2023 · ATS/ESICM/SCCM · ARDS

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Summary

2023 ESICM update of the 2017 ATS/ESICM/SCCM ARDS guideline covering adult patients and non-pharmacological respiratory support (plus neuromuscular blockade) for ARDS including COVID-19 ARDS. The guideline addresses 21 PICO questions across nine domains: definition, phenotyping, HFNO, NIV/CPAP, low tidal volume ventilation, PEEP and recruitment maneuvers, prone positioning, neuromuscular blockade, and extracorporeal life support. New since 2017: explicit recommendations for HFNO over conventional oxygen, awake prone positioning in COVID-19, against routine recruitment maneuvers, and stronger guidance on VV-ECMO in EOLIA-eligible patients.

Key Recommendations

  • Use HFNO rather than conventional oxygen therapy in non-intubated patients with acute hypoxemic respiratory failure (not from cardiogenic edema or COPD) to reduce intubation, including in COVID-19.
  • In COVID-19 AHRF, CPAP/NIV may be considered instead of HFNO to reduce intubation risk; no recommendation either way in unselected non-COVID AHRF.
  • Use low tidal volume ventilation (4–8 mL/kg predicted body weight) in ARDS, including COVID-19 ARDS, to reduce mortality.
  • No recommendation for higher vs lower PEEP/FiO2 tables or for mechanics-based vs PEEP/FiO2 table titration — individualize.
  • Recommend AGAINST prolonged high-pressure recruitment maneuvers (≥35 cmH2O for ≥1 minute); suggest against routine brief high-pressure RMs.
  • Use prone positioning for moderate-to-severe ARDS (PaO2/FiO2 < 150 mmHg with PEEP ≥ 5 despite optimization), applied early after intubation in prolonged sessions of ≥16 hours.
  • Suggest awake prone positioning in non-intubated COVID-19 AHRF to reduce intubation; insufficient evidence in non-COVID AHRF.
  • Routine continuous NMBA infusion is not recommended for moderate-to-severe ARDS; reserve for selected patients (e.g., severe asynchrony, high transpulmonary pressures, risk of pneumothorax).
  • Refer patients with severe ARDS meeting EOLIA criteria to an experienced ECMO center for VV-ECMO, applying an EOLIA-like management strategy; this applies to COVID-19 severe ARDS as well.
  • Recommend AGAINST extracorporeal CO2 removal (ECCO2R) outside of randomized trials due to lack of mortality benefit and increased bleeding risk.
  • Helmet interface may be preferable to face mask for NIV delivery in AHRF (expert opinion); requires expertise to manage synchrony.
  • Recognize ARDS sub-phenotypes (hyper- vs hypo-inflammatory; focal vs diffuse morphology) as prognostically and potentially predictively important, though not yet ready for routine bedside use.

Thresholds & Doses

  • Low tidal volume target: 4–8 mL/kg predicted body weight.
  • Moderate-to-severe ARDS threshold for proning: PaO2/FiO2 < 150 mmHg with PEEP ≥ 5 cmH2O.
  • Prone positioning duration: ≥16 consecutive hours per session.
  • Prolonged high-pressure RM definition (recommended against): airway pressure ≥35 cmH2O held ≥1 minute.
  • Brief high-pressure RM definition (suggested against): airway pressure ≥35 cmH2O held <1 minute.
  • Berlin definition PEEP requirement for ARDS diagnosis: ≥5 cmH2O.
  • HFNO flow capability: up to 60 L/min; generates 3–5 cmH2O PEEP.
  • EOLIA VV-ECMO criteria: PaO2/FiO2 <50 mmHg for >3 h, OR PaO2/FiO2 <80 mmHg for >6 h, OR pH <7.25 with PaCO2 ≥60 mmHg for >6 h (with RR up to 35 and Pplat ≤32 cmH2O).
  • ACURASYS/ROSE NMBA protocol: 48-hour continuous cisatracurium infusion in moderate-to-severe ARDS (PaO2/FiO2 <150 with PEEP ≥5).
  • ECCO2R blood flow ranges in trials: ~450 mL/min (REST) to 1–2 L/min (Xtravent); ~500 mL/min likely insufficient to meaningfully reduce VILI.
  • ARDS incidence and mortality: ~10% of ICU admissions, 23% of ventilated patients; mortality up to 45% in severe category.

Citations

  • Recommendation 3.1 — HFNO over conventional oxygen to reduce intubation in AHRF including COVID-19.
  • Recommendation 5.1 — Low tidal volume (4–8 mL/kg PBW) in ARDS and COVID-19 ARDS.
  • Recommendations 6.3 and 6.4 — Against prolonged and routine brief high-pressure recruitment maneuvers.
  • Recommendations 7.1 and 7.2 — Prone positioning for moderate-severe ARDS (PaO2/FiO2 <150) for ≥16 hours.
  • Recommendation 7.3 — Awake prone positioning in COVID-19 AHRF to reduce intubation.
  • Recommendation 9.1 — VV-ECMO in EOLIA-eligible severe ARDS at expert centers.
  • Recommendation 9.2 — Against ECCO2R outside RCTs for ARDS.
  • Domain 8 / ROSE and ACURASYS trial discussion — Routine continuous NMBA not recommended in moderate-severe ARDS.
  • Table 3 — Comparison of 2017 vs 2023 ARDS guideline recommendations.