ICU SAQs · ARDS & lung protection
Refractory hypoxaemia in severe ARDS — the rescue ladder
A core Second-Part question on refractory hypoxaemia in ARDS — the contemporary step-up rescue ladder (prone, selective NMB, inhaled nitric oxide, venovenous ECMO) and the retired strategies (high-frequency oscillation, aggressive recruitment) that increase mortality. A favourite 'which trial changed practice' topic.
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Prompt
A patient with severe ARDS (PaO2/FiO2 65 mmHg) remains profoundly hypoxaemic despite optimised lung-protective ventilation, high PEEP and prone positioning. Outline your escalation strategy, citing the evidence for each step, and state which formerly popular rescue strategies you would specifically avoid.
Question
A patient with severe ARDS (PaO2/FiO2 65 mmHg) remains profoundly hypoxaemic despite optimised lung-protective ventilation, high PEEP and prone positioning. Outline your escalation strategy, citing the evidence for each step, and state which formerly popular rescue strategies you would specifically avoid.
[1]References6ShowHide
- [1]Guérin C, Reignier J, Richard JC, et al. Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2013.PMID 23688302
- [2]Ferguson ND, Cook DJ, Guyatt GH, et al. High-Frequency Oscillation in Early Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2013.PMID 23339639
- [3]Young D, Lamb SE, Shah S, et al. High-Frequency Oscillation for Acute Respiratory Distress Syndrome. New England Journal of Medicine, 2013.PMID 23339638
- [4]Cavalcanti AB, Suzumura ÉA, Laranjeira LN, et al. Effect of Lung Recruitment and Titrated PEEP vs Low PEEP on Mortality in Patients With ARDS. JAMA, 2017.PMID 28973363
- [5]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
- [6]Bersten AD, Soni N (eds). Oh's Intensive Care Manual. 8th edition, Elsevier, 2018.