Treatment of Acute Respiratory Failure in Acute Respiratory Distress Syndrome with Bilateral Shadows

Acute respiratory failure (ARF) occurring in the context of acute respiratory distress syndrome (ARDS) with bilateral lung infiltration is a critical presentation requiring a structured, evidence-based ventilation strategy.

Clinical scenario This protocol applies to patients meeting the Berlin diagnostic criteria for ARDS: bilateral shadows in the lung fields, a PaO2/FiO2 ratio at or below 300 under PEEP or CPAP of at least 5 cmH₂O, acute onset within one week, and respiratory failure not explained by cardiac failure or excess fluid alone.

Treatment approach (overview only) Management is built around invasive mechanical ventilation with a lung-protective strategy; in moderate-to-severe ARDS, additional positioning-based interventions are part of the structured approach. The complete sequenced regimen is available via the link below.

Instant Access to Structured Evidence-Based Regimens

References

DOI: 10.1186/s40560-023-00658-3

Among ARF, acute respiratory distress syndrome (ARDS) is a serious condition associated with bilateral lung infiltration.

The clinical diagnosis of ARDS is currently based on the Berlin definition: (1) PaO2/FIO2 ratio ≤ 300 under positive end-expiratory pressure (PEEP)/continuous positive airway pressure (CPAP) ≥ 5 cmH2O; (2) acute onset within a week; (3) bilateral shadows in the lung fields, and (4) respiratory failure that cannot be explained by cardiac failure or excess fluid alone.

Low tidal volume ventilation is weakly recommended for ARF in SSCG2021 and SRLF-GL2019, and strongly recommended for ARDS in JRS/JSICM/JSRCM-GL2021, SSCG2021, SRLF-GL2019 and FICM/ICS-GL2018.

Limiting plateau pressure and high-level PEEP is recommended weakly to strongly in all guidelines, although the most recent Cochrane analysis did not find a survival benefit for high-level PEEP.

Prone position ventilation with prolonged hours is weakly to strongly recommended for moderate-to-severe ARDS in all guidelines.

Early and limited use of muscle relaxants are weakly to strongly recommended for patients with moderate to severe ARDS.

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