ARDS Clinical Practice Guideline 2021
Authors: Tasaka Sadatomo , Ohshimo Shinichiro , Takeuchi Muneyuki , Yasuda Hideto , Ichikado Kazuya , Tsushima Kenji , Egi Moritoki , Hashimoto Satoru , Shime Nobuaki , Saito Osamu , Matsumoto Shotaro , Nango Eishu , Okada Yohei , Hayashi Kenichiro , Sakuraya Masaaki , Nakajima Mikio , Okamori Satoshi , Miura Shinya , Fukuda Tatsuma , Ishihara Tadashi , Kamo Tetsuro , Yatabe Tomoaki , Norisue Yasuhiro , Aoki Yoshitaka , Iizuka Yusuke , Kondo Yutaka , Narita Chihiro , Kawakami Daisuke , Okano Hiromu , Takeshita Jun , Anan Keisuke , Okazaki Satoru Robert , Taito Shunsuke , Hayashi Takuya , Mayumi Takuya , Terayama Takero , Kubota Yoshifumi , Abe Yoshinobu , Iwasaki Yudai , Kishihara Yuki , Kataoka Jun , Nishimura Tetsuro , Yonekura Hiroshi , Ando Koichi , Yoshida Takuo , Masuyama Tomoyuki , Sanui Masamitsu ,   ARDS Clinical Practice Guideline 2021 committee from the Japanese Society of Intensive Care Medicine, the Japanese Respiratory Society, and the Japanese Society of Respiratory Care Medicine, Nakashima Takuro , Masunaga Aiko , Tanaka Aiko , Inoue Akihiko , Higashi Akiko , Tanikawa Atsushi , Ujiro Atsushi , Takayama Chihiro , Kasugai Daisuke , Kawakami Daisuke , Ueno Daisuke , Satoh Daizoh , Kai Shinichi , Ota Kohei , Hagiwara Yoshihiro , Hamaguchi Jun , Fujii Ryo , Hongo Takashi , Kishihara Yuki , Masunaga Naohisa , Yamamoto Ryohei , Okazaki Satoru Robert , Uchimido Ryo , Terayama Tetsuro , Hokari Satoshi , Sakamoto Hitoshi , Dongli  , Nakataki Emiko , Tabata Erina , Okazawa Seisuke , Kotajima Futoshi , Ishimaru Go , Hoshino Haruhiko , Yoshida Hideki , Iwai Hidetaka , Nakagawa Hiroaki , Sugimura Hiroko , Narumiya Hiromichi , Okano Hiromu , Nakamura Hiroshi , Sugimoto Hiroshi , Hashimoto Hiroyuki , Ito Hiroyuki , Dote Hisashi , Imahase Hisashi , Sato Hitoshi , Katsurada Masahiro , Osawa Ichiro , Kamei Jun , Maki Jun , Sugihara Jun , Takeshita Jun , Fujimoto Junichi , Ishikawa Junichi , Kosaka Junko , Shibata Junpei , Hashimoto Katsuhiko , Nakano Yasushi , Kikuyama Kazuki , Shimizu Kazushige , Okada Kazuya , Kawano Keishi , Anan Keisuke , Ota Keisuke , Kano Ken-ichi , Asano Kengo , Hondo Kenichi , Ishii Kenji , Fujita Kensuke , Ogawa Kenta , Ito Kentaro , Tokunaga Kentaro , Ishii Kenzo , Kusumoto Kohei , Takimoto Kohei , Yamada Kohei , Naito Koichi , Yamashita Koichi , Yoshinaga Koichi , Yamauchi Kota , Murata Maki , Konda Makiko , Hamamoto Manabu , Aga Masaharu , Kashiura Masahiro , Ishikawa Masami , Ozaki Masayuki , Kono Michihiko , Kyo Michihito , Hayashi Minoru , Abe Mitsuhiro , Sato Mitsunori , Sakai Mizu , Kainuma Motoshi , Tominaga Naoki , Iguchi Naoya , Nakagawa Natsuki , Aoki Nobumasa , Nishioka Norihiro , Miyashita Norihisa , Seki Nozomu , Ikebe Ryo , Imai Ryosuke , Tate Ryota , Sato Ryuhei , Miyakawa Sachiko , Kazuma Satoshi , Nakano Satoshi , Tetsumoto Satoshi , Yoshimura Satoshi , Yoshitake Shigenori , Hoshi Shin-etsu , Ohki Shingo , Sato Shintaro , Yoshihiro Shodai , Ihara Shoichi , Yamamoto Shota , Koide Shunichi , Kimata Shunsuke , Saito Shunsuke , Yasuo Shunsuke , Sekine Shusuke , Mimuro Soichiro , Wada Soichiro , Sugimura Sosuke , Ishihara Tadashi , Kaneko Tadashi , Nagato Tadashi , Maruhashi Takaaki , Tamura Takahiro , Ohno Takanori , Ichiyama Takashi , Niwa Takashi , Ueji Takashi , Ogura Takayuki , Kawasaki Takeshi , Tanaka Takeshi , Umegaki Takeshi , Furukawa Taku , Omura Taku , Nagao Takumi , Mayumi Takuya , Taniguchi Takuya , Yoshida Takuya , Shimatani Tatsutoshi , Murata Teppei , Sato Tetsuya , Sawamoto Tohru , Koukei Yoshifumi , Takehara Tomohiro , Ueda Tomomi , Katsuta Tomoya , Nishino Tomoya , Yokoyama Toshiki , Higashijima Ushio , Iwanaga Wataru , Inoue Yasushi , Iwashita Yoshiaki , Yamada Yoshie , Kubota Yoshifumi , Suido Yoshihiro , Tomioka Yoshihiro , Fujimoto Yoshihisa , Fujita Yoshihito , Yamaguchi Yoshikazu , Nakamura Yoshimi , Abe Yoshinobu , Eguchi Yoshitomo , Oshima Yoshiyasu , Fukuda Yosuke , Iwasaki Yudai , Yasufuku Yuichi , Shono Yuji , Nakatani Yuka , Nakamori Yuki , Ito Yukie , Tanabe Yuko , Nagamine Yusuke , Nakamura Yuta , Kurihara Yutaro 
Published: July 2022

Abstract
Background
The joint committee of the Japanese Society of Intensive Care Medicine/Japanese Respiratory Society/Japanese Society of Respiratory Care Medicine on ARDS Clinical Practice Guideline has created and released the ARDS Clinical Practice Guideline 2021.

Methods
The 2016 edition of the Clinical Practice Guideline covered clinical questions (CQs) that targeted only adults, but the present guideline includes 15 CQs for children in addition to 46 CQs for adults. As with the previous edition, we used a systematic review method with the Grading of Recommendations Assessment Development and Evaluation (GRADE) system as well as a degree of recommendation determination method. We also conducted systematic reviews that used meta-analyses of diagnostic accuracy and network meta-analyses as a new method.

Results
Recommendations for adult patients with ARDS are described: we suggest against using serum C-reactive protein and procalcitonin levels to identify bacterial pneumonia as the underlying disease (GRADE 2D); we recommend limiting tidal volume to 4–8 mL/kg for mechanical ventilation (GRADE 1D); we recommend against managements targeting an excessively low SpO2 (PaO2) (GRADE 2D); we suggest against using transpulmonary pressure as a routine basis in positive end-expiratory pressure settings (GRADE 2B); we suggest implementing extracorporeal membrane oxygenation for those with severe ARDS (GRADE 2B); we suggest against using high-dose steroids (GRADE 2C); and we recommend using low-dose steroids (GRADE 1B). The recommendations for pediatric patients with ARDS are as follows: we suggest against using non-invasive respiratory support (non-invasive positive pressure ventilation/high-flow nasal cannula oxygen therapy) (GRADE 2D), we suggest placing pediatric patients with moderate ARDS in the prone position (GRADE 2D), we suggest against routinely implementing NO inhalation therapy (GRADE 2C), and we suggest against implementing daily sedation interruption for pediatric patients with respiratory failure (GRADE 2D).

Conclusions
This article is a translated summary of the full version of the ARDS Clinical Practice Guideline 2021 published in Japanese (URL: https://www.jsicm.org/publication/guideline.html). The original text, which was written for Japanese healthcare professionals, may include different perspectives from healthcare professionals of other countries.