

    Adults only. Within 1 week of a known insult. Bilateral opacities not fully explained by effusion, collapse or nodules. Not fully explained by heart failure or fluid overload. P/F ≤300 mmHg (or SpO2/FiO2 ≤315 with SpO2 ≤97%) on PEEP ≥5 cmH2O. Find and treat the trigger (for example pneumonia, sepsis, aspiration, trauma).

  2. 02Action

    All ARDS: lung protective ventilation

    Strong recommendation. Raised ICP or pregnancy: do not allow permissive hypercapnia; set a PaCO2 target with specialist advice. Pregnancy: keep PaO2 ≥70 mmHg (SpO2 about 95%) with obstetric input.

    • Tidal volume 6 mL/kg predicted body weight (PBW); range 4-8 mL/kg PBW
    • Plateau pressure <30 cmH2O: check at least every 4 h and after each PEEP or tidal volume change
    • PBW male (kg) = 50 + 0.91 x (height cm - 152.4)
    • PBW female (kg) = 45.5 + 0.91 x (height cm - 152.4)
    • Oxygen goal: SpO2 88-95% or PaO2 55-80 mmHg (not in pregnancy)
    • pH goal 7.30-7.45: raise respiratory rate (max 35/min) first
    • Driving pressure (plateau pressure - PEEP): keep as low as possible, ideally ≤15 cmH2O
    • Do not use high-frequency oscillatory ventilation routinely (strong recommendation against)
  3. 03Action

    All ARDS: corticosteroids and conservative fluids

    Corticosteroids (conditional): start within 14 days of ARDS onset; a later start may cause harm. Conservative fluids only after shock has resolved.

    • Steroid regimen: no single regimen is recommended. Dose: see ATS 2024 guideline, Table E10
    • Severe community-acquired pneumonia, COVID-19 or HIV-related Pneumocystis pneumonia: use the regimen proven for that condition
    • Watch closely for harm if immunocompromised, diabetic or metabolic syndrome, or at risk of TB or parasitic infection
    • Conservative fluid strategy once off vasopressors and shock has resolved
  4. 04Action

    Classify severity and set PEEP

    Use P/F (or SpO2/FiO2 if SpO2 ≤97%) on PEEP ≥5 cmH2O after the initial setup; reclassify every day. Shock or RV failure: raise PEEP in small steps and watch BP.

    • Mild (P/F >200 to 300; S/F >235 to 315): lower PEEP/higher FiO2 table (ARDSNet); higher PEEP may increase mortality
    • Moderate (P/F >100 to 200; S/F >148 to 235) or severe (P/F ≤100; S/F ≤148): higher PEEP without recruitment manoeuvres (conditional)
    • Do not use prolonged recruitment manoeuvres (≥35 cmH2O for ≥60 s): they increase mortality (strong)
    • Higher PEEP method: PEEP/FiO2 table, or titrate to plateau pressure or compliance; monitor mechanics and haemodynamics
    • Severe (P/F ≤100): discuss early with an ECMO centre
  5. 05Decision

    Severe ARDS (P/F ≤100) within 48 h of onset?

    ATS 2024 suggests NMBA only in early severe ARDS. ESICM 2023 recommends against routine continuous NMBA infusion.

  6. If Yes
    1. 06Action

      Yes: consider NMBA, only with deep sedation

      Conditional recommendation (ATS 2024). Use only if already deeply sedated, or if severe dyssynchrony with deterioration persists despite ventilator and sedation changes. Never give without deep sedation.

      • Most trials gave NMBA for up to 48 h; stop earlier if improving
      • Cisatracurium was used in the largest trials. Dose: see local ICU protocol or product information
      • Monitor for ICU-acquired weakness
    2. 07Warning

      Prone contraindications: unstable spine fracture, shock, raised ICP

      Absolute: unstable spinal fracture. Relative: see below.

      • Relative: haemodynamic instability, unstable pelvic or long-bone fracture, open abdomen
      • Relative: raised ICP; late pregnancy (possible with careful positioning and fetal monitoring)
      • Needs a trained team: secure the tube and lines; protect eyes, face and pressure areas
    3. 08Decision

      P/F <150 on PEEP ≥5 and no contraindication?

      Assess after a short period of stabilisation on lung protective ventilation and adjusted PEEP.

    4. If Yes
      1. 09Action

        Yes: prone position, sessions of 16 h or more

        Start early after intubation. Strong recommendation (ATS, ESICM).

        • Repeat daily until supine P/F ≥150 with PEEP ≤10 cmH2O and FiO2 ≤0.6, at least 4 h after turning supine
        • Stop for a life-threatening complication. Do not stop only because oxygenation has not improved
        • Secure the tube and lines; protect eyes, face and pressure areas
      2. 10Decision

        Refractory despite optimal care?

        P/F <80 mmHg after optimal care including a trial of prone position (unless contraindicated), or pH <7.25 with PaCO2 ≥60 mmHg despite RR 35/min and plateau pressure ≤30 cmH2O.

      3. If Yes
        1. 11Warning

          Refractory: refer for VV-ECMO now

          Selected severe ARDS (ATS 2024, conditional).

          • Best candidates: reversible cause, ARDS <7 days, few risk factors for futility
          • No ECMO on site: call the ECMO centre early and arrange transfer
          • Continue lung protective ventilation and prone position while you wait
        2. 12Action

          Daily reassessment

          Reclassify severity every day and step care up or down.

          • Reduce FiO2, then PEEP, as oxygenation improves
          • NMBA: stop by 48 h, or earlier if improving
          • SBT screen daily: FiO2 ≤0.4 and PEEP ≤8 (or FiO2 <0.5 and PEEP <5), PEEP and FiO2 ≤ previous day, breathing effort present, no NMBA, systolic BP ≥90 mmHg without vasopressors
          • Corticosteroids: many trials stopped them at extubation
        3. Improving
        4. 13Outcome

          Improving: start liberation (SBT, then extubation)

          Use the daily SBT screen and local weaning protocol.

        5. Not improving
        6. 14Outcome

          Not improving: review the cause and escalate

          Recheck the cause of ARDS. Reconsider prone position and VV-ECMO referral.

        If No
        1. Path rejoins step 12Shared downstream outcome
      If No
      1. 15Action

        No: stay supine, reassess prone every day

        P/F ≥150 or prone contraindicated. Continue lung protective ventilation and PEEP strategy.

      2. Path rejoins step 10Shared downstream outcome
    If No
    1. Path rejoins step 07Shared downstream outcome

Guideline Source

An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline

DOI: 10.1164/rccm.202311-2011STView Guideline

Clinical Safety Information

Clinical Decision Support — Not a Substitute for Clinical Judgment

Individual patient factors may require deviation from these recommendations.

Known Limitations

  • Adults on invasive ventilation only. Not for children, NIV or high-flow nasal oxygen.
  • ATS 2024 and ESICM 2023 differ on higher PEEP and NMBA. No steroid or NMBA doses: use the local ICU protocol.
  • VV-ECMO candidacy needs ECMO centre input.
  • P/F needs an arterial blood gas; SpO2/FiO2 (SpO2 ≤97%) is an accepted alternative for diagnosis and severity.
  • Local protocols may vary.

Contraindicated Populations

pediatricneonatal

Applicable Regions

USEUGlobal

AU: VV-ECMO is available only at designated adult ECMO centres: refer early.

EU: ESICM 2023 makes no recommendation for or against higher PEEP, and recommends against routine continuous NMBA infusion in moderate-severe ARDS not due to COVID-19.

US: Based on the ATS 2024 guideline update (includes 2017 recommendations that remain in place).

Version 2Next review: 2027-09-30

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Frequently Asked Questions

What is the ARDS Mechanical Ventilation Management?

The ARDS Mechanical Ventilation Management is a management clinical algorithm for Critical Care. It provides a structured decision tree to guide clinical decision-making, based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline.

What guideline is the ARDS Mechanical Ventilation Management based on?

This algorithm is based on An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: ATS Clinical Practice Guideline (DOI: 10.1164/rccm.202311-2011ST).

What are the limitations of the ARDS Mechanical Ventilation Management?

Known limitations include: Adults on invasive ventilation only. Not for children, NIV or high-flow nasal oxygen.; ATS 2024 and ESICM 2023 differ on higher PEEP and NMBA. No steroid or NMBA doses: use the local ICU protocol.; VV-ECMO candidacy needs ECMO centre input.; P/F needs an arterial blood gas; SpO2/FiO2 (SpO2 ≤97%) is an accepted alternative for diagnosis and severity.; Local protocols may vary.. Individual patient factors may require deviation from these recommendations.

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