missed moderate-severe ards window (>72hrs) - window starts when patient is intubated with a qualifying p/f ratio of ≤ 200 with peep ≥ 8 cm h2o or on high flow oxygen with well-fitting nasal cannula with flow ≥ 65 lpm and fio2 ≥ 0.65 or on non-invasive pressure ventilation with peep ≥ 8 cm h2o and fio2 ≤ 0.6. missed nmb window: (>48 hrs) missed mechanical ventilation window (>7 days) refractory hypotension (continuous infusion of >0.2 mcg/kg/min of norepinephrine or equivalent dose of other pressors for >6 continuous hours prior to randomization) core temperature <35.5°c for ≥6 hours while not receiving crrt on day of randomization significant, active bleeding (>3u blood products and/or surgical/ir intervention) on day of randomization platelets <10k/mm3 (uncorrected) on day of randomization active hematologic malignancy skin process that precludes cooling device moribund, not likely to survive 72h pre-morbid condition makes it unlikely that patient will survive 28 days do not resuscitate status at time of randomization not likely to remain intubated for ≥48h physician of record unwilling to participate severe underlying lung disease needs ≥ 2 lpm home o2 on bipap (except for osa) prior lung transplantation pregnant at time of randomization bmi consistently >50 kg/m2 known nyha class iv heart disease acute coronary syndrome (mi, unstable angina) within 30 days of randomization cardiac arrest within 30 days of randomization burns over >20% of the body surface severe chronic liver disease (child-pugh score 12-15) previously randomized in chill study simultaneous enrollment in another interventional trial

missed moderate-severe ards window (>72hrs) - window starts when patient is intubated with a qualifying p/f ratio of ≤ 200 with peep ≥ 8 cm h2o or on high flow oxygen with well-fitting nasal cannula with flow ≥ 65 lpm and fio2 ≥ 0.65 or on non-invasive pressure ventilation with peep ≥ 8 cm h2o and fio2 ≤ 0.6. missed nmb window: (>48 hrs) missed mechanical ventilation window (>7 days) refractory hypotension (continuous infusion of >0.2 mcg/kg/min of norepinephrine or equivalent dose of other pressors for >6 continuous hours prior to randomization) core temperature <35.5°c for ≥6 hours while not receiving crrt on day of randomization significant, active bleeding (>3u blood products and/or surgical/ir intervention) on day of randomization platelets <10k/mm3 (uncorrected) on day of randomization active hematologic malignancy skin process that precludes cooling device moribund, not likely to survive 72h pre-morbid condition makes it unlikely that patient will survive 28 days do not resuscitate status at time of randomization not likely to remain intubated for ≥48h physician of record unwilling to participate severe underlying lung disease needs ≥ 2 lpm home o2 on bipap (except for osa) prior lung transplantation pregnant at time of randomization bmi consistently >50 kg/m2 known nyha class iv heart disease acute coronary syndrome (mi, unstable angina) within 30 days of randomization cardiac arrest within 30 days of randomization burns over >20% of the body surface severe chronic liver disease (child-pugh score 12-15) previously randomized in chill study simultaneous enrollment in another interventional trial

missed ards window (>72hrs) missed nmb window: (>48 hrs) missed mechanical ventilation window (>7 days) refractory hypotension (continuous infusion of >0.2 mcg/kg/min of norepinephrine or equivalent dose for >6 h prior to randomization) core temperature <35.5°c while not receiving crrt on day of randomization significant, active bleeding (>3u blood products and/or surgical/ir intervention) on day of randomization platelets <10k/mm3 (uncorrected) on day of randomization active hematologic malignancy skin process that precludes cooling device moribund, not likely to survive 72h pre-morbid condition makes it unlikely that patient will survive 28 days do not resuscitate status at time of randomization not likely to remain intubated for ≥48h physician of record unwilling to participate severe underlying lung disease on home o2 on bipap (except for osa) prior lung transplantation pregnant at time of randomization bmi consistently >50 kg/m2 known nyha class iv heart disease acute coronary syndrome (mi, unstable angina) within 30 days of randomization cardiac arrest within 30 days of randomization burns over >20% of the body surface severe chronic liver disease (child-pugh score 12-15) previously randomized in chill study simultaneous enrollment in another interventional trial

missed ards window (>72hrs) missed nmb window: (>48 hrs) missed mechanical ventilation window (>7 days) refractory hypotension (continuous infusion of >0.2 mcg/kg/min of norepinephrine or equivalent dose for >6 h prior to randomization) core temperature <35.5°c while not receiving crrt on day of randomization significant, active bleeding (>3u blood products and/or surgical/ir intervention) on day of randomization platelets <10k/mm3 (uncorrected) on day of randomization active hematologic malignancy skin process that precludes cooling device moribund, not likely to survive 72h pre-morbid condition makes it unlikely that patient will survive 28 days do not resuscitate status at time of randomization not likely to remain intubated for ≥48h physician of record unwilling to participate severe underlying lung disease on home o2 on bipap (except for osa) prior lung transplantation pregnant at time of randomization bmi consistently >50 kg/m2 known nyha class iv heart disease acute coronary syndrome (mi, unstable angina) within 30 days of randomization cardiac arrest within 30 days of randomization burns over >20% of the body surface severe chronic liver disease (child-pugh score 12-15) previously randomized in chill study simultaneous enrollment in another interventional trial

missed ards window (>48hrs) missed nmb window: (>12 hrs) missed mechanical ventilation window (>7 days) refractory hypotension (> 0.2 mcg/kg/min of norepinephrine or equivalent dose for 6 h or longer) core temperature <35.5°c while not receiving crrt patient is unable to give consent and no legally authorized representative is available significant, active bleeding (>3u blood products and/or surgical/ir intervention) platelets <10k/mm3 (uncorrected) active hematologic malignancy skin process that precludes cooling device moribund, not likely to survive 72h pre-morbid condition makes it unlikely that patient will survive 28 days do not resuscitate status not likely to remain intubated for ≥48h physician of record unwilling to participate severe underlying lung disease on home o2 on bipap (except for osa) prior lung transplantation pregnant bmi >50 kg/m2 known nyha class iv heart disease acute coronary syndrome past 30 days (mi, unstable angina) cardiac arrest within 30 days of enrollment burns over >20% of the body surface severe chronic liver disease (child-pugh score 12-15) previously randomized in chill study

missed ards window (>48hrs) missed nmb window: (>12 hrs) missed mechanical ventilation window (>7 days) refractory hypotension (> 0.2 mcg/kg/min of norepinephrine or equivalent dose for 6 h or longer) core temperature <35.5°c while not receiving crrt patient is unable to give consent and no legally authorized representative is available significant, active bleeding (>3u blood products and/or surgical/ir intervention) platelets <10k/mm3 (uncorrected) active hematologic malignancy skin process that precludes cooling device moribund, not likely to survive 72h pre-morbid condition makes it unlikely that patient will survive 28 days do not resuscitate status not likely to remain intubated for ≥48h physician of record unwilling to participate severe underlying lung disease on home o2 on bipap (except for osa) prior lung transplantation pregnant bmi >50 kg/m2 known nyha class iv heart disease acute coronary syndrome past 30 days (mi, unstable angina) cardiac arrest within 30 days of enrollment burns over >20% of the body surface severe chronic liver disease (child-pugh score 12-15) previously randomized in chill study