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We compared two de-escalation strategies guided by either extravascular lung water or global end-diastolic volume-oriented algorithms in patients with sepsis and ARDS. Sixty patients with sepsis and ARDS were randomized to receive de-escalation fluid therapy, guided either by the extravascular lung water index (EVLWI, n = 30) or the global end-diastolic volume index (GEDVI, n = 30). In cases of GEDVI &gt; 650 mL/m 2 or EVLWI &gt; 10 mL/kg, diuretics and/or controlled ultrafiltration were administered to achieve the cumulative 48-h fluid balance in the range of 0 to -3000 mL. During 48 h of goal-directed de-escalation therapy, we observed a decrease in the SOFA score ( p &lt; 0.05). Extravascular lung water decreased only in the EVLWI-oriented group ( p &lt; 0.001). In parallel, PaO 2 /FiO 2 increased by 30% in the EVLWI group and by 15% in the GEDVI group ( p &lt; 0.05). The patients with direct ARDS demonstrated better responses to dehydration therapy concerning arterial oxygenation and lung fluid balance. In sepsis-induced ARDS, both fluid management strategies, based either on GEDVI or EVLWI, improved arterial oxygenation and attenuated organ dysfunction. The de-escalation therapy was more efficient for direct ARDS.

Optimizing Fluid Management Guided by Volumetric Parameters in Patients with Sepsis and ARDS