Unspecified respiratory failure
ICD-10 J96.9 · ICD-11 CB41.2Z

Treatment of Unspecified Respiratory Failure in Acute Respiratory Distress Syndrome (ARDS)

Clinical scenario

This protocol addresses unspecified respiratory failure in patients who meet the Berlin definition of acute respiratory distress syndrome (ARDS) — a distinct sub-population characterised by acute hypoxaemic failure with bilateral pulmonary infiltrates on a background of a known clinical insult, not attributable to cardiac failure or fluid overload alone.

Diagnostic criteria (Berlin definition)
  • PaO2/FiO2 ratio ≤ 300 mmHg under PEEP or CPAP ≥ 5 cmH2O
  • Acute onset within one week of a recognised clinical insult
  • Bilateral opacities on chest imaging
  • Respiratory failure not fully explained by cardiac failure or fluid overload alone
Treatment approach

For severe ARDS that remains refractory after optimal medical management, veno-venous extracorporeal membrane oxygenation (ECMO) is an escalation strategy addressed in this protocol — the precise clinical thresholds, indications, and full management pathway are detailed in the structured regimen.

Instant Access to Structured Evidence-Based Regimens

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 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.

The benefit of extracorporeal membrane oxygenation (ECMO) has been clarified in recent studies, with ECMO now weakly recommended for severe ARDS in most guidelines.

In the latest ELSO guidelines, common indications for veno-venous ECMO are: (1) hypoxemic respiratory failure (PaO2/FiO2 < 80 mmHg) after optimal medical management including, in the absence of contraindications, a trial of prone positioning; (2) hypercapnic respiratory failure (pH < 7.25) despite optimal conventional mechanical ventilation (respiratory rate 35 breaths per minute and plateau pressure [Pplat] ≤ 30 cm H2O); and (3) ventilatory support as a bridge to lung transplantation or primary graft dysfunction following lung transplantation.

View source ↗