ARDS Clinical Practice Guideline 2021

Abstract

Background The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021. Methods The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method. Results Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D). Conclusions This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.

Morphological and functional findings in COVID-19 lung disease as compared to Pneumonia, ARDS, and High-Altitude Pulmonary Edema

“…All these four pathophysiological entities present similar but also peculiar characteristics of treatment. There is not specific treatment for AIP and ARDS being the management of these two conditions is mainly supportive ( Tasaka et al, 2022 , Xaubet et al, 2013 ). In AIP and ARDS of infective etiology, broad-spectrum antibiotics are recommended initially until infectious etiology is confirmed, thereby selecting narrower spectrum antibiotics.…”

“…Supportive therapies for AIP are like those applied for ARDS, using a stepwise approach to increase the complexity of treatment according to the increased severity of lung disease. In mechanically ventilated subjects, a lung protective ventilator strategy should be adopted ( Tasaka et al, 2022 , Xaubet et al, 2013 ). In HAPE, the first-line treatment is the administration of oxygen and the rapid descent to lower altitudes.…”

“…This is matter of debate since HAPE is a poorly defined pathophysiological entity, hence not clearly supporting the use of this terminology and its implication for therapy to date ( Sinha et al, 2020 ). A universal agreement on the use of corticosteroids in non-COVID ARDS is still lacking, but national guidelines started to consider the use of low-dose steroids in ARDS, while recommending against the use of high doses that may result in immune suppression and increased risk of opportunistic infections ( Tasaka et al, 2022 ). COVID-19 has boosted the pharmacological research investigating the role of several immunomodulating agents in respiratory failure, including steroids, anti-interleukin monoclonal antibodies and drugs with indirect action on the immune response ( Battaglini et al, 2022 ).…”

The Sequential Organ Failure Assessment (SOFA) Score: has the time come for an update?

“…The need for "respiratory support" is currently a criterion for a respiratory sub-SOFA score of 3 or 4, which could now include use of high-flow oxygen therapy (HFOT) [21], non-invasive mechanical ventilation, and even venovenous extracorporeal membrane oxygenation (VV-ECMO) [22,23] as these are more widely used. Similarly, renal replacement therapies are now widely available and could be considered as an indicator of renal dysfunction, unless used for non-renal indications (e.g., removal of toxic products).…”

Personalized medicine using omics approaches in acute respiratory distress syndrome to identify biological phenotypes

“…In contrast, pharmacologic treatments and some possible supportive therapies may benefit from personalization; specific physiologic thresholds, clinical characteristics, biological or omics subphenotypes have been targeted to find treatable traits. Supportive treatments for ARDS include protective mechanical ventilation using a low tidal volume (4–6 mL/kg of predicted body weight), plateau pressure (< 28–30 cmH 2 O) [ 9 , 10 ], low driving pressure (< 13–15 cmH 2 O), and individualized levels of positive end-expiratory pressure (PEEP) [ 7 ]. In the case of refractory hypoxemia, neuromuscular blocking agents, prone positioning, recruitment maneuvers, extracorporeal membrane oxygenation should be considered [ 7 ].…”