Guideline on The Management Of Acute Respiratory

Distress Syndrome (ARDS) in Adult ICU

Aim and Scope
1)To ensure that all patients in ICU with ARDS are correctly identified and receive
the best evidence based treatment.

Definition
Onset of ARDS (diagnosis) must be acute, within 7 days of some defined event,
which may be sepsis, pneumonia, or simply a patients recognition of worsening
respiratory symptoms. (Most cases of ARDS occur within 72 hours of recognition of
the presumed trigger.)
Bilateral opacities consistent with pulmonary edema must be present but may be
detected on CT or chest X-ray. Ultrasound may also be used to define lung
pathology and the presence of non cardiogenic extra vascular lung water
Respiratory failure can be not fully explained by cardiac failure or fluid overload,
in the physicians best estimation using available information.

ARDS Severity
Mild
Moderate
Severe

PaO2/FiO2*
()kpa
200 300
(27 40)
100 200
(13-27)
< 100
(<13)
*on PEEP 5+

Mortality
27%
32%
45%

General Measures
1

All patients should have 100% compliance with the Ventilator Care bundle

No chest physiotherapy unless as a trial to improve lobar collapse

Minimal suctioning via ETT

Normal feed as per protocol

Fluids. All patients will have a liberal fluid strategy during the initial resuscitation
phase (usually 0-48hours). If patients are then still vasopressor dependent, we will
aim to maintain a neutral fluid balance. Once inotropes are discontinued or are
being used in low doses to compensate for sedation, then we will aim to remove
the excess fluid that has been given. This will initially be performed using diuretics
but may require CVVHF if the fluid balance remains positive. Vasopressor may be
required to support the BP and allow diuresis
6.

Ventilation

Mode: 1)VC SIMV ( Volume control, synchronized mandatory ventilation)

2) Volume assured PC SIMV (Pressure control, volume assured,
synchronized mandatory ventilation) This is not available on all ventilators
Settings: Peep 5-10cmH2O
TV 6ml/kg ideal body weight.
Plateau pressure < 30cmH20
Rate: titrated to control PaCO2
Ideal body weight is calculated as follows:
Males
Length (in cm) 100
Females Length (in cm) 105
The tidal volume required must be written every day at the top on the ICU
observation chart in red. It is the responsibility of the ICU consultant 1 to ensure that
this is done
7 All patients will have subglottic suction

The following patient group will be managed with an

extended ARDS care bundle
Diagnosis of ARDS as per above criteria
Ventilated for <36hours
A PaO2/FiO2 ratio<20kpa(150mmHg) for 12-24 hours on an FiO2 >0.6.
NDMR
All patients who meet the above criteria will be given a cisatracurium infusion. This
will be titrated to a train of four (TOF of 2 twitches). Paralyses will continue for as
long as they meet prone ventilation criteria.
Prone ventilation
All patients who do not have specific contraindications to prone ventilation will be
prone ventilated. They will be placed prone as per unit guidelines. They will remain
prone ventilated for at least 16 hours.

Prone ventilation will be stopped when any of the following criteria are met:
1) Improvement in oxygenation. This is defined as a Pao2:Fio2 ratio of 20, with a
PEEP of 10 cm of water and an Fio2 of 0.6. These criteria have to be sustained in
the supine position at least 4 hours after the end of the last prone session
2) A patient deteriorates compared to their PaO2:FiO2 ratio when supine
3) > 96 hours since first episode of prone ventilation
Management of a raised PaCO2
1) pH> 7.2 secondary to a respiratory acidosis will be tolerated
The respiratory rate and not the tidal volume should be adjusted to help maintain
a pH >7.2
2) If the pH remains less than 7.2 for >24 hours then consideration should be given
to using extra corporeal CO2 clearance
3) If the pH is < 7.1 for 4 hours or more with no other therapy (nebulisers etc)
available to reduce it, then extra corporeal CO2 clearance should be considered.
4) All patients being considered for extra corporeal CO2 clearance should initially
be discussed with our regional ECMO centre.
Management of a persistently low PaO2 (<8kpa)
1) Increase FiO2
2) Add nebulised prostacycline as per guideline
3) Maintain TV and peep
4) Discuss with regional ECMO centre
Recruitment maneuvers
1) All patients will have inspiratory hold recruitment. This will be performed by
using the inspiratory hold function on the ventilators.
2) This will be 30cm H2O for 30 seconds
3) It should be performed after each disconnection or suctioning episode
4) It should be repeated as required when clinically it is felt that recruitment is
required.
5) It may be used as a trial to improve the PaO2

Steroids
All patients will be given methylprednisolone 0,5mg/kg/day (or equivalent) for 14
days unless contraindicated for standard reasons.

Documentation Control
Development of Policy:

Dr James Low

Consultation with:

Dr. Craig Morris, Dr. Nick Reynolds

Approved by:

ICU Clinical Group

Signature:
Print name and position:
Date of Approval:

Nov 2013

Review Date:

Nov 2016

References
1)
2)
3)
4)

JAMA, June 2012 Vol 307, No. 23

NEJM June 2013 Vol 368, No 23
NEJM August 2001- Vol 345, No. 8
Crit Care Med. 2009 37(9):2680.