Treatment of Moderate to Severe ARDS with Low P/F Ratio: Prone Positioning Protocol

Acute respiratory distress syndrome (ARDS) with significantly impaired oxygenation requires targeted interventions beyond standard ventilatory support. When the P/F ratio falls below 20 kPa, the approach involves specific adjunct strategies supported by GRADE-level evidence.

This protocol addresses moderate to severe ARDS characterised by a P/F ratio below 20 kPa — a threshold at which standard measures alone are insufficient and additional interventions carry strong guideline support.

The regimen involves a positional strategy applied for an extended daily period, combined with a short-course neuromuscular blocking agent given by continuous infusion — both with specific timing requirements. The complete sequencing, durations, and criteria are available in the full protocol.

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References

DOI: 10.1136/bmjresp-2019-000420

We recommend the use of prone positioning for at least 12 hours per day in patients with moderate/severe ARDS (P/F ratio<20 kPa: GRADE recommendation: strongly in favour).
We suggest the use of cisatracurium besylate by continuous 48 hours infusion in patients suffering early moderate/severe ARDS (P/F<20 kPa: GRADE Recommendation: weakly in favour).

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