Diagnose ARDS with the 2024 global definition (including SpO2/FiO2 and ultrasound for resource-limited settings), ventilate with 6 mL/kg PBW and plateau ≤ 30, choose PEEP sensibly, prone early for P/F < 150, use neuromuscular blockade and conservative fluids selectively, consider steroids, and refer for ECMO in time.
6 topics
- 01
Defining and diagnosing ARDS
ARDS is acute (≤ 1 week) hypoxaemic respiratory failure with bilateral opacities not fully explained by cardiac failure or fluid overload. The 2024 global definition adds non-intubated patients on HFNC ≥ 30 L/min, SpO2/FiO2 criteria, and lung ultrasound for resource-limited settings.
5 stepsAlgorithmNew - 02
Lung-protective ventilation and PEEP
Tidal volume 6 mL/kg PBW (4-8), plateau ≤ 30 cmH2O, driving pressure ideally ≤ 15, PEEP by table or mechanics (higher PEEP in moderate-severe ARDS), no prolonged recruitment manoeuvres, permissive hypercapnia with pH ≥ 7.20-7.25.
7 stepsAlgorithmNew - 03
Prone positioning
Prone early (within 36 h) when P/F < 150 mmHg on FiO2 ≥ 0.6 and PEEP ≥ 5 despite optimisation, for at least 16 h per session, using a trained team and a checklist. Repeat daily until P/F ≥ 150 is sustained supine.
6 stepsAlgorithmNew - 04
Neuromuscular blockade and fluid management
Use a 24-48 h cisatracurium infusion in early severe ARDS if asynchrony or high pressures persist despite deep sedation. After shock resolves, use a conservative fluid strategy with diuretics to reduce lung water.
6 stepsAlgorithm3 dosesNew - 05
Corticosteroids and pharmacological adjuncts
ATS 2024 suggests corticosteroids for ARDS. Use an evidence-based regimen matched to the cause (dexamethasone for COVID-19 and DEXA-ARDS; hydrocortisone for severe CAP). Avoid in influenza. Inhaled vasodilators improve oxygenation but not survival.
6 stepsAlgorithm2 dosesNew - 06
Refractory hypoxaemia and VV-ECMO
If P/F stays < 80 mmHg (or < 50 for 3 h) or pH < 7.25 with PaCO2 ≥ 60 despite optimised ventilation, proning and NMB, refer early to an ECMO centre (EOLIA criteria). Transfer before the patient is too unstable.
5 stepsAlgorithmNew
Drugs in this module
Doses written for this module's context. The same drug may read differently in another module.
Cisatracurium
Benzylisoquinolinium non-depolarising neuromuscular blocker
Cisatracurium
Benzylisoquinolinium non-depolarising neuromuscular blocker
- Indications
- Early severe ARDS (P/F < 150) with persistent asynchrony or high plateau pressure despite deep sedation; prone positioning.
- Adult dose
- Bolus 0.15-0.2 mg/kg, then 1-3 mcg/kg/min (ACURASYS used a fixed 15 mg bolus then 37.5 mg/h for 48 h).
- Preparation (India)
- 2 mg/mL (5 mL and 10 mL vials); 100 mg in 50 mL = 2 mg/mL undiluted.
- Renal / hepatic
- Hofmann elimination: no adjustment in renal or hepatic failure.
- Cautions
- Must be deeply sedated first (awareness). ICU-acquired weakness with prolonged use; eye care and pressure care.
- Monitoring
- Train-of-four (aim 1-2 twitches if titrating), sedation depth (BIS if available).
Atracurium
Benzylisoquinolinium neuromuscular blocker
Atracurium
Benzylisoquinolinium neuromuscular blocker
- Indications
- Alternative to cisatracurium where unavailable.
- Adult dose
- Bolus 0.5 mg/kg, then 0.3-0.6 mg/kg/h (≈ 5-10 mcg/kg/min).
- Preparation (India)
- 10 mg/mL (2.5 mL and 5 mL ampoules).
- Cautions
- Histamine release (hypotension, bronchospasm) with fast boluses; laudanosine accumulation (seizure risk theoretical).
Dexamethasone
Corticosteroid
Dexamethasone
Corticosteroid
- Indications
- Moderate-severe ARDS (DEXA-ARDS regimen); COVID-19 requiring oxygen (6 mg daily for 10 days).
- Adult dose
- DEXA-ARDS: 20 mg IV daily days 1-5, then 10 mg daily days 6-10. COVID-19: 6 mg daily up to 10 days.
- Preparation (India)
- 4 mg/mL (2 mL and 30 mL vials) and 8 mg/2 mL ampoules.
- Cautions
- Hyperglycaemia; secondary infections; avoid in influenza ARDS (observational harm).
Hydrocortisone
Corticosteroid
Hydrocortisone
Corticosteroid
- Indications
- Severe community-acquired pneumonia (CAPE COD regimen).
- Adult dose
- 200 mg/day infusion for 4 days (or 8 days if not improving), then taper over 8-14 days total.
- Preparation (India)
- 100 mg vials.
- Cautions
- CAPE COD excluded influenza and septic shock patients; hyperglycaemia.
Furosemide
Loop diuretic
Furosemide
Loop diuretic
- Indications
- Conservative fluid strategy once shock has resolved (FACTT).
- Adult dose
- 20-40 mg IV boluses, or infusion 5-20 mg/h, titrated to negative fluid balance with CVP/perfusion monitoring.
- Preparation (India)
- 10 mg/mL, 2 mL ampoules.
- Cautions
- Hypokalaemia, hypomagnesaemia, metabolic alkalosis, ototoxicity at high bolus doses.
Module references (16)
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