Clinical Practice Guideline: Mechanical Ventilation and Extracorporeal Membrane Oxygenation in Acute Respiratory Insufficiency.

Summary

This evidence-based guideline recommends early use of noninvasive support, enabling spontaneous breathing during invasive ventilation, individualized PEEP titration (with higher-PEEP strategies conferring an absolute 9% mortality reduction in moderate–severe ARDS), and selective VV-ECMO in experienced centers. Routine neuromuscular blockade and corticosteroids are discouraged in moderate–severe ARDS.

Key Findings

• Noninvasive respiratory support is suggested to avoid intubation in acute respiratory failure.
• Early spontaneous breathing during invasive ventilation is suggested.
• For moderate–severe ARDS, individualized PEEP titration is recommended; higher-PEEP strategies reduce mortality by 9% absolute (95% CI 1 to 16) versus lower-PEEP.
• Strong recommendations against routine neuromuscular blockade or corticosteroid therapy in moderate–severe ARDS.
• VV-ECMO should be considered for persistent severe gas exchange failure in ARDS at experienced centers.

Clinical Implications

Adopt early noninvasive support when feasible; enable early spontaneous breathing; implement individualized PEEP titration aiming for protective ranges; avoid routine neuromuscular blockade or corticosteroids in moderate–severe ARDS; consider VV-ECMO at experienced centers when conventional strategies fail.

Limitations

• Guideline depends on heterogeneity and quality of included studies
• Some recommendations are conditional and require contextual implementation

Future Directions

Prospective trials comparing PEEP titration strategies, strategies to safely enable early spontaneous breathing, and networked outcomes for VV-ECMO referral pathways.