Fig. 3.

Algorithm for management of acute respiratory distress syndrome.

*With respiratory rate increased to 35 breaths per minute and mechanical ventilation settings adjusted to keep a plateau airway pressure of 32 cm of water. †Consider neuromuscular blockade. ‡There are no absolute contraindications that are agreed upon except end-stage respiratory failure when lung transplantation will not be considered; exclusion used in the EOLIA trial¹ can be taken as a conservative approach to contraindications to ECMO. ∫ Eg neuromuscular blockade, high PEEP strategy, inhaled pulmonary vasodilators, recruitment maneuvers, high-frequency oscillatory ventilation. ¶Recommend early ECMO as per EOLIA trial criteria; salvage ECMO, which involves deferral of ECMO initiation until further decompensation (as in the crossovers to ECMO in the EOLIA control group), is not supported by the evidence but might be preferable to not initiating ECMO at all in such patients. PEEP, positive end-expiratory pressure; PaO₂: HO₂, ratio of partial pressure of oxygen in arterial blood to the fractional concentration of oxygen in inspired air; ECMO, extracorporeal membrane oxygenation; PaCO₂, partial pressure of carbon dioxide in arterial blood.