ICU · Respiratory / ventilation
Refractory Hypoxaemia Adjuncts — Proning, iNO, Recruitment, NMBA, ECMO
Also known as Refractory hypoxaemia · Prone positioning · Prone ventilation · PROSEVA · Inhaled nitric oxide · iNO · Recruitment manoeuvre · Neuromuscular blockade · NMBA · ACURASYS · ROSE trial · VV-ECMO · EOLIA · CESAR · ART trial · ECCO2R · Apnoeic oxygenation · Driving pressure
Refractory hypoxaemia in severe ARDS is defined as a PaO2/FiO2 under 100 despite optimised lung-protective ventilation (Vt 6 mL/kg PBW, Pplat under 30 cmH2O, optimised PEEP, FiO2 1.0). A staged set of adjuncts is deployed: optimise ventilation (driving-pressure-guided PEEP, permissive hypercapnia), then PRONE POSITIONING (PROSEVA, NEJM 2013 — at least 16 h/day in PaO2/FiO2 under 150) which is the ONLY adjunct that reduces mortality, then transient oxygenation therapies (inhaled nitric oxide or inhaled epoprostenol — no survival benefit, AKI/rebound risk), then short neuromuscular blockade for asynchrony (ACURASYS 2010 benefit refuted by ROSE 2019 — NOT routine), then VV-ECMO (EOLIA 2018, CESAR 2009) for the refractory case, with ECCO2R as a partial support. Aggressive recruitment plus very high PEEP is harmful (ART 2017).
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Overview & definition
When severe ARDS stays hypoxaemic despite optimised lung-protective ventilation (low tidal volume, adequate PEEP, plateau under 30 cmH2O), you have four adjuncts to deploy — proning, inhaled nitric oxide, recruitment manoeuvres, and neuromuscular blockade — and one rescue — VV-ECMO. Proning is the only one that consistently reduces mortality. The others are temporising or selective.[1][4]
References40ShowHide
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