MedeliX
Start asking

ARDS Clinical Practice Guideline 2021

JSICM/JRS/JSRCM · 2022 · Japan

Source and licence

Authors
Sadatomo Tasaka, Shinichiro Ohshimo, Muneyuki Takeuchi et al.
Title
ARDS Clinical Practice Guideline 2021
Journal
Journal of Intensive Care, 2022
DOI
10.1186/s40560-022-00615-6
Licence
CC BY 4.0
Changes
Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC9263056

Licence statement of the original publication

Open AccessThis article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

This page reproduces excerpts of the original publication; the original is authoritative. It has not been reviewed by a physician, does not state a recommendation of Medelix and does not replace medical advice. The guideline may have been updated since.

Open the original publication →Full text on Europe PMC

Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Step 2: Panel meeting

  • When there was no agreement (Median < 6.5 or DI ≥ 1) Discussions were held within the committee, after which amendments were made to the EtoD and recommended text, and a second vote was held. Voting was conducted up to three times.
  • When there was agreement (Median ≥ 6.5 and DI < 1)

Recommendation

  • We recommend that ARDS should be suspected for patients with acute respiratory failure (GPS).
  • We suggest using blood BNP or NT-proBNP levels for identifying cardiogenic pulmonary edema in patients with acute respiratory failureweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against identifying bacterial pneumonia as the underlying disease of ARDS only with serum CRP and PCT resultsweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest the use of pneumococcal urinary antigen testing and sputum Gram staining for identifying pneumococcal pneumonia as the causative disease of ARDS (weak recommendation/very low certainty of evidence: GRADE 2D.
  • We suggest using Legionella urinary antigen testing for identifying Legionella pneumonia as the causative disease of ARDSweak recommendation/very low certainty of evidence GRADE 2D
  • We suggest using PCR tests of BAL fluid and blood antigenemia methods for identifying CMV pneumonia as the causative disease of ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest using serum β-d-glucan tests for identifying PCP as the causative disease of ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against identifying IPA as the causative disease of ARDS using only serum β-d-glucan test resultsweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest identifying IPA as the causative disease of ARDS using galactomannan antigen tests in blood and BAL fluidweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against using only lung pathology or only chest CT imaging for predicting prognosis of patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against ARDS patient prognosis prediction using only P/F ratio (cutoff: 100, 200) resultsweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest conducting non-invasive respiratory support (NPPV, HFNC) instead of conventional oxygen therapy as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absent.
  • We suggest conducting non-invasive respiratory support (NPPV, HFNC) over tracheal intubation.
  • We suggest conducting NPPV over conventional oxygen therapy as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absentweak recommendation/moderate certainty of evidence: GRADE 2B
  • We suggest conducting HFNC over oxygen therapy as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absentweak recommendation/moderate certainty of evidence: GRADE 2B
  • We suggest conducting NPPV over tracheal intubation as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absentweak recommendation/moderate certainty of evidence: GRADE 2B
  • We suggest conducting HFNC over tracheal intubation as an initial respiratory management for adult patients with acute respiratory failure suspected of having ARDS if there are no contraindications for non-invasive respiratory support or if organ failure other than respiratory failure is absentweak recommendation/moderate certainty of evidence: GRADE 2B
  • We recommend limiting tidal volume to 4–8 mL/kg for mechanically ventilated adult patients with ARDSstrong recommendation/very low certainty of evidence: GRADE 1D
  • We suggest using high levels of PEEP for mechanically ventilated adult patients with ARDS.
  • We suggest plateau pressure restrictions when using a ventilator on adult patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against the routine use of the recruitment maneuver in adult patients with ARDS.
  • We suggest protocolized ventilator weaning in adult patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against implementing HFOV for adult patients with moderate or severe ARDSweak recommendation/high certainty of evidence: GRADE 2A
  • We suggest against conducting management that targets an excessively low SpO2 (PaO2) in adult patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest administering neuromuscular blockers at an early phase for adult patients with moderate or severe ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against using transpulmonary pressure as a routine basis in PEEP settings for patients with ARDS.
  • We suggest performing the prone positioning in adult patients with moderate or severe ARDS for long periods of timeweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest implementing ECMO for adult patients with severe ARDSweak recommendation/moderate certainty of evidence: GRADE 2B
  • We suggest performing early tracheostomy in adult patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We recommend conducting a VAP prevention bundle routinely in adult patients with ARDS on a ventilator (GPS).
  • We suggest against using NO inhalation in patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against using sivelestat in patients with ARDS.
  • We suggest against using high-dose corticosteroids for adult patients with ARDS.
  • We recommend using low-dose corticosteroids for adult patients with ARDS.
  • We suggest conducting early (i.e., within 72 h) rehabilitation for adult patients with ARDSweak recommendation/low certainty of evidence: GRADE 2C
  • We suggest conducting no sedation or minimal sedation management for adult patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest performing the restrictive fluid management strategies for adult patients with ARDSweak recommendation/moderate certainty of evidence: GRADE 2B
  • We suggest giving enteral nutrition with high ω3 fatty acid content to patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against using non-invasive respiratory support (NPPV/HFNC) in pediatric patients with ARDS.
  • We suggest to use a protocol when liberating pediatric patients with acute respiratory failure who have been mechanically ventilated for more than 24 h from ventilator.weak recommendation/ very low certainty of evidence: GRADE 2D
  • We suggest against implementing HFOV for pediatric patients with ARDS.
  • We suggest against implementing APRV as a ventilation mode in pediatric patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest placing pediatric patients with moderate to severe ARDS in the prone positionweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest against routinely implementing NO inhalation therapy for pediatric patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2C
  • We suggest against using surfactants for pediatric patients with ARDSweak recommendation/very low certainty of evidence: GRADE 2D
  • We suggest the use of protocols for the sedation of pediatric respiratory failure patientsweak recommendation/moderate certainty of evidence: GRADE 2B
  • We suggest against implementing DSI for pediatric respiratory failure patientsweak recommendation/very low certainty of evidence: GRADE 2D

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.

Supplementary Information: The online version contains supplementary material available at 10.1186/s40560-022-00615-6.

Contents of the original publication

The section headings of the original.

  • Background
  • Methods
  • Composition of ARDS Clinical Practice Guideline Creation Committee
  • Setting of important CQs
  • Analytic framework
  • Creation of PICO sheet
  • Relative importance of outcomes
  • SR policy
  • SR and meta-analysis
  • Creation of recommendations
  • Good practice statement
  • In our practice statement
  • Recommendation decision in panel meeting
  • Strength of recommendation
  • Creation of recommendation text and public comments
  • Recommendations on COVID-19
  • Results
  • CQ1: Should ARDS diagnoses be conducted for patients with acute respiratory failure?
  • CQ2: Should blood brain natriuretic peptide (BNP) and NT-proBNP levels be used for identifying cardiogenic pulmonary edema as the causative disease of acute respiratory failure?
  • CQ3: Should serum C-reactive protein (CRP) and procalcitonin (PCT) levels be used for identifying bacterial pneumonia as the underlying disease of ARDS?
  • CQ4: Should pneumococcal urinary antigen tests and sputum Gram staining be used for identifying pneumococcal pneumonia as the causative disease of ARDS?
  • CQ5: Should Legionella urinary antigen testing be used for identifying Legionella pneumonia as the causative disease of ARDS?
  • CQ6: Should antigen and PCR tests of the pharyngeal swabs and serum antibody tests be used to identify Mycoplasma pneumonia as the causative disease of ARDS?
  • CQ7: Should antigen tests of the pharyngeal/nasopharyngeal swabs and PCR tests of the bronchoalveolar lavage fluid be used for identifying influenza pneumonia as the causative disease of ARDS?
  • CQ8: Should PCR tests of the bronchoalveolar lavage fluid and blood antigenemia methods be used for identifying cytomegalovirus pneumonia as the causative disease of ARDS?
  • CQ9: Should serum β-D-glucan be used for identifying Pneumocystis pneumonia as the causative disease of ARDS?
  • CQ10: Should serum β-d-glucan and galactomannan antigens of the blood or BAL fluid be used for identifying invasive pulmonary aspergillosis as the causative disease of ARDS?
  • CQ11: Should plain chest X-rays, chest high-resolution CT, and interferon γ release assays be used for identifying miliary tuberculosis as the causative disease of ARDS?
  • CQ12: Should lung pathology or chest CT imaging be used for predicting prognosis of ARDS patients?
  • CQ13: Should PaO2/FIO2 (P/F) ratio be used for predicting prognosis of patients with ARDS?
  • CQ 14: Should non-invasive respiratory support be used for patients with ARDS?
  • CQ 15: Should NPPV be used over oxygen therapy for patients with ARDS?
  • CQ 16: Should HFNC be used over conventional oxygen therapy for patients with ARDS?
  • CQ 17: Should NPPV be used prior to conducting tracheal intubation in patients with ARDS?
  • CQ 18: Should HFNC be used prior to conducting tracheal intubation in patients with ARDS?
  • CQ 19: Should low tidal volume be used in mechanically ventilated adult patients with ARDS?
  • CQ 20: Should high levels of positive end-expiratory pressure (PEEP) be used for mechanically ventilated adult patients with ARDS?
  • CQ21: Should plateau pressure be limited for mechanically ventilated adult patients with ARDS?
  • CQ22: Which, between pressure-control ventilation (PCV) and volume-control ventilation (VCV), is desirable for mechanical ventilation in adult patients with ARDS?
  • CQ23: Should airway pressure release ventilation (APRV) be used in the mechanical ventilation of adult patients with ARDS?
  • CQ24: Which is preferable for ventilatory management of adult patients with ARDS: synchronized intermittent mandatory ventilation (SIMV) or assisted controlled ventilation (A/C)?
  • CQ25: When using mechanical ventilation in adult patients with ARDS with spontaneous breathing, is pressure support ventilation (PSV) or A/C preferred?
  • CQ26: Should we perform a recruitment maneuver when ventilating an adult patient with ARDS?
  • CQ27: Are ventilator weaning protocols useful in patients with mechanical ventilation?
  • CQ28: Should high-frequency oscillatory ventilation (HFOV) be used for adult patients with ARDS?
  • CQ29: Should driving pressure be used as an index when implementing mechanical ventilation in adult patients with ARDS?
  • CQ30: Is low SpO2 (PaO2) a target for management in adult patients with ARDS?
  • CQ31: Should neuromuscular blockers be used at an early phase in adult patients with moderate or severe ARDS?
  • CQ32: Should transpulmonary pressure be used when setting PEEP in patients with ARDS?
  • CQ33: Should electrical impedance tomography (EIT) be used in PEEP settings for patients with ARDS?
  • CQ34: Should pulmonary ultrasound be used for PEEP settings in patients with ARDS?
  • CQ35: Should prone positioning be used in adult patients with moderate or severe ARDS?
  • CQ36: Should ECMO be conducted in adult patients with severe ARDS?
  • CQ37: Should early tracheostomy be performed in adult patients with ARDS?
  • CQ38: Should a VAP prevention bundle be routinely conducted for adult patients with ARDS?
  • CQ39: Should thrombomodulin be used in patients with ARDS?
  • CQ40: Should nitric oxide inhalation be used for patients with ARDS?
  • CQ41: Should sivelestat be used for patients with ARDS?
  • CQ42: Should corticosteroids be used for adult patients with ARDS?
  • CQ43: Should early rehabilitation intervention be conducted for adult patients with ARDS?
  • CQ44: Should non-sedative or light-sedative management be conducted for adult patients with ARDS?
  • CQ45: Should restrictive fluid management strategies be implemented for adult patients with ARDS?
  • CQ46: Should enteral nutrition with high ω3 fatty acid content be given to patients with ARDS?
  • PCQ1: Should non-invasive respiratory support (NPPV/HFNC) be used for pediatric patients with ARDS?
  • PCQ2: Should tidal volume be restricted in pediatric patients with ARDS?
  • PCQ3: Should high PEEP be used in pediatric patients with moderate to severe ARDS?
  • PCQ4: Should plateau pressure be restricted in pediatric patients with ARDS?
  • PCQ5: Should a protocol be used when liberating pediatric patients with acute respiratory failure from mechanical ventilator?
  • PCQ6: Should HFOV be used for pediatric patients with moderate to severe ARDS?
  • PCQ7: Should APRV be used for pediatric patients with ARDS?
  • PCQ8: How should target SpO2 values be set in pediatric patients with ARDS?
  • PCQ9: Should muscle relaxants be used at an early stage in pediatric patients with moderate or severe ARDS?
  • PCQ10: Should pediatric patients with moderate to severe ARDS be placed in the prone position?
  • PCQ11: Should nitric oxide inhalation therapy be used in pediatric patients with ARDS?
  • PCQ12: Should surfactant be used in pediatric patients with ARDS?
  • PCQ13: Should steroids be used in pediatric patients with ARDS?
  • PCQ14: Should a protocol be used for the sedation of pediatric respiratory failure patients?
  • PCQ15: Should daily sedation interruption (DSI) be implemented for pediatric respiratory failure patients?
  • Conclusions
  • Contributor Information

A question about this guideline?

Medelix answers clinical questions from guidelines and studies – every statement with its source.

Are you the rights holder and object to this reproduction? Write to contact@medelix.ai and we will take the page down promptly. Imprint