Chronic respiratory failure
ICD-10 J96.1 · ICD-11 CB41.1

Treatment of Chronic Respiratory Failure in Acute Respiratory Distress Syndrome with PaO2/FiO2 ≤ 300

This protocol applies to chronic respiratory failure arising in the setting of acute respiratory distress syndrome (ARDS), characterised by a PaO2/FiO2 ratio ≤ 300 and bilateral lung field opacities consistent with the Berlin diagnostic criteria.

Clinical Scenario
  • Acute respiratory distress syndrome (ARDS)
  • PaO2/FiO2 ratio ≤ 300
  • Bilateral shadows in the lung fields

The Berlin definition requires PaO2/FiO2 ≤ 300 under PEEP or CPAP, acute onset within one week, bilateral lung field shadows, and respiratory failure not fully explained by cardiac failure or excess fluid alone.

Treatment Approach — Partial Overview
The primary intervention is invasive positive pressure ventilation (IPPV) using a low tidal volume strategy with limited plateau pressure. High-flow nasal cannula oxygenation (HFNC) and noninvasive positive pressure ventilation (NPPV) are weakly recommended as alternative initial options. The complete regimen also addresses adjunctive pharmacological therapy and fluid management strategy — details are in the full structured protocol.

The full protocol includes the complete decision algorithm, specific thresholds, and sequenced management steps.

Instant Access to Structured Evidence-Based Regimens

References

  • 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.
  • 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.
  • Based on this evidence, the JRS/JSICM/JSRCM-GL2021 and FICM/ICS-GL 2018 weakly recommend restrictive fluid management.
DOI: 10.1186/s40560-023-00658-3
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