Roy Brower – Managing Severe ARDS and Being on the Edge of the Evidence

Dr. Roy Brower is one of the original ARDSnet authors that brought Low Tidal-Volume ventilation to the masses.  We asked him to speak his mind on what he thinks we should do once the traditional ARDSnet goals no longer apply.

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Evidence behind ARDSnet protocol and beyond

1. EXPRESS PEEP Trial
   • Raise PEEP until Pplat = 28-30
   • No mortality benefit, improved lung function, and reduced the duration of mechanical ventilation
2. High vs. Low PEEP in ALI Meta-analysis
   • Higher PEEP associated with improved survival among the subgroup of patients with ARDS
   • PaO2/FiO2 < 200
3. Neuromuscular blockade for 48 hours
   • Improved 90 day survival
   • Reduced time off ventilator
   • PaO2/FiO2 < 150
   • Used cisatracurium x 48 hours
4. Proning WORKS
   • Minimal cost intervention
   • Proned for 16 hours, supine for 6 hours
   • Decreased 28-day and 90-day mortality

What else should you consider with a high Plateau Pressure?

• We actually have no idea what the best Pplat is for each patient
• The lungs are surrounded by a number of different variable forces, that contribute to the plateau pressure
  • Abdominal pressure (estimated by bladder pressure)
  • Force of the chest wall, thoracic cavity on the lungs
  • Pleural effusions
  • Pneumothorax
  • Lung diseases
• Are you measuring the Pplat correctly?
  • Don’t be fooled, the real plateau can appear to be falsely elevated if the patient is making an inspiratory effort at the end of your end-inspiratory hold.  Look at the waveform!!

Troubleshooting a Pplat > 30

• Check to see if the patient is a PEEP responder (Lower the PEEP)
• Stop worry about it! (as long as you can justify the higher Pplat based on the above variables)
• Lower the VT to < 4 cc/kg IBW – Mechanically vented patients rarely die from a high PaCO2
• We probably should stop using the Oscillator – Reason 1, Reason 2

Problem 2: What about ECMO?

• Rationale makes sense
• Not completely clear if ECMO is any better
• The clinical trials need to be done to prove mortality/safety benefit