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RAND appropriateness panel to determine the applicability of UK guidelines on the management of acute respiratory distress syndrome (ARDS) and other strategies in the context of the COVID-19 pandemic
  1. Mark Griffiths1,2,3,
  2. Susanna Meade4,
  3. Charlotte Summers5,
  4. Daniel Francis McAuley6,7,
  5. Alastair Proudfoot2,
  6. Marta Montero Baladia8,
  7. Paul M Dark9,
  8. Kate Diomede10,
  9. Simon J Finney11,
  10. Lui G Forni12,13,
  11. Chris Meadows14,
  12. Ian A Naldrett15,16,
  13. Brijesh Patel17,18,
  14. Gavin D Perkins19,
  15. Mark A Samaan4,
  16. Laurence Sharifi8,
  17. Ganesh Suntharalingam20,
  18. Nicholas T Tarmey21,
  19. Harriet F Young2,
  20. Matt P Wise22,
  21. Peter M Irving4,23
  1. 1 NHLI, Imperial College London, London, UK
  2. 2 Barts Heart Centre, St Bartholomews Hospital, London, UK
  3. 3 William Harvey Research Institute, Queen Mary University of London, London, UK
  4. 4 Guy’s and St Thomas’ NHS Foundation Trust, London, UK
  5. 5 Department of Medicine, University of Cambridge School of Clinical Medicine, Cambridge, UK
  6. 6 Wellcome-Wolfson Institute for Experimental Medicine, School of Medicine, Dentistry and Biomedical Science, Queen’s University Belfast, Belfast, UK
  7. 7 Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, UK
  8. 8 The Royal London Hospital, London, UK
  9. 9 Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
  10. 10 East Kent Hospitals NHS Foundation Trust, London, UK
  11. 11 Perioperative Medicine, Barts Health NHS Trust, London, UK
  12. 12 Intensive Care, Royal Surrey County Hospital NHS Foundation Trust, Guildford, Surrey, UK
  13. 13 University of Surrey Faculty of Health and Medical Sciences, Guildford, Surrey, UK
  14. 14 Department of Critical Care, Guy's & St Thomas' Hospitals NHS Foundation Trust, London, UK
  15. 15 University of West London, Ealing, UK
  16. 16 Royal Brompton & Harefield NHS Foundation Trust, London, UK
  17. 17 AICU, Royal Brompton & Harefield NHS Foundation Trust, London, UK
  18. 18 Anaesthetics, Imperial College London, London, UK
  19. 19 Clinical Trials Unit, University of Warwick, Coventry, UK
  20. 20 London North West University Hospitals, London, UK
  21. 21 Academic Department of Critical Care, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
  22. 22 Adult Critical Care, University Hopsital of Wales, Cardiff, UK
  23. 23 School of Immunology and Microbial Sciences, King's College London, London, UK
  1. Correspondence to Professor Mark Griffiths, NHLI, Imperial College London, London SW7 2AZ, UK; m.griffiths{at}


Background COVID-19 has become the most common cause of acute respiratory distress syndrome (ARDS) worldwide. Features of the pathophysiology and clinical presentation partially distinguish it from ‘classical’ ARDS. A Research and Development (RAND) analysis gauged the opinion of an expert panel about the management of ARDS with and without COVID-19 as the precipitating cause, using recent UK guidelines as a template.

Methods An 11-person panel comprising intensive care practitioners rated the appropriateness of ARDS management options at different times during hospital admission, in the presence or absence of, or varying severity of SARS-CoV-2 infection on a scale of 1–9 (where 1–3 is inappropriate, 4–6 is uncertain and 7–9 is appropriate). A summary of the anonymised results was discussed at an online meeting moderated by an expert in RAND methodology. The modified online survey comprising 76 questions, subdivided into investigations (16), non-invasive respiratory support (18), basic intensive care unit management of ARDS (20), management of refractory hypoxaemia (8), pharmacotherapy (7) and anticoagulation (7), was completed again.

Results Disagreement between experts was significant only when addressing the appropriateness of diagnostic bronchoscopy in patients with confirmed or suspected COVID-19. Adherence to existing published guidelines for the management of ARDS for relevant evidence-based interventions was recommended. Responses of the experts to the final survey suggested that the supportive management of ARDS should be the same, regardless of a COVID-19 diagnosis. For patients with ARDS with COVID-19, the panel recommended routine treatment with corticosteroids and a lower threshold for full anticoagulation based on a high index of suspicion for venous thromboembolic disease.

Conclusion The expert panel found no reason to deviate from the evidence-based supportive strategies for managing ARDS outlined in recent guidelines.

  • ARDS
  • assisted ventilation
  • COVID-19
  • critical care
  • non invasive ventilation
  • viral infection

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All the data relevant to this study are contained within this manuscript and are therefore freely available.

This article is made freely available for personal use in accordance with BMJ’s website terms and conditions for the duration of the covid-19 pandemic or until otherwise determined by BMJ. You may use, download and print the article for any lawful, non-commercial purpose (including text and data mining) provided that all copyright notices and trade marks are retained.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. All the data relevant to this study are contained within this manuscript and are therefore freely available.

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  • Twitter @charlot_summers, @ICUDocAP

  • MG, SM, CS, DFM and AP contributed equally.

  • Contributors The data have been verified by SM, PMI and MG. KD, AP, CS, SM, PMI and MG designed the original survey. The RAND methodology experts were MAS, SM and PMI. The literature searches were performed by MBM, LS and HY. The expert panel comprised PD, SJF, LGF, MG, DFM, IN, BP, AGP, CS, NTT and MPW. The first draft of the manuscript was written by MG, SM, PMI, DFM and AGP. All authors contributed to revising and final approval of the manuscript.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; externally peer reviewed.