ATS/ESICM/SCCM Guidelines for mechanical ventilation : ARDS

Fan E, Del Sorbo L, Goligher EC, Hodgson CL et el published official guidelines for mechanical ventilation in ARDS which were published recently.

Guidelines are in a question answer format and they answer 6 questions. They did not comment on  Airway pressure release ventilation and use of NM blockade.

Here is the summary

FOR RecommendationAGAINST RecommendationNo Recommendation
1. Limit tidal volumes to 4-8ml/kg of ideal body weight.
Also try to keep plateau pressures below 30cm H2O.
The initial tidal volume should be set at 6 ml/kg PBW and can be increased up to 8 ml/kg PBW if the patient is double triggering or if inspiratory airway pressure decreases
below PEEP. It may not always be possible to achieve strict control of tidal volumes and inspiratory
pressures in spontaneously breathing patients with ARDS.
HFOV not be used routinely in patients with
moderate or severe ARDS
Use of ECMO in patients with severe ARDS
2. Adult patients with severe ARDS((PaO2/FIO2 <100) receive
prone positioning for more than 12 hours per day
3. Adult patients with moderate or severe ARDS receive higher rather than lower levels of PEEP
4. Adult patients with ARDS receive RMs(Recruitment maneuvers). A variety of maneuvers have been described, including prolonged high continuous positive airway pressure (30–40 cm H2O), progressive incremental increases in PEEP at constant driving pressure , and high driving pressures

Future studies are needed to resolve following issues

  1. Ventilatory strategies targeting reduced Driving Pressure(plateau pressure – PEEP) versus those targeting tidal volume or plateau pressure.
  2. Trial  of spontaneous breathing under partially assisted ventilation versus strictly controlled mechanical ventilation in patients with ARDS are needed.
  3. Role of very low tidal volume ie 4 to 6 ml/kg in ARDS
  4. Role of higher PEEP during prone positioning.
  5. Role of HFOV as rescue therapy in patients with severe ARDS with refractory hypoxemia
  6. Currently a large international trial is comparing VV ECMO to conventional mechanical ventilation (EOLIA [Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome]
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