ARDS
Also known as: acute respiratory distress syndrome
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An Update on Management of Adult Patients with Acute Respiratory Distress Syndrome: An Official American Thoracic Society Clinical Practice Guideline
American Thoracic Society (ATS) · 2024 · 2024 update
The ATS's current clinical practice guideline update on managing adult ARDS, published in the American Journal of Respiratory and Critical Care Medicine. It revisits selected interventions from the earlier 2017 multi-society ARDS ventilation guideline using GRADE methodology.
- The update addresses four intervention areas: corticosteroids, venovenous ECMO, neuromuscular blockade, and PEEP strategy. source
- It reaffirms earlier recommendations on lung-protective ventilation and prone positioning while issuing mostly conditional recommendations for the newly reviewed topics. source
ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies
European Society of Intensive Care Medicine (ESICM) · 2023
ESICM's current ARDS guideline, published open access in Intensive Care Medicine in 2023, which the taskforce states updates the society's 2017 clinical practice guideline. Its scope is limited to adults and to non-pharmacological respiratory support.
- The guideline is organized around nine domains including ARDS definition, phenotyping, high-flow nasal oxygen, non-invasive ventilation, tidal volume, PEEP and recruitment, prone positioning, neuromuscular blockade, and extracorporeal life support. source
- It explicitly states its aim is to update the 2017 ESICM clinical practice guideline. source
US vs EU key differences
- PEEP strategy is the sharpest split: the ATS guideline makes a conditional recommendation for higher versus lower PEEP in moderate-to-severe ARDS, whereas ESICM declined to issue any recommendation on PEEP titration, judging the trial evidence insufficiently robust. source
- Neuromuscular blockade points in opposite directions: ATS conditionally supports it in early severe ARDS (within 48 hours, PaO2/FiO2 below 100), while ESICM issues a strong recommendation against routine continuous infusion. source
- Both endorse venovenous ECMO in severe ARDS but with different force: the ATS recommendation is conditional, while ESICM makes it a strong recommendation, conditioned on delivery in an ECMO centre. source
- Prone positioning is strongly recommended by both, but the dose differs: ATS specifies more than 12 hours per day in moderate-to-severe ARDS, ESICM more than 16 hours per day. source
- Scope explains part of the divergence: the ESICM document is deliberately limited to definition, phenotyping and respiratory support — so it addresses ECCO2R (strong recommendation against) and awake proning but not corticosteroids, which the ATS guideline covers with a conditional recommendation in favour. source
What changed recently
- US2017 → 2024 update2023-11-30
The 2024 update to the 2017 ATS guideline adds conditional recommendations in favour of corticosteroids, venovenous ECMO in selected severe ARDS, and neuromuscular blockade in early severe ARDS, all of which the 2017 document had left unresolved. It also now favours higher PEEP without recruitment manoeuvres in moderate-to-severe ARDS and recommends strongly against prolonged recruitment manoeuvres, which meta-analysis suggested increase mortality.
See the full update feed for changes across every system.