Acute respiratory distress syndrome (ARDS) clinical practice guideline

Key points

• Joint guideline of the Japanese Society of Intensive Care Medicine, the Japanese Respiratory Society and the Japanese Society of Respiratory Care Medicine, with 46 clinical questions for adults and 15 for children.
• Recommends limiting tidal volume to 4-8 mL/kg in mechanically ventilated adults (GRADE 1D) and recommends low-dose corticosteroids (GRADE 1B).
• Suggests ECMO for adults with severe ARDS (GRADE 2B) and long-duration prone positioning in moderate or severe ARDS (GRADE 2D).
• Suggests against high-dose corticosteroids, routine recruitment maneuvers, nitric oxide (NO) inhalation and sivelestat.
• For children, suggests against non-invasive respiratory support and against routine NO inhalation.

Overview

The ARDS Clinical Practice Guideline 2021 is a translated English summary of a Japanese guideline that gives GRADE-based recommendations on diagnosis, non-invasive and invasive respiratory support, treatment adjacent to ventilator use, and drug and non-drug therapy. It aims to help professionals from multiple disciplines, including non-specialist physicians, make appropriate decisions; the authors note that ARDS mortality remains high at approximately 25-40%.

Methods

Systematic reviews were assessed with the GRADE system, with meta-analyses of diagnostic accuracy and network meta-analyses added as new methods. Recommendations were agreed by a modified Delphi vote. Where evidence was lacking, the panel issued either a good practice statement or an 'in our practice statement' that describes current practice without a recommendation. COVID-19 was not covered because of insufficient evidence.

Diagnosis

ARDS should be suspected in patients with acute respiratory failure (good practice statement), and diagnosis is based on the Berlin Definition. The guideline suggests BNP or NT-proBNP to identify cardiogenic pulmonary edema. It suggests against identifying bacterial pneumonia from CRP and procalcitonin alone, and against predicting prognosis from the P/F ratio, lung pathology or chest CT alone (all GRADE 2D).

Respiratory support

For adults with acute respiratory failure suspected of ARDS, without contraindications or other organ failure, NPPV or high-flow nasal cannula is suggested over conventional oxygen therapy and over tracheal intubation as initial management (GRADE 2B). Because delayed intubation could increase mortality, these patients should be managed where intubation can be performed. In ventilated adults the guideline suggests high PEEP, limiting plateau pressure and protocolized weaning. It suggests against excessively low SpO2 targets, routine transpulmonary pressure-based PEEP setting and HFOV in moderate or severe ARDS (GRADE 2A).

Adjunctive and drug therapy

The guideline suggests early neuromuscular blockers for no longer than 48 hours, prone positioning for over 12 hours, ECMO for severe ARDS, early tracheostomy and early rehabilitation within 72 hours, and it recommends a VAP prevention bundle. High-dose corticosteroids (about 30 mg/kg methylprednisolone) are suggested against, whereas low-dose corticosteroids (about 1-2 mg/kg) are recommended.

Frequently asked questions

What tidal volume does the guideline recommend?

It recommends limiting tidal volume to 4-8 mL/kg in mechanically ventilated adults with ARDS (strong recommendation, very low certainty of evidence).

Are corticosteroids recommended?

Low-dose corticosteroids are recommended (GRADE 1B), while high-dose corticosteroids are suggested against (GRADE 2C).

What does it say about children?

It suggests against non-invasive respiratory support, routine NO inhalation and daily sedation interruption, and suggests prone positioning in moderate ARDS.

Source

Tasaka S, Ohshimo S, Takeuchi M, Yasuda H, Ichikado K, Tsushima K, et al. ARDS clinical practice guideline 2021. Respiratory Investigation 2022;60(4):446-495. DOI: 10.1016/j.resinv.2022.05.003. Open access under a Creative Commons licence. This page is a summary prepared by Medpresso from the original publication and is not a substitute for the full text or for medical advice.