Episode 3: Refractory ARDS

What stops do you make along the garden path of hypoxic respiratory failure?

Resources

References

An ARDS review: Fan E, Brodie D, Slutsky A. Acute Respiratory Distress: Syndrome Advances in Diagnosis and Treatment. JAMA. 2018;319(7):698-710

Lung protective ventilation (The original ARDSnet ARMA trial): Acute Respiratory Distress Syndrome Network, Brower RG, Matthay MA, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med. 2000;342(18):1301–1308.

Steroids for ARDS (SCCM/ESICM guidelines): Guidelines for the Diagnosis and Management of Critical Illness-Related Corticosteroid Insufficiency (CIRCI) in Critically Ill Patients (Part I): Society of Critical Care Medicine (SCCM) and European Society of Intensive Care Medicine (ESICM) 2017

Prone positioning (PROSEVA trial): Guérin C, Reignier J, Richard JC, et al. Prone positioning in severe acute respiratory distress syndromeN Engl J Med. 2013;368(23):2159–2168.

Driving pressure: Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndromeN Engl J Med. 2015;372(8):747–755.

… and a driving pressure meta-analysis: Aoyama H, Pettenuzzo T, Aoyama K, Pinto R, et al. Association of Driving Pressure With Mortality Among Ventilated Patients With Acute Respiratory Distress Syndrome: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(2):300–306.

APRV: Zhou Y, Jin X, Lv Y, et al. Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndromeIntensive Care Med. 2017;43(11):1648–1659.

Recruitment maneuvers (ART trial): Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators, Cavalcanti AB, Suzumura ÉA, et al. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017;318(14):1335–1345.

Paralysis (PETAL trial): National Heart, Lung, and Blood Institute PETAL Clinical Trials Network, Moss M, Huang DT, et al. Early Neuromuscular Blockade in the Acute Respiratory Distress SyndromeN Engl J Med. 2019;380(21):1997–2008.

ECMO (EOLIA trial): Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress SyndromeN Engl J Med. 2018;378(21):1965–1975.

2 thoughts on “Episode 3: Refractory ARDS”

  1. Hi there,
    I’ve just recently started listening to your podcast and I’m loving it! Thank you for doing this, it’s an easy way to think through a case and develop a better understanding of disease processes and the progression of the hospital stay. I am an ICU nurse, so to be able to come to the MRP with suggestions is invaluable.
    One thing I do think you might have glossed over in this ARDS episode was the heart. As far as I heard, no Echo was ever done. It really reminded me of a similar case that we had a while ago, a 27 year old developmentally delayed morbidly obese woman who came in with respiratory failure. We tried EVERYTHING! We went through the exact same process you did, from high PEEP to APRV to considering proning and even possible ECMO (which is not performed at our hospital). Finally we did an Echo and found she had a septal shunt! Her poor ABGs and horrible oxygenation had nothing to do with her lungs!
    Anyways, I just thought I’d add that for your consideration. It’s extremely unlikely, but it’s something that can happen!
    Thanks and keep up the good work!
    Fraser

    1. Great point Fraser. You really can’t definitively diagnose ARDS without ruling out cardiogenic pulmonary edema, so in anybody this sick an echo is appropriate. (In reality I would probably be doing it at the bedside as soon as the patient turned up.)

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