ARDS Clinical Pearl

ECMO is useful, BUT try the following therapies first:

Supported
1. Vt 4-8cc/kg, Pplat <30cm/H2O
2. Proning: Mod-Severe ARDS
Literature: PROSEVA
Recommendation: at least 12 hours
Physiology: V/Q Matching, VILI, End Exp. Volume
3. High PEEP
4. Limit fluids when able
Against
High Frequency Oscillation
Literature: OSCAR, OSCILLATE
Physiology: Concept of Open Lung
Conditional
Higher Peep: Mod-Severe ARDS
Literature: ALVEOLI, ARMA, LOVES, EXPRESS, EPIVENT II
Recruitment
30 for 30
40 for 40
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%