Table 2.
Summary of Recommendations and Results
| Review | Care Continuum Phase | Evidence-Based Practice | Evidence-Based Practice Description | Impact on Outcome |
Recommended for Use | Level of Evidence | |
|---|---|---|---|---|---|---|---|
| Mechanical Duration | Death | ||||||
| Aggarwal et al13 (2018) | 1 | Conservative oxygen therapy | The goal of Po2 in arterial blood is 55-80 mm Hg; oxygen exposure >80 mm Hg is associated with worse patient outcomes, irrespective of the severity of ARDS. | Yes | Yes | Yes | Moderate |
| Aoyama et al17 (2018) | 1 | Driving pressure | Higher driving pressure is associated with death. | … | Yes | No | Moderate |
| Fan et al4 (2017) | 1 | Lung protective ventilation | Invasive mechanical ventilation with the use of lower tidal volumes (4-8 mL/kg predicted body weight). | … | Yes | Yes | Moderate |
| Walkey et al28 (2017) | 1 | Lung protective ventilation | Invasive mechanical ventilation with the use of lower tidal volumes (4-8 mL/kg predicted body weight). | … | Yes | Yes, conditional on higher positive-end expiratory pressure among patients with moderate-to-severe ARDS | Moderate |
| Murray et al25 (2016) | 1 | Neuromuscular blocking agent | Conditional recommendation to administer a neuromuscular blocking agent by continuous IV infusion early in the course of ARDS. | Yes | Yes | Yes, conditional, for patients with moderate-to-severe ARDS | Moderate |
| Fan et al4 (2017) | 1 | Positive-end expiratory pressure | Conditional recommendation for higher positive-end expiratory pressure, of approximately 15 cm water. | … | Yes | Yes, conditional, for patients with moderate-to-severe ARDS | Moderate |
| Goligher et al18 (2017) | 1 | Positive-end expiratory pressure | Conditional recommendation for higher positive-end expiratory pressure, of approximately 15 cm water. | … | Yes | Yes, conditional, in combination with lung recruitment maneuvers for patients with moderate-to-severe ARDS | Low |
| Guo et al19 (2018) | 1 | Positive-end expiratory pressure | Conditional recommendation for higher positive-end expiratory pressure, of approximately 15 cm water. | … | Yes | Yes, conditional on patients who have better oxygenation in response to positive-end expiratory pressure | Low |
| Walkey et al28 (2017) | 1 | Positive-end expiratory pressure | Conditional recommendation for higher positive-end expiratory pressure, of approximately 15 cm water. | … | Yes | Yes, conditional when used in combination with lung protective ventilation when compared to high tidal volumes low positive-end expiratory pressure | Low |
| Fan et al4 (2017) | 1 | Prone position | Conditional recommendation for prone positioning | … | Yes | Yes, conditional, when used for >12 h/d for patients with moderate-to-severe ARDS | Moderate |
| Munshi et al24 (2017) | 1 | Prone position | Conditional recommendation for prone positioning | … | Yes | Yes, conditional, when used for >12 h/d for patients with moderate-to-severe ARDS | Moderate |
| Devlin et al10 (2018) | 2 | Analgesia-first approach to sedation and pain management | Minimize the use of opioids and sedatives; administer pharmacologic adjuvants to opioid therapy or nonpharmacologic interventions to reduce pain. | Yes | … | Yes | Moderate |
| Silversides et al14 (2017) | 2 | Conservative fluid management | Use protocols for patients who are diuresing, and/or monitor extravascular lung water, pulse pressure variation, or intrathoracic blood volume index, while restricting or minimizing fluid. | Yes | … | Yes | Moderate |
| Devlin et al10 (2018) | 2 | Delirium assessment, prevention, and management | Use screening tools to regularly assess delirium; avoid benzodiazepine; only short-term use of antipsychotic agents should be used while patients are in distress; consider multicomponent, nonpharmacologic interventions that reduce modifiable risk factors. | … | Yes | Yes | Low |
| Devlin et al10 (2018) | 2 | Early mobility protocols | Protocolized rehabilitation directed toward early mobilization for patients receiving invasive mechanical ventilation for >24 h. | Yes | … | Yes | Low |
| Girard et al11 (2017) | 2 | Early mobility protocols | Protocolized rehabilitation directed toward early mobilization for patients receiving invasive mechanical ventilation for >24 h. | Yes | … | Yes | Low |
| Schmidt et al27 (2017) | 2 | Early mobility protocols | Protocolized rehabilitation directed toward early mobilization for patients receiving invasive mechanical ventilation for >24 h. | Yes | … | Yes | Low |
| Meduri et al22 (2016) | 2 | Glucocorticoid treatment | Early- and low-dose methylprednisolone treatment helps resolve ARDS symptoms. | Yes | Yes | Yes | Moderate |
| Meduri et al23 (2018) | 2 | Glucocorticoid treatment | Conditional recommendation to provide methylprednisolone. | Yes | Yes | Yes, conditional on early moderate-to-severe and late persistent ARDS | Moderate |
| Yang et al29 (2017) | 2 | Glucocorticoid treatment | Early- and low-dose methylprednisolone treatment helps resolve ARDS symptoms. | Yes | Yes | Yes | Low |
| Fan et al4 (2017) | 2 | High-frequency oscillatory ventilation | Conditional recommendation regarding routine use high-frequency oscillatory ventilation. | Yes | Yes | No, conditional, not to be used for patients with moderate-to-severe ARDS | Strong |
| Devlin et al10 (2018) | 2 | Sedation protocols | Monitor sedation; use protocols that attempt to minimize sedation in patients who are not receiving neuromuscular blockades by interrupting sedation daily or continuously titrating sedatives to maintain a light level of sedation (ie, use a targeted sedation strategy). | Yes | Yes | Yes | Low |
| Ouellette et al12 (2017) | 2 | Sedation protocols | Monitor sedation; use protocols that attempt to minimize sedation. | Yes | … | Yes | Low |
| Schmidt et al27 (2017) | 2 | Sedation protocols | Monitor sedation; use protocols that attempt to minimize sedation. | Yes | … | Yes | Low |
| Devlin et al10 (2018) | 2 | Sleep management | Do not administer propofol to assist in sleep. | Yes | … | No | Low |
| Schmidt et al27 (2017) | 2 | Spontaneous awakening trial | Lighten or discontinue sedation for a period of time each day to wake the patient up and evaluate alertness. | Yes | … | Yes | Low |
| Schmidt et al27 (2017) | 2 | Spontaneous breathing trial | Turn ventilator support down or off with pressure augmentation to exercise the lungs and assess readiness for extubation. | Yes | … | Yes | Moderate |
| Girard et al11 (2017) | 3 | Cuff leak test | Perform cuff leak test for patients who meet extubation criteria and are deemed high risk for postextubation stridor; if failed but are ready for extubation, administer systemic steroids at least 4 hours before extubation; repeat cuff test not required. | Yes | … | Yes | Low |
| Schmidt et al27 (2017) | 3 | Cuff leak test | Perform cuff leak test for patients who meet extubation criteria and are deemed high risk for postextubation stridor; if failed but are ready for extubation, administer systemic steroids at least 4 hours before extubation; repeat cuff test not required. | Yes | … | Yes | Low |
| Huang et al20 (2018) | 3 | Extubation to high-flow nasal cannula | Extubate to high-flow nasal cannula is an effective alternative to patients who cannot tolerate noninvasive mechanical ventilation. | Yes | Yes | Yes | Low |
| Maitra et al21 (2016) | 3 | Extubation to high-flow nasal cannula | Extubate to high-flow nasal cannula is an effective alternative to patients who cannot tolerate noninvasive mechanical ventilation. | Yes | Yes | Yes | Low |
| Ni et al26 (2017) | 3 | Extubation to high-flow nasal cannula | Extubate to high-flow nasal cannula is an effective alternative to patients who cannot tolerate noninvasive mechanical ventilation. | Yes | Yes | Yes | Moderate |
| Huang et al20 (2018) | 3 | Extubation to noninvasive mechanical ventilation | Noninvasive mechanical ventilation appears to be comparable with high-flow nasal oxygen. | Yes | Yes | Yes | Low |
| Maitra et al21 (2016) | 3 | Extubation to noninvasive mechanical ventilation | Noninvasive mechanical ventilation appears to be comparable with high-flow nasal oxygen. | Yes | Yes | Yes | Low |
| Ni et al26 (2017) | 3 | Extubation to noninvasive mechanical ventilation | Noninvasive mechanical ventilation appears to be comparable with high-flow nasal oxygen. | Yes | Yes | Yes | Moderate |
| Ouellette et al12 (2017) | 3 | Extubation to noninvasive mechanical ventilation | For patients at risk for extubation failure who have received invasive mechanical ventilation >24 h and who have passed a spontaneous breathing trial, extubate to preventive noninvasive mechanical ventilation. | Yes | Yes | Yes | Moderate |
| Schmidt et al27 (2017) | 3 | Extubation to noninvasive mechanical ventilation | For patients at risk for extubation failure who have received invasive mechanical ventilation >24 h and who have passed a spontaneous breathing trial, extubate to preventive noninvasive mechanical ventilation. | Yes | Yes | Yes | Moderate |
| Girard et al11 (2017) | 3 | Ventilator liberation protocol | Treat patients who have received invasive mechanical ventilation for >24 h with a ventilator liberation protocol; however, insufficient evidence to recommend any single protocol over another. | Yes | … | Yes | Low |
| Schmidt et al27 (2017) | 3 | Ventilator liberation protocol | Treat patients who have received invasive mechanical ventilation for >24 h with a ventilator liberation protocol; however, insufficient evidence to recommend any single protocol over another. | Yes | … | Yes | Low |