ICU Cases · ARDS & lung protection
Long case — severe influenza ARDS and the escalation to ECMO
A CICM Second-Part long case on the disease-management arc of severe viral ARDS — recognition and Berlin classification, the step-up rescue ladder (lung-protective ventilation, prolonged prone positioning, selective neuromuscular blockade, conservative fluids, right-ventricular protection), and the threshold and logistics for venovenous ECMO referral. The candidate must defend each step with trial evidence.
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Candidate summary. This is a 34-year-old obese man (BMI 36) with no significant past history, now on day 3 of confirmed influenza A (H1N1) pneumonia that has progressed to severe ARDS. He is intubated and ventilated lung-protectively on FiO2 0.85, PEEP 14, tidal volume 420 mL (6 mL/kg predicted body weight). His latest gas shows a PaO2 of 52 mmHg giving a PaO2/FiO2 ratio of about 60, his plateau pressure has risen to 31 cmH2O, and his chest film shows dense bilateral airspace consolidation. He is febrile, vasopressor-dependent on a low-dose noradrenaline, and his net fluid balance is +6 litres over three days.
[3]The problem is refractory, severe ARDS in a young patient with reversible disease, and the task is to escalate through the evidence-based rescue ladder while protecting the lung and the right ventricle, and to decide when to refer for venovenous ECMO.[1][9]
References13ShowHide
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- [9]Combes A, Hajage D, Capellier G, et al. Extracorporeal Membrane Oxygenation for Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2018.PMID 29791822
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