Today we have the pleasure of undergoing something we have NEVER before demonstrated on MCCP, our first whiteboard lecture! And we have the best person possible to accomplish this monumental feat: Patricia A. Kritek, MD, EDM. Dr. Kritek is a Professor in the Division of Pulmonary and Critical Care Medicine and Associate Medical Director of Critical Care at the University of Washington Medical Center. In addition, she has revolutionized the way training programs use technology to teach medical students, residents and fellows, having earned her EdM from the Harvard Graduate School of Education. Today she was kind enough to cross the USA and grace us with a fantastic, interactive, and highly educational talk on the ways we should and should not treat ARDS. Don’t miss this opportunity to experience her brilliance!
Clinical Pearl (assisted by Dr. Tony Basel)
After a recent meeting on ARDS, world renowned experts released the following guidelines:
- ECMO is useful, BUT try the following therapies first:
- Supported
- Vt 4-8cc/kg, Pplat <30cm/H2O
- Proning: Mod-Severe ARDS
- Literature: PROSEVA
- Recommendation: “at least 12 hours”
- Physiology: ⇑V/Q Matching, ⇓VILI, ⇑End Exp. Volume
- Literature: PROSEVA
- High PEEP
- Limit fluids when able
- Against
- Conditional
- Higher Peep: Mod-Severe ARDS
- Literature: ALVEOLI, ARMA, LOVES, EXPRESS, EPIVENT II
- Recruitment
- 30 for 30
- 40 for 40
- Higher Peep: Mod-Severe ARDS
- Deferred Comments
- Neuromuscular Blocking Agents
- Pros: Synchrony, improved mechanics
- Con: Weakness, increased sedation needs, myopathy
- APRV
- APRV Basics (overall very similar to Pressure Control Ventilation)
- Trigger: Time
- Cycle: Time
- Limited: Pressure
- What we Set
- Pressure High: usually the tolerated Pplat (<30cmH2O)
- Pressure Low: usually Zero (although some argue setting at 5)
- Time High: Initially 5 sec
- Time Low: Initially 0.5 sec
- Monitoring
- Releases
- Minute Ventilation
- Auto-peep using flow
- Use 50% and 25%
- Trigger: Time
- APRV Basics (overall very similar to Pressure Control Ventilation)
- Neuromuscular Blocking Agents
Suggested Reading
- Facchin F, Fan E. Airway Pressure Release Ventilation and High-Frequency Oscillatory Ventilation: Potential Strategies to Treat Severe Hypoxemia and Prevent Ventilator-Induced Lung Injury. Respir Care. 2015 Oct;60(10):1509-21.[Pubmed Link]
- Kacmarek RM. Proportional assist ventilation and neurally adjusted ventilatory assist. Respir Care. 2011 Feb;56(2):140-8; discussion 149-52. [Pubmed Link]
About the Author
