• Conference Reports and Expert Panel
• Open Access
• Published: 16 June 2023

ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies

Grasselli, G., Calfee, C.S., Camporota, L. et al.

Intensive Care Med (2023). https://doi.org/10.1007/s00134-023-07050-7

Domain 6: PEEP and recruitment maneuvers

Question 6.1: In patients with ARDS undergoing invasive mechanical ventilation, does routine PEEP titration using a higher PEEP/FiO₂ strategy compared to a lower PEEP/FiO₂ strategy reduce mortality?

Recommendation 6.1
We are unable to make a recommendation for or against routine PEEP titration with a higher PEEP/FiO2 strategy versus a lower PEEP/FiO2 strategy to reduce mortality in patients with ARDS.No recommendation; high level of evidence of no effect.
This statement applies also to ARDS from COVID-19.No recommendation; moderate level of evidence of no effect for indirectness.

Question 6.2: In patients with ARDS undergoing invasive mechanical ventilation, does routine PEEP titration based principally on respiratory mechanics compared to PEEP titration based principally on a standardized PEEP/FiO₂ table reduce mortality?

Recommendation 6.2
We are unable to make a recommendation for or against PEEP titration guided principally by respiratory mechanics, compared to PEEP titration based principally on PEEP/FiO2 strategy, to reduce mortality in patients with ARDS.No recommendation; high level of evidence of no effect.
This statement applies also to ARDS from COVID-19.No recommendation; moderate level of evidence for indirectness.

Question 6.3: In patients with ARDS undergoing invasive mechanical ventilation, does use of prolonged high-pressure recruitment maneuvers, compared to not using prolonged high-pressure RMs, reduce mortality?

Recommendation 6.3
We recommend against use of prolonged high-pressure recruitment maneuvers (defined as airway pressure maintained ≥ 35 cmH2O for at least one minute) to reduce mortality of patients with ARDS.Strong recommendation; moderate level of evidence against.
This recommendation applies also to ARDS from COVID-19.Strong recommendation; low level of evidence against for indirectness.

Question 6.4: In patients with ARDS undergoing invasive mechanical ventilation, does routine use of brief high-pressure recruitment maneuvers, compared to no use of brief high-pressure recruitment maneuvers, reduce mortality?

Recommendation 6.4
We suggest against routine use of brief high-pressure recruitment maneuvers (defined as airway pressure maintained ≥ 35 cmH2O for less than one minute) to reduce mortality in patients with ARDS.Weak recommendation; high level of evidence of no effect.
This suggestion applies also to ARDS from COVID-19.Weak recommendation; moderate level of evidence of no effect for indirectness.

Domain 7: Prone positioning

Question 7.1: In intubated patients with ARDS, does prone position compared to supine position reduce mortality?

Recommendation 7.1
We recommend 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) to reduce mortality.Strong recommendation, high level of evidence in favor.
This recommendation applies also to ARDS from COVID-19.Strong recommendation; moderate level of evidence in favor for indirectness.

Question 7.2: In patients with moderate-severe ARDS, when should prone positioning be started to reduce mortality?

Background

Recommendation 7.2
We recommend 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; and proning should be applied for prolonged sessions (16 consecutive hours or more) to reduce mortality.Strong recommendation; high level of evidence in favor.
This recommendation applies also to ARDS from COVID-19.Strong recommendation; moderate level of evidence in favor for indirectness.

Question 7.3: In non intubated patients with AHRF, does awake prone positioning (APP) as compared to supine positioning reduce intubation or mortality?

Recommendation 7.3
We suggest awake prone positioning as compared to supine positioning for non-intubated patients with COVID-19-related AHRF to reduce intubation.Weak recommendation; low level of evidence in favor.
We are unable to make a recommendation for or against APP for non-intubated patients with COVID-19-related AHRF to reduce mortality.No recommendation; moderate level of evidence of no effect.
We are unable to make a recommendation for or against APP for patients with AHRF not due to COVID-19.No recommendation; no evidence.

Domain 8: Neuromuscular blocking agents

Question 8.1: Does the routine use of a continuous infusion of neuromuscular blocking agents (NMBA) in patients with moderate-to-severe ARDS not due to COVID-19 or moderate-to-severe ARDS due to COVID-19 reduce mortality?

Recommendation 8.1
We recommend against the routine use of continuous infusions of NMBA to reduce mortality in patients with moderate-to-severe ARDS not due to COVID-19.Strong recommendation, moderate level of evidence.
We are unable to make a recommendation for or against the routine use of continuous infusions of NMBA to reduce mortality in patients with moderate-to-severe ARDS due to COVID-19.No recommendation; no evidence.

Domain 9: Extracorporeal life support

Question 9.1: In adult patients with severe acute respiratory distress syndrome (ARDS) or COVID-19 does veno-venous extracorporeal membrane oxygenation (VV-ECMO) compared with conventional ventilation improve outcomes?

Recommendation 9.1
We recommend that patients with severe ARDS not due to COVID-19 as defined by the EOLIA trial eligibility criteria, should be treated with ECMO in an ECMO center which meets defined organizational standards, adhering to a management strategy similar to that used in the EOLIA trial.Strong recommendation, moderate level of evidence in favor
This recommendation applies also to patients with severe ARDS due to COVID-19.Strong recommendation; low level of evidence in favor for indirectness.

Question 9.2: In adult patients with ARDS, does extracorporeal carbon dioxide removal (ECCO₂R) compared with conventional ventilation improve outcomes?

Recommendation 9.2
We recommend against the use of ECCO2R for the treatment of ARDS not due to COVID-19 to prevent mortality outside of randomized controlled trials.Strong recommendation, high level of evidence of no effect.
This recommendation applies also to patients with severe ARDS due to COVID-19.Strong recommendation; moderate level of evidence of no effect for indirectness.