Acute Respiratory Distress Syndrome (ARDS) — Pathway

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Oxygenation grade
   Meets the Berlin definition? Oxygenation grade (PEEP ≥5)? (Berlin definition: 1) within 1 week of a known insult / new or worsening respiratory symptoms 2) bilateral infiltrates not fully explained by effusion/atelectasis/nodules 3) respiratory failure not fully explained by heart failure/fluid overload (echo to exclude cardiogenic if needed) 4) oxygenation (PEEP/CPAP ≥5): mild P/F 200–300, moderate 100–200, severe ≤100. Causes: pneumonia/sepsis (most common), aspiration, trauma, transfusion, pancreatitis.)
   • Moderate–severe (P/F ≤200, especially <150) → Moderate–severe → prone / ECMO
   • Mild (P/F 200–300) → Mild · lung-protective ventilation
2. [End] Mild · lung-protective ventilation
   Mild (P/F 200–300): lung-protective ventilation — tidal volume 6 mL/kg predicted body weight, plateau pressure <30 cmH2O, low driving pressure, titrated PEEP, permissive hypercapnia (pH >7.15); conservative fluids; treat the underlying cause; conservative oxygenation target, monitor for progression.
3. [End] Moderate–severe → prone / ECMO
   Moderate–severe (P/F ≤200, especially <150): on top of lung-protective ventilation (6 mL/kg, plateau <30) — prone positioning ≥16 h/day (survival benefit in moderate-severe) ± neuromuscular blockade (early severe); optimize PEEP, conservative fluids; refractory hypoxemia → veno-venous ECMO; aggressively treat the underlying cause (sepsis, etc.).

Source guidelines & references

• ARDS Berlin definition (JAMA 2012); ARDSNet; PROSEVA prone positioning

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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