ICU Cases · Mechanical ventilation
Severe pneumonia with ARDS — protecting the lung and then liberating it
A full CICM Second-Part long case spanning the complete arc of mechanical ventilation in severe ARDS — recognising the syndrome, setting the lung-protective targets from the landmark trials, escalating for refractory hypoxaemia, and weaning — built on ARDSNet 2000, the driving-pressure analysis, the baby-lung concept and the weaning-methods trials.
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A 58-year-old previously well man presented with three days of fever, productive cough, and pleuritic chest pain, and was intubated in the emergency department for severe type 1 respiratory failure from pneumococcal pneumonia. Twenty-four hours into his ICU admission he is sedated and ventilated on volume control, FiO2 0.8, PEEP 14 cmH2O, with a set tidal volume of 450 mL. His latest arterial gas shows pH 7.30, PaCO2 52 mmHg, PaO2 56 mmHg, and bicarbonate 26 mmol/L. A chest radiograph shows dense bilateral airspace opacification. The ventilator reports a peak pressure of 36 cmH2O and, on an inspiratory hold, a plateau pressure of 32 cmH2O.
[1]The synthesis the examiner wants is one sentence: he has severe ARDS, and his current ventilation is not yet lung-protective — the plateau pressure is above 30 cmH2O, which both fails the protective target and signals that the set tidal volume is over-distending the small amount of aerated lung he has left.[1][3]
References9ShowHide
- [1]Brower RG, Matthay MA, Morris A, et al. Ventilation with Lower Tidal Volumes as Compared with Traditional Tidal Volumes for Acute Lung Injury and the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2000.PMID 10793162
- [2]Amato MBP, et al. Driving Pressure and Survival in the Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2015.PMID 25693014
- [3]Gattinoni L, et al. Regional Physiology of ARDS. Critical Care, 2017.PMID 29297365
- [4]Dreyfuss D, et al. High Inflation Pressure Pulmonary Edema. Respective Effects of High Airway Pressure, High Tidal Volume, and Positive End-Expiratory Pressure. American Review of Respiratory Disease, 1988.PMID 3057957
- [5]Yang KL, Tobin MJ. A Prospective Study of Indexes Predicting the Outcome of Trials of Weaning from Mechanical Ventilation. New England Journal of Medicine, 1991.PMID 2023603
- [6]Brochard L, et al. Comparison of Three Methods of Gradual Withdrawal from Ventilatory Support during Weaning from Mechanical Ventilation. American Journal of Respiratory and Critical Care Medicine, 1994.PMID 7921460
- [7]Esteban A, Frutos F, Tobin MJ, et al. A Comparison of Four Methods of Weaning Patients from Mechanical Ventilation. New England Journal of Medicine, 1995.PMID 7823995
- [8]Bersten AD, Soni N (eds). Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.
- [9]Marino PL. The ICU Book. 4th edition, Lippincott Williams & Wilkins, 2014.