Table 1:

Summary of mechanical ventilation interventions for the acute respiratory distress syndrome (ARDS) and recommendations from the clinical practice guidelines of the American Thoracic Society (ATS), European Society of Intensive Care Medicine (ESICM), Society of Critical Care Medicine (SCCM), Societé de réanimation de langue Française (SRLF) and Intensive Care Society (ICS)

InterventionARDS severityRationaleStrength of recommendation
ATS/ESICM/SCCM2SRLF3ICS4
Low tidal volumes (4–8 mL/kg predicted body weight)AnyMechanical ventilation may potentiate acute lung injury, and lower tidal volumes may mitigate VILIStrong recommendation for routine useStrong agreement for routine useStrong recommendation for routine use
Lower inspiratory pressures (plateau pressure < 30 cm H2O)AnyIncreased plateau pressures may contribute to VILI, even with appropriate tidal volumesStrong recommendation for routine useStrong agreement for routine useStrong recommendation for routine use
Higher PEEP instead of lower PEEPModerate/severeHigher PEEP may optimize alveolar recruitment, and acts to decrease intrapulmonary shunt and reduce the risk of VILIConditional recommendation for routine useStrong agreement for routine useWeak recommendation for routine use
Prone positioningSevereProne positioning improves lung recruitment, primarily in dependent regions, and therefore increases end-expiratory lung volume, improves ventilation–perfusion matching and decreases VILIStrong recommendation for routine use (> 12 h per day)Strong agreement for routine use (in patients with Pao2/FiO2 < 150 mm Hg; 16 consecutive hours)Strong recommendation for routine use (> 12 h per day)
High-frequency oscillatory ventilationModerate/severeMethod of ventilation that provides very small tidal volumes at higher mean airway pressures, therefore minimizing tidal stress and strainStrong recommendation against routine useStrong agreement against routine useStrong recommendation against routine use
Recruitment manoeuvresAnyRecruitment manoeuvres (i.e., transient elevations in applied airway pressures) may reduce atelectasis and increase end-expiratory lung volume by opening collapsed alveoliConditional recommendation for routine useStrong agreement against routine useNo recommendation on the basis of poor evidence at the time of guideline development
VV-ECMOSevereExtracorporeal oxygenation and removal of carbon dioxide can replace the function of diseased lungs in ARDS, and allow for minimal ventilator settings to reduce incidence of VILINo recommendation on the basis of poor evidence at the time of guideline developmentStrong agreement for use in severe ARDS with Pao2/FiO2 < 80 or in cases of refractory hypoxemiaWeak recommendation for use in selected patients
  • Note: PEEP = positive end-expiratory pressure, VILI = ventilator-induced lung injury, VV-ECMO = venovenous extracorporeal membrane oxygenation.