ARDS: Lung-Protective Strategy

• Berlin ARDS: onset within 1 week, bilateral opacities not fully explained by effusions/collapse/nodules, and oedema not fully explained by cardiac failure or fluid overload. With PEEP/CPAP ≥5 cmH₂O: mild 200 < P/F ≤300, moderate 100 < P/F ≤200, severe P/F ≤100. The 2024 Global Definition also includes nonintubated patients on HFNO ≥30 L/min: P/F ≤300 or S/F ≤315; use S/F only when SpO₂ ≤97%, with the other diagnostic criteria satisfied.
• Ventilate at VT 6 mL/kg PBW, plateau ≤30, driving pressure ≤15; accept permissive hypercapnia (pH ≥7.20; ARDSNet goal 7.30–7.45).
• If P/F remains <150 after optimization, use prone sessions ≥16 h; use conservative fluids after resuscitation. Consider short-course neuromuscular blockade in selected early severe ARDS when needed to achieve lung-protective ventilation or proning; do not use continuous paralysis routinely for every patient.
• Seek early VV-ECMO-centre advice for potentially reversible severe ARDS with refractory hypoxaemia or severe hypercapnic acidosis despite optimized lung-protective ventilation and proning when feasible. Trial-based severity examples include P/F <50 for >3 h, P/F <80 for >6 h, or pH <7.25 with PaCO₂ >60 mmHg for >6 h despite optimized ventilation. These support assessment, not automatic cannulation; refer before deterioration prevents safe transfer.

First tests: Oxygenation assessment, Chest X-ray, Trigger-directed assessment.

Only if indicated: Bedside echocardiography, CT chest, Respiratory culture.

Repeat monitoring: Arterial blood gas, Ventilator pressures and mechanics.

• Ventilator Strategies in Acute Lung Injury/ARDS
• Fluid Strategies in Acute Lung Injury/ARDS