by Laurent Papazian, Cécile Aubron, Laurent Brochard,
Jean-Daniel Chiche, Alain Combes, Didier Dreyfuss, Jean-Marie Forel, Claude
Guérin, Samir Jaber, Armand Mekontso-Dessap, Alain Mercat, Jean-Christophe
Richard, Damien Roux, Antoine Vieillard-Baron and Henri Faure
Abstract
Fifteen recommendations and a therapeutic algorithm
regarding the management of acute respiratory distress syndrome (ARDS) at the
early phase in adults are proposed. The Grade of Recommendation Assessment,
Development and Evaluation (GRADE) methodology has been followed. Four
recommendations (low tidal volume, plateau pressure limitation, no oscillatory
ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 −);
four (high positive end-expiratory pressure [PEEP] in moderate and severe ARDS,
muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane
oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 −); seven
(surveillance, tidal volume for non ARDS mechanically ventilated patients,
tidal volume limitation in the presence of low plateau pressure, PEEP > 5 cmH2O,
high PEEP in the absence of deleterious effect, pressure mode allowing
spontaneous ventilation after the acute phase, and nitric oxide) corresponded
to a level of proof that did not allow use of the GRADE classification and were
expert opinions. Lastly, for three aspects of ARDS management (driving
pressure, early spontaneous ventilation, and extracorporeal carbon dioxide
removal), the experts concluded that no sound recommendation was possible given
current knowledge. The recommendations and the therapeutic algorithm were
approved by the experts with strong agreement.
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