New UK guidelines for the management of adult patients with ARDS

Acute respiratory distress syndrome (ARDS) was first reported in a case series from Denver in 1967,1 and remains a major problem in the severely ill. This was highlighted by data from the recently published Large observational study to UNderstand the Global impact of Severe Acute respiratory FailurE (LUNG SAFE) trial, which recorded admissions over 4 weeks to 459 intensive care units (ICUs) in 50 countries and included 29 144 patients. In total, 3022 (10.4%) cases fulfilled ARDS criteria, including almost a quarter of those supported with invasive mechanical ventilation.2 ARDS was associated both with high mortality and prolonged length of stay. In addition, long-term follow-up studies of patients with ARDS indicate high long-term morbidity and decreased quality of life.3 There is therefore a real need to improve outcomes in ARDS. With this aim in mind, the Intensive Care Society (ICS)/Faculty of Intensive Care Medicine (FICM) guideline for the management of the ARDS in adults was published towards the end of 2018.4 The multidisciplinary Guideline Development Group used Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology.5 The group allocated selected outcomes as being either of critical (mortality up to 1 year, quality of life at 3 months) or high importance (quality of life at 6–12 months, length of ICU and hospital stay and treatment-associated harms). Ten interventions used in patients with ARDS were examined, based on existing recommendations and the experience of committee members, and informed by a survey of ICS members. The evidence-based findings are summarised in table 1. Two strong recommendations (using GRADE terminology) in favour of interventions and one strong recommendation against an intervention were made. Where mechanical ventilation is required, the use of low tidal volumes (<6 mL/kg ideal body weight) and airway pressures (plateau pressure <30 cmH2O) was recommended. For …