Table 2 ATS/ESICM clinical practice guidelines for supportive therapy in ARDS/CARDS
Management | Patients | Quality of Evidence (GRADE) | Strength of Recommendation | Comments | Future Research Priorities & Validations | Guideline |
|---|---|---|---|---|---|---|
HFNO | AHRF | Moderate | Strong | Recommendation to reduce the intubation but no recommendation to reduce mortality. | Long-term functional outcome data; duration of HFNO. | ESICM |
AHRF from COVID-19 | Low-moderate | Strong | Low level of evidence in favor for intubation and no recommendation; moderate level of evidence of no effect for mortality, for indirectness. | |||
CPAP/NIV | AHRF | Moderate-high | No recommendation | High level of evidence for mortality, moderate level of evidence for intubation. | Optimal indications for CPAP/NIV | ESCIM |
AHRF from COVID-19 | Moderate | No recommendation | Weak recommendation to reduce intubation, but no recommendation to reduce mortality. | |||
Low tidal volume ventilation | ARDS | High | Strong | Use of low tidal volume ventilation strategies (i.e., 4–8 ml/kg PBW), compared to larger tidal volumes (traditionally used to normalize blood gases) | Merits of additional lung-protective strategies and personalized ventilator targets. investigation of VIVL. | ESCIM |
CARDS | Moderate | Strong | ||||
Higher PEEP/FiO2 strategy | ARDS | High | No recommendation | No recommendation for or against routine PEEP titration with a higher PEEP/FiO2 strategy versus a lower PEEP/FiO2 strategy. | / | ESCIM |
CARDS | Moderate | No recommendation | ||||
ARDS | Moderate | Strong | Recommendation for using higher PEEP without LRMs rather than lower PEEP in patients with moderate to severe ARDS | Optimal strategy for setting PEEP; effect of PEEP strategies in specific populations and specific ARDS phenotypes. | ATS | |
PEEP titration guided principally by respiratory mechanics | ARDS | High | No recommendation | No recommendation for or against PEEP titration guided principally by respiratory mechanics, compared to PEEP titration based principally on PEEP/FiO2 strategy. | Individual effect of different levels of PEEP; hemodynamic cost of higher PEEP; Esophageal pressure-guided PEEP and distending pressure. | ESCIM |
CARDS | Moderate | No recommendation | ||||
Prolonged high-pressure recruitment maneuvers | ARDS | Moderate | Strong | Recommendation for against use of prolonged high-pressure recruitment maneuvers (defined as airway pressure maintained ≥ 35 cmH2O for at least one minute). | / | ESCIM |
CARDS | Low | Strong | ||||
ARDS | Moderate | Strong | Recommendation for against using prolonged (PEEP ⩾35 cm H2O for >60 s) LRMs in patients with moderate to severe ARDS | / | ATS | |
Brief high-pressure recruitment maneuvers | ARDS | High | Weak | Recommendation for against routine use of brief high-pressure recruitment maneuvers (defined as airway pressure maintained ≥ 35 cmH2O for less than one minute). | Safety risks; frequency and benefit group. | ESCIM |
CARDS | Moderate | Weak | ||||
Prone position | ARDS | High | Strong | Recommendation for using prone position as compared to supine position for patients with moderate-severe ARDS (defined as PaO2/FiO2 < 150 mmHg and PEEP ≥ 5 cmH2O, despite optimization of ventilation settings) | Trials in moderate-severe CARDS | ESCIM |
CARDS | Moderate | Strong | ||||
Time of prone position | ARDS | High | Strong | Recommendation for starting prone position in patients with ARDS receiving invasive mechanical ventilation early after intubation, after a period of stabilization during which low tidal volume is applied and PEEP adjusted and at the end of which the PaO2/FiO2 remains < 150 mmHg. | Different durations of prone position; guidance on when to cease prone position. | ESCIM |
CARDS | Moderate | Strong | ||||
Awake prone positioning | AHRF | No evidence | No recommendation | Recommendation for awake prone positioning as compared to supine positioning for non-intubated patients with AHRF./ | The location (ICU vs non-ICU), the optimal respiratory support (HFNO, CPAP, NIV), and the impact of APP on inspiratory effort, work of breathing, and potential lung injury. | ESCIM |
AHRF from COVID-19 | Low-moderate | No recommendation | ||||
NMBA | ARDS | Moderate | Strong | Recommendation for against the routine use of continuous infusions of NMBA in patients with moderate-to-severe ARDS. | Successful extubation, re-intubation, paralysis recall, ICU acquired weakness and health-related quality of life and the specific role of NMBA in a prone position; patient-ventilator interaction; views of patients and caregivers. | ESCIM |
CARDS | No evidence | No recommendation | ||||
Early ARDS (≤48 h of MV) with PaO2/FiO2 ≤ 100 | Low | Conditional | Uncertainty around the harms of the concomitant sedation required with NMBA. | Patient-ventilator interaction; NMBA agent selection; the impact of the timing of initiation, dosing, and duration; Longitudinal data of NMBAs on long-term outcomes. | ATS | |
VV-ECMO | ARDS | Moderate | Strong | Patients with severe ARDS as defined by the EOLIA trial eligibility criteria; ECMO center should meet defined organizational standards; management strategy similar to that used in the EOLIA trial. | Long-term multidimensional outcomes for patients and families; ECMO-specific morbidities | ESCIM |
CARDS | Low | Strong | ||||
ARDS (PaO2/FiO2 ≤ 80 or PH <7.25 with pCO2 ≥ 60) | Low | Conditional | Limitations of available data and practical concerns; less invasive therapies before the consideration of VV-ECMO; focus on individuals most likely to benefit; high-volume, dedicated ECMO center. | Long-term outcomes in ECMO survivors; appropriate supportive measures for patients receiving ECMO；the impact of ECMO on resource allocation | ATS | |
ECCO2R | ARDS | High | Strong | Recommendation against the use of ECCO2R for the treatment of ARDS to prevent mortality outside of randomized controlled trials | Response to ECCO2R in a specific population of ARDS patients | ESCIM |
CARDS | Moderate | Strong | ||||
Corticosteroids | ARDS (PaO2/FiO2 ≤ 300) | Moderate | Conditional | The initiation of corticosteroid treatment >2 weeks after the onset of ARDS may be associated with harm; close surveillance for adverse effects is needed in particular patients. | Optimal corticosteroid regimen; effects on different subpopulations of ARDS patients. | ATS |
