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pulm.ards.core.v1PRODUCTION
pulm.ards.core.v1

Acute Respiratory Distress Syndrome

pulmonologyacuteadult
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12/12 authored

Canonical 12-phase frame with authored status for this dossier.

Current phase

Frame

Detailed

Confirm acute (≤1 wk of insult), bilateral opacities (CXR/CT/lung-US) not fully explained by cardiac failure or fluid overload, hypoxemia on respiratory support incl. non-intubated HFNO ≥30 L/min or CPAP/NIV PEEP ≥5 (2024 Global Definition, Matthay AJRCCM 2024 PMID 37487152)

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Advance rule
Set
Advance when

2024 Global Definition (or legacy Berlin) criteria met

Patient inputs (17)

Predicted body weight calc + age-related mortality risk (ARMA Brower NEJM 2000 PMID 10793162)

S/F ratio + oxygenation severity — resource-variable Global Definition (Matthay AJRCCM 2024 PMID 37487152)

P/F + S/F denominator (2024 Global Definition PMID 37487152)

ROX index + ventilator dyssynchrony screen (Roca AJRCCM 2019)

Hemodynamic management; vasopressor decision; PEEP tolerance (SSC 2021)

Bilateral opacities — Global/Berlin definition criterion (Matthay AJRCCM 2024 PMID 37487152)

Predicted body weight (Devine) for Vt 6 mL/kg setting — PBW not actual weight, esp in obesity (ARMA PMID 10793162; LUNG SAFE PMID 26903337)

Sex-specific PBW formula (ARMA Brower NEJM 2000 PMID 10793162)

Cardiogenic-edema discriminator — markedly elevated favours HF; <1000 pg/mL argues against (2024 Global Definition non-cardiogenic criterion PMID 37487152)

Exclude cardiogenic pulmonary edema (LVEF, E/e', LV filling); RV strain monitoring (ATS 2024 PMID 38032683)

Pregnancy alters permissive-hypercapnia limits (keep pH ≥7.30) + proning protocol (ATS 2024 PMID 38032683)

Tissue perfusion adequacy; hyperinflammatory subphenotype marker (SSC 2021; Calfee Lancet RM 2014 PMID 24853585)

TRALI screen — transfusion within 6 h (2024 Global Definition PMID 37487152)

Aspiration pneumonitis as ARDS trigger — route to pulm.aspiration-pneumonia.core.v1 (2024 Global Definition PMID 37487152)

Lower intubation threshold; broaden differential to DAH / PJP / drug-induced; early BAL (ATS 2024 PMID 38032683)

Drug-induced lung injury differential (ATS 2024 PMID 38032683)

P/F ratio for Global/Berlin severity grading (2024 Global Definition PMID 37487152)

* = hard-required. Engine cannot meaningfully run until these are filled.

Severity triggers (8)

8 need judgement
  • informationallife_threateningpf_under_100_or_refractory
    P/F <100 OR EOLIA refractory cut-points (P/F <50 ×3 h, <80 ×6 h, or pH <7.25 + PaCO2 ≥60 ×6 h with Pplat ≤32) despite prone + NMB
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationallife_threateningtension_pneumothorax_in_ARDS
    Sudden hypoxia, hypotension, raised airway pressures in ventilated ARDS patient
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseverepf_under_150_sustained
    PaO2/FiO2 <150 sustained ≥12 h despite optimised lung-protective settings (PROSEVA enrolment threshold)
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereplateau_pressure_over_30
    Plateau pressure >30 cmH2O despite Vt 6 mL/kg PBW
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveredriving_pressure_over_15
    Driving pressure (Pplat − PEEP) >15 cmH2O on lung-protective settings
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalseveresevere_RV_failure_acute_cor_pulmonale
    Echo: severe RV dilation with septal flattening, TAPSE <14 mm, persistent hypotension on vasopressor
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalsevereearly_severe_or_COVID_ARDS_steroid_window
    Moderate-severe non-COVID ARDS within first 72 h OR COVID-ARDS on O2/IMV
    Trigger could not be auto-evaluated — needs clinician judgement.
  • informationalmoderatepersistent_dyssynchrony
    Patient-ventilator dyssynchrony despite optimal sedation, with high Pplat or worsening oxygenation
    Trigger could not be auto-evaluated — needs clinician judgement.

Workflow calculators

Run this disease's risk and dosing calculators inline.

RISK_STRATIFICATIONoptionalDrives risk stratification
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Recommended regimen

ARDS lung-protective ventilation + adjunct ladder (mild → severe → refractory)
axis: ards_lung_protective_ladderstep mild_HFNO_or_NIV - Mild ARDS (P/F 200–300) — HFNO or NIV trial in selected patients
Selected step "Mild ARDS (P/F 200–300) — HFNO or NIV trial in selected patients" — P/F 200-300 OR S/F 235-315; no AMS, hemodynamically stable, awake/cooperative (2024 Global Definition non-intubated category PMID 37487152)
  • oxygen_HFNO
    first line
    oxygen_high_flow
    HFNC 30–60 L/min, FiO2 titrate to SpO2 92–96% • inhaled • continuous
    triggers: mild_ARDS_no_intubation_yet
    FLORALI (Frat NEJM 2015 PMID 25981908) — HFNO reduced 90-d mortality vs standard O2 (HR 2.01, 95% CI 1.01–3.99 favouring HFNO) and intubation in P/F ≤200 subgroup
    rxcui 7806
  • NIV_helmet_preferred
    second line
    noninvasive_ventilation
    Helmet PEEP 8–10, PS 8–14, FiO2 titrated • NIV • continuous, ROX index q1h
    triggers: HFNO_failure_OR_immunocompromised
    Patel (JAMA 2016 PMID 27179847) — helmet NIV vs face-mask reduced intubation 18.2% vs 61.5% and 90-d mortality 34.1% vs 56.4% (single-centre, stopped early)

ed playbook — drug actions (6)

  1. 1. oxygen escalation HFNO
    30–60 L/min, FiO2 to SpO2 92–96% • inhaled • continuous
    trigger: P/F 200–300, no AMS, hemodynamically stable
    FLORALI (Frat NEJM 2015 PMID 25981908) — 90-d mortality HR 2.01 favouring HFNO
  2. 2. NIV helmet (preferred) or face-mask
    Helmet PEEP 8–10, PS 8–14, FiO2 titrated • NIV • continuous, ROX q1h
    trigger: HFNO failure, immunocompromised
    Patel (JAMA 2016 PMID 27179847) — helmet intubation 18.2% vs 61.5%
  3. 3. intubation + lung-protective settings
    Vt 6 mL/kg PBW, PEEP per table, FiO2 to SpO2 88–95%, Pplat ≤30 • invasive_ventilator • continuous
    trigger: NIV/HFNO failure, AMS, hemodynamic instability
    ARMA (Brower NEJM 2000 PMID 10793162) — mortality 31% vs 39.8%, NNT ~11
  4. 4. fentanyl + propofol
    Fentanyl 25–100 µg/h; propofol 5–50 µg/kg/min • IV • continuous, RASS −1 to 0
    trigger: Mechanical ventilation
    Analgesia-first sedation (SCCM PADIS 2018)
  5. 5. norepinephrine
    0.05–1 µg/kg/min IV • IV • continuous to MAP ≥65
    trigger: Hypotension during induction or septic shock
    First-line vasopressor (SSC 2021)
  6. 6. empirical antibiotics for sepsis-ARDS
    Per id.sepsis.core.v1 / pulm.cap.core.v1 / pulm.aspiration-pneumonia.core.v1 • IV • within 1 h of recognition
    trigger: Suspected infectious driver
    SSC 2021 Hour-1 bundle — route to inciting-cause engine

Auto-drafted A&P note

ed

Subjective

- Possible entry pathways: Acute progressive dyspnea / hypoxemic respiratory failure (2024 Global Definition, Matthay AJRCCM 2024 PMID 37487152); Bilateral pulmonary opacities on CXR/CT/lung-US not fully explained by cardiac failure or fluid overload (2024 Global Definition PMID 37487152); PaO2/FiO2 ≤300 on PEEP/CPAP ≥5 OR HFNO ≥30 L/min FiO2 ≥0.4 (2024 Global Definition PMID 37487152).

Objective

- No vitals, labs, or imaging entered for this encounter.

Assessment

**Acute Respiratory Distress Syndrome** (pulm.ards.core.v1).
Phenotype framing: Severity grade — mild P/F 200-300, moderate 100-200, severe ≤100 (mortality ≈35/40/46% LUNG SAFE Bellani JAMA 2016 PMID 26903337); non-intubated ARDS not severity-graded; distinguish cardiogenic edema / DAH / AEP / AIP; flag hyper- vs hypo-inflammatory subphenotype (Calfee Lancet RM 2014 PMID 24853585)
Scope: Confirm acute (≤1 wk of insult), bilateral opacities (CXR/CT/lung-US) not fully explained by cardiac failure or fluid overload, hypoxemia on respiratory support incl. non-intubated HFNO ≥30 L/min or CPAP/NIV PEEP ≥5 (2024 Global Definition, Matthay AJRCCM 2024 PMID 37487152)

No severity triggers fired against current inputs.

Plan

Regimen axis: **ARDS lung-protective ventilation + adjunct ladder (mild → severe → refractory)** — step "Mild ARDS (P/F 200–300) — HFNO or NIV trial in selected patients".
1. oxygen_HFNO HFNC 30–60 L/min, FiO2 titrate to SpO2 92–96% inhaled continuous (oxygen_high_flow, first line) — FLORALI (Frat NEJM 2015 PMID 25981908) — HFNO reduced 90-d mortality vs standard O2 (HR 2.01, 95% CI 1.01–3.99 favouring HFNO) and intubation in P/F ≤200 subgroup
2. NIV_helmet_preferred Helmet PEEP 8–10, PS 8–14, FiO2 titrated NIV continuous, ROX index q1h (noninvasive_ventilation, second line) — Patel (JAMA 2016 PMID 27179847) — helmet NIV vs face-mask reduced intubation 18.2% vs 61.5% and 90-d mortality 34.1% vs 56.4% (single-centre, stopped early)

Setting playbook (ed) — Recognise ARDS early (LUNG SAFE under-recognition ~60% — Bellani JAMA 2016 PMID 26903337), HFNO/NIV trial when appropriate, intubate with lung-protective initial settings, identify + treat inciting cause, rapid ICU transfer
3. oxygen escalation HFNO 30–60 L/min, FiO2 to SpO2 92–96% inhaled continuous — P/F 200–300, no AMS, hemodynamically stable (FLORALI (Frat NEJM 2015 PMID 25981908) — 90-d mortality HR 2.01 favouring HFNO)
4. NIV helmet (preferred) or face-mask Helmet PEEP 8–10, PS 8–14, FiO2 titrated NIV continuous, ROX q1h — HFNO failure, immunocompromised (Patel (JAMA 2016 PMID 27179847) — helmet intubation 18.2% vs 61.5%)
5. intubation + lung-protective settings Vt 6 mL/kg PBW, PEEP per table, FiO2 to SpO2 88–95%, Pplat ≤30 invasive_ventilator continuous — NIV/HFNO failure, AMS, hemodynamic instability (ARMA (Brower NEJM 2000 PMID 10793162) — mortality 31% vs 39.8%, NNT ~11)
6. fentanyl + propofol Fentanyl 25–100 µg/h; propofol 5–50 µg/kg/min IV continuous, RASS −1 to 0 — Mechanical ventilation (Analgesia-first sedation (SCCM PADIS 2018))
7. norepinephrine 0.05–1 µg/kg/min IV IV continuous to MAP ≥65 — Hypotension during induction or septic shock (First-line vasopressor (SSC 2021))
8. empirical antibiotics for sepsis-ARDS Per id.sepsis.core.v1 / pulm.cap.core.v1 / pulm.aspiration-pneumonia.core.v1 IV within 1 h of recognition — Suspected infectious driver (SSC 2021 Hour-1 bundle — route to inciting-cause engine)

Non-pharmacologic actions:
- Etomidate or ketamine induction (avoid prolonged etomidate in septic shock) (ATS 2024 PMID 38032683)
- Rocuronium for intubation paralysis (ATS 2024 PMID 38032683)
- Position upright pre-intubation; avoid supine bag-mask (ATS 2024 PMID 38032683)
- Avoid excessive crystalloid — ARDS-specific fluid restraint after resuscitation (FACTT Wiedemann NEJM 2006 PMID 16714767)

AVOID / contraindication checks:
-  NMB (cisatracurium) MUST pair with deep sedation RASS −4/−5 — avoid awareness (ACURASYS Papazian NEJM 2010 PMID 20843245; SCCM PADIS 2018)
-  NMB selective only — ROSE (Moss NEJM 2019 PMID 31112383) neutral; avoid routine early NMB
-  dexamethasone gate by O2 requirement — RECOVERY (Horby NEJM 2021 PMID 32678530) no benefit/possible harm if not on O2; avoid in active GI bleed / uncontrolled hyperglycemia; renal impair: no dose change but monitor glucose
-  avoid routine recruitment manoeuvres + high PEEP titration — ART (Cavalcanti JAMA 2017 PMID 28973363) increased mortality (HR 1.20) + barotrauma
-  HFNO/NIV avoid in AMS or hemodynamic instability — intubate (2024 Global Definition / ATS 2024 PMID 38032683)
-  ECMO relative contraindications — severe irreversible neuro/systemic disease, futility (EOLIA Combes NEJM 2018 PMID 29791822)
-  propofol infusion syndrome — monitor lactate + CK + triglycerides (SCCM PADIS 2018)
-  pregnancy — keep pH ≥7.30 (limit permissive hypercapnia; fetal CO2 transfer); left lateral tilt; specialised proning protocol (ATS 2024 PMID 38032683)
-  obesity — Vt on predicted body weight (Devine) NOT actual; consider esophageal pressure guided PEEP in high pleural pressure phenotype (ATS 2024 PMID 38032683; LUNG SAFE PMID 26903337)

Monitoring

Regimen monitoring:
- plateau pressure q1h, target ≤30 (ARMA Brower NEJM 2000 PMID 10793162)
- driving pressure ΔP q1h, target ≤15 (Amato NEJM 2015 PMID 25693014)
- P/F or S/F ratio q4h (2024 Global Definition PMID 37487152)
- ABG q4h or after setting change (ATS 2024 PMID 38032683)
- CXR daily while intubated (ATS 2024 PMID 38032683)
- lactate q4h in septic shock (SSC 2021)
- fluid balance q shift, target even-to-negative once shock resolved (FACTT Wiedemann NEJM 2006 PMID 16714767)
- SAT/SBT daily (SCCM PADIS 2018)
- RASS q1h; RASS −4/−5 during NMB (SCCM PADIS 2018)
- CAM-ICU q shift (SCCM PADIS 2018)
- glucose q4-6h while on dexamethasone (DEXA-ARDS Villar Lancet RM 2020 PMID 32043986)
- ECMO circuit anti-Xa or aPTT q shift (ELSO 2024)

Setting (ed) monitoring:
- SpO2 / RR / BP continuous (2024 Global Definition PMID 37487152)
- ROX index q1h on HFNO (Roca AJRCCM 2019)
- ABG q1h post-intubation (ATS 2024 PMID 38032683)
- Plateau pressure check after intubation (ARMA Brower NEJM 2000 PMID 10793162)

Follow-up plan: ICU follow-up clinic, post-ICU syndrome screen (cognitive/mood/physical), pulmonary rehab, lung-function recovery 6MWT + DLCO at 3 + 6 mo (ATS 2024 PMID 38032683)
- Close-out criterion: Post-ARDS / PICS bundle in place

Monitoring phase: Serial P/F + S/F, Pplat, ΔP, compliance, lactate, fluid balance, daily SAT/SBT, CAM-ICU/RASS (ARMA PMID 10793162; Amato PMID 25693014; ATS 2024 PMID 38032683)

Disposition

Current setting: ed — Recognise ARDS early (LUNG SAFE under-recognition ~60% — Bellani JAMA 2016 PMID 26903337), HFNO/NIV trial when appropriate, intubate with lung-protective initial settings, identify + treat inciting cause, rapid ICU transfer

Disposition criteria:
- ICU admission for any ARDS regardless of severity — lung-protective setup + monitoring (ATS 2024 PMID 38032683)

Escalation triggers (move to higher acuity):
- P/F <150 → ICU, likely needs prone (PROSEVA Guerin NEJM 2013 PMID 23688302)
- Refractory hypoxia → ICU + ECMO consult (EOLIA Combes NEJM 2018 PMID 29791822)
- Hemodynamic instability → ICU vasopressor (SSC 2021)

Earlier-Return Triggers

Return-precaution thresholds (watch for):
- [LIFE_THREATENING] P/F <100 OR EOLIA refractory cut-points (P/F <50 ×3 h, <80 ×6 h, or pH <7.25 + PaCO2 ≥60 ×6 h with Pplat ≤32) despite prone + NMB
- [LIFE_THREATENING] Sudden hypoxia, hypotension, raised airway pressures in ventilated ARDS patient
- [SEVERE] PaO2/FiO2 <150 sustained ≥12 h despite optimised lung-protective settings (PROSEVA enrolment threshold)

Citations

- 2024 Global Definition of ARDS (Matthay et al, Am J Respir Crit Care Med 2024;209:37-47) + 2024 ATS Update on Management of Adult ARDS (Qadir et al, AJRCCM 2024;209:24-36) + 2023 ESICM ARDS CPG (Grasselli) [PMID:37487152](https://pubmed.ncbi.nlm.nih.gov/37487152/)
- Cited evidence (PMID 38032683) [PMID:38032683](https://pubmed.ncbi.nlm.nih.gov/38032683/)
- Cited evidence (PMID 10793162) [PMID:10793162](https://pubmed.ncbi.nlm.nih.gov/10793162/)
- Cited evidence (PMID 23688302) [PMID:23688302](https://pubmed.ncbi.nlm.nih.gov/23688302/)
- Cited evidence (PMID 29791822) [PMID:29791822](https://pubmed.ncbi.nlm.nih.gov/29791822/)

Last reconciled with current guidelines: 2026-05-26.
References
  • 2024 Global Definition of ARDS (Matthay et al, Am J Respir Crit Care Med 2024;209:37-47) + 2024 ATS Update on Management of Adult ARDS (Qadir et al, AJRCCM 2024;209:24-36) + 2023 ESICM ARDS CPG (Grasselli) — PMID:37487152
  • Cited evidence (PMID 38032683) — PMID:38032683
  • Cited evidence (PMID 10793162) — PMID:10793162
  • Cited evidence (PMID 23688302) — PMID:23688302
  • Cited evidence (PMID 29791822) — PMID:29791822