Treatment of Acute Respiratory Failure in Acute Respiratory Distress Syndrome (ARDS) with PaO2/FiO2 ≤ 300
This protocol covers acute respiratory failure arising in the setting of acute respiratory distress syndrome (ARDS), specifically where the PaO2/FiO2 ratio is ≤ 300. The presentation is characterised by bilateral pulmonary involvement of acute onset, not attributable to cardiac failure or fluid overload alone.
ARDS is defined by the Berlin criteria: PaO2/FIO2 ratio ≤ 300 under PEEP or CPAP ≥ 5 cmH₂O; acute onset within one week; bilateral shadows on chest imaging; and respiratory failure not explained by cardiac failure or excess fluid alone. This protocol applies when all four criteria are met.
Initial respiratory management in this setting may involve non-invasive support strategies — including high-flow nasal cannula oxygenation (HFNC) or noninvasive positive pressure ventilation (NPPV) — considered as alternatives to invasive positive pressure ventilation.
The full protocol specifies the decision criteria, clinical thresholds, and stepwise selection and escalation of respiratory support. Access below.
References
DOI: 10.1186/s40560-023-00658-3
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 cmHO2; (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.
Regarding ARDS, IPPV has been the gold standard; however, HFNC and NPPV are weakly recommended as alternative options to initial management in JRS/JSICM/JSRCM-GL2021.
As a result of the rapid spread and accumulation of evidence for high-flow nasal cannula oxygenation, it is now weakly recommended for the respiratory management of ARF in general and even for initial management of ARDS.
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