Consensus statement for managing patients with ARDS in low-resource settings: a Delphi study - 27/08/26

Doi : 10.1016/j.aicoj.2026.100144

Pedja Kovacevic ^a,^b,⁎ , Jesús Villar ^c, Boris Tomic ^a,^b, Fabio Silvio Taccone ^d, Giacomo Grasselli ^e, Luigi Camporota ^f, Marlies Ostermann ^g, Ivan Palibrk ^h, Rajesh Mishra ⁱ, Sasa Dragic ^a,^b, Jose Diaz-Gomez ^j, Danica Momcicevic ^a,^b, Ali Ait Hssain ^k, Biljana Zlojutro ^a,^b, Jihad Mallat ^l, Milka Jandric ^a,^b, Owoniya Temitope ^m, Roman Zahorec ⁿ, Omar Shahed ^o, Mohamed Boussarsar ^p, F. Joachim Meyer ^q, Ahmed Mukhtar ^r, Marko Kutlesa ^s, Vladimir Krajinovic ^s, John Laffey ^t, Radmilo Jankovic ^u, Samir Jaber ^v, Dejan Markovic ^w, Oluwayemisi Esther Ekor ^x, Rotimi Muyiwa ^y, Rihard Knafelj ^z, Matija Jurjevic ^A, Natasa Milivojevic ^B, Ahmed El Masry ^C, Jasminka Persec ^D, Anusha Cherian ^E, Younes Aissaoui ^F, Oguz Kilickaya ^G, Kent Doi ^H, Daniel Lovric ^I, Wael Alqassem ^J, Natasa Gocic ^K, Aderonke Adesiyan ^L, Reuben Okioma ^M, Ayalew Zewdie ^N, Mumbere Kigayi Jean Pierre ^O, Subhash Acharya ^P, Ognjen Gajic ^G

^a University Clinical Centre of the Republic of Srpska, Medical Intensive Care Unit, Banja Luka, the Republic of Srpska, Bosnia and Herzegovina

^b Faculty of Medicine, University of Banja Luka, Banja Luka, the Republic of Srpska, Bosnia and Herzegovina

^c Research Unit at Hospital Universitario Dr. Negrín, Fundación Canaria Instituto de Investigación Sanitaria de Canarias, Las Palmas, Spain, CIBER de Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain, Faculty of Health Sciences, Universidad del Atlántico Medio, Tafira, Las Palmas. Spain, Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Toronto, Canada

^d Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium

^e Department of Emergency, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy, Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy

^f Department of Adult Critical Care, Guy's and St Thomas' NHS Foundation Trust, London, SE1 7EH, United Kingdom

^g Department of Critical Care, King's College London, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom

^h Department of Anesthesiology, Reanimatology and Intensive Care, Clinic for Abdominal Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia

ⁱ Critical Care, Shaibya Comprehensive Care Clinic, ESICM National Representative of India, Ahmedabad, Gujarat, India

^j Integrated Hospital Care Institute (Divisions of Anesthesiology, Critical Care Medicine, Emergency Medicine, Hospital Medicine, Infectious Disease, and Pulmonary Medicine), Cleveland Clinic Abu Dhabi, Abu Dhabi, United Arab Emirates

^k Medical Intensive Care Unit, Hamad General Hospital, Doha, Qatar, Department of Medicine, Weill Cornell Medical College, Doha, Qatar

^l Critical Care Division, Integrated Hospital Care Institute, Cleveland Clinic Abu Dhabi, 112412, Abu Dhabi, United Arab Emirates and Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH, 44106, United States of America

^m Department of Anaesthesia and Intensive Care Unit, Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife, Nigeria

ⁿ Department of Anesthesiology and Intensive Medicine, Medical School, Comenius University, Heydukova 10, 812 50 Bratislava, Slovakia

^o Division of Critical Care, University of Witwatersrand, Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

^p Medical Intensive Care Unit, Research Laboratory LR12SP09 "Heart Failure", Farhat Hached University Hospital, Sousse, Tunisia

^q München Klinik gGmbH and Medical Faculty, Lung Center Munich, University of Heidelberg, Heidelberg, Germany

^r Department of Anesthesia and Critical Care, Cairo University, Cairo, Egypt

^s Department for Intensive Care, University Hospital for Infectious Diseases "Dr. Fran Mihaljević", 10000 Zagreb, Croatia

^t Anaesthesia and Intensive Care Medicine, School of Medicine, Clinical Sciences Institute, Galway University Hospitals, University of Galway, Galway, Ireland

^u University Clinical Center Niš, Department of Anesthesia and Intensive Therapy, Faculty of Medicine, University of Niš, Niš, Serbia

^v Department of Anesthesia and Intensive Care Unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, PhyMedExp, INSERM U1046, CNRS UMR, Montpellier, France

^w Department of Anesthesiology, Reanimatology and Intensive Care, Clinic for Cardiac Surgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia

^x University of Cape Coast Ghana, Ghana

^y Department of Anaesthesia, Lagos University Teaching Hospital, Idi-Araba, Lagos State, Nigeria

^z Center for Internal Intensive Medicine, University Medical Center Ljubljana, Ljubljana, Slovenia

^A Clinic of Anesthesiology, Resuscitation and Intensive Care, General Hospital Josip Bencevic, Slavonski Brod, Croatia

^B Neurological Intensive Care Unit, University Clinical Centre of Ljubljana, Ljubljana, Slovenia

^C Al Adan Hospital, Al Ahmadi, Kuwait

^D Clinical Department for Anesthesiology, Reanimatology and Intensive Care Medicine, University Hospital Dubrava, University of Zagreb School of Dental Medicine, 10000 Zagreb, Croatia

^E Department of Anesthesiology and Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India

^F Department of Critical Care Medicine, Avicenna Military Hospital, Marrakesh, Morocco

^G Department of Medicine, Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, United States of America

^H Department of Emergency and Critical Care Medicine, The University of Tokyo, Tokyo, Japan

^I Cardiology Clinic, University Hospital Center Zagreb, 10000 Zagreb, Croatia

^J Critical Care Department, Prince Mohammed Bin Abdulaziz Hospital, Riyadh, Saudi Arabia

^K University Clinical Centre of Vojvodina, Emergency Center, Novi Sad, Serbia

^L Africa Health Science University, Rwanda

^M Department of Critical Care, The Nairobi Hospital, Nairobi, Kenya

^N St Paul's Hospital Millenium Medical College, Addis Ababa, Ethiopia

^O Department of Anesthesiology and Intensive Care, HEAL Africa Tertiary Hospital, Goma, North Kivu, Congo

^P Department of Critical Care Medicine, MMC, Institute of Medicine, Tribhuvan University, Kathmandu, Nepal

^⁎ Corresponding author.

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Graphical abstract

Le texte complet de cet article est disponible en PDF.

Abstract

Background

Despite decades of research and advances in critical care, mortality of the Acute Respiratory Distress Syndrome (ARDS) remains high, ranging from 30 to 45% in high-income countries and markedly higher in low-resource settings (LRS), where management guidelines implementation is constrained. An international consensus aimed to provide statements for ARDS management tailored to LRS.

Methods

Since management of critically ill patients is a major public health problem in LRS, the Bosnia and Herzegovina Society of Intensive Care Medicine convened an international, multidisciplinary Steering Committee with expertise in ARDS management. The committee appointed an international panel of clinicians and investigators specialized in the field of ARDS. Through an iterative Delphi process, a panel of 52 experts developed several consensus statements.

Results

After three Delphi rounds, consensus was reached on 44 out of 56 of statements (79%). The survey covered eight domains related to ARDS management in LRS related to: critical care infrastructure, diagnostic tools, respiratory support, other supportive therapies, sedation strategies, weaning, nutrition, and management of complications. Statements were compared with recent ESICM guidelines, highlighting specific LRS considerations.

Conclusion

Using the Delphi method, international experts developed clinical practice statements guiding clinicians on ARDS management in LRS. These statements complemented existing guidelines by addressing areas where evidence is limited, and highlight aspects of ARDS management pertinent for LRS not covered by current international recommendations. Future studies are needed to evaluate the adherence and impact of these statements and to address remaining uncertainties.

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Keywords : Acute respiratory distress syndrome, Low resource settings, Mechanical ventilation, Non-invasive ventilation, Therapeutic management

Abbreviations : ARDS, COVID-19, RCTs, HICs, LRS, LMICs, ABG, ESICM, IQR, ICU, HFNO, NIV, V-VECMO, CERTAIN, SpO₂, PaO₂, FiO₂, LUS, PBW, Ppeak, Pplat, PEEP, POC, POCUS, NMBAs, RRT, RASS, BPS, SBTs, pH, PaCO ₂ , mNUTRIC score, NRS-2002, SGA, EN, PN