Summary: Dr. Roy Brower is one of the original ARDSnet authors that brought Low Tidal-Volume ventilation to the masses. We asked him to speak his mind on what he thinks we should do once the traditional ARDSnet goals no longer apply.<br> <br> Evidence behind ARDSnet protocol and beyond<br> <br> * <a href="http://jama.jamanetwork.com/data/Journals/JAMA/4404/jce80001_646_655.pdf">EXPRESS PEEP Trial</a><br> <br> * Raise PEEP until Pplat = 28-30<br> * No mortality benefit, improved lung function, and reduced the duration of mechanical ventilation<br> <br> <br> * <a href="http://jama.jamanetwork.com/data/Journals/JAMA/4502/jce05002_865_873.pdf">High vs. Low PEEP in ALI Meta-analysis</a><br> <br> * Higher PEEP associated with improved survival among the subgroup of patients with ARDS<br> * PaO2/FiO2 < 200<br> <br> <br> * <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1005372">Neuromuscular blockade for 48 hours</a><br> <br> * Improved 90 day survival<br> * Reduced time off ventilator<br> * PaO2/FiO2 < 150<br> * Used cisatracurium x 48 hours<br> <br> <br> * <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1214103">Proning WORKS</a><br> <br> * Minimal cost intervention<br> * Proned for 16 hours, supine for 6 hours<br> * Decreased 28-day and 90-day mortality<br> <br> <br> <br> What else should you consider with a high Plateau Pressure?<br> <br> * We actually have no idea what the best Pplat is for each patient<br> * The lungs are surrounded by a number of different variable forces, that contribute to the plateau pressure<br> <br> * Abdominal pressure (estimated by bladder pressure)<br> * Force of the chest wall, thoracic cavity on the lungs<br> * Pleural effusions<br> * Pneumothorax<br> * Lung diseases<br> <br> <br> * Are you measuring the Pplat correctly?<br> <br> * Don’t be fooled, the real plateau can appear to be falsely elevated if the patient is making an inspiratory effort at the end of your end-inspiratory hold. Look at the waveform!!<br> <br> <br> <br> Troubleshooting a Pplat > 30<br> <br> * Check to see if the patient is a PEEP responder (Lower the PEEP)<br> * Stop worry about it! (as long as you can justify the higher Pplat based on the above variables)<br> * Lower the VT to < 4 cc/kg IBW – Mechanically vented patients rarely die from a high PaCO2<br> * We probably should stop using the Oscillator – <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1215716">Reason 1</a>, <a href="http://www.nejm.org/doi/pdf/10.1056/NEJMoa1215554">Reason 2 </a><br> <br> Problem 2: What about ECMO?<br> <br> * Rationale makes sense<br> * Not completely clear if ECMO is any better<br> * The clinical trials need to be done to prove mortality/safety benefit<br> <br> <br> References<br> <br> * <a href="http://marylandccproject.org/wp-content/uploads/2014/04/NEJM-Low-Vt-Ventilation.pdf">Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301-8.</a><br> * <a href="http://marylandccproject.org/wp-content/uploads/2014/04/Hager-Pplat-quartiles-ajrccm-.pdf">Hager DN, Krishnan JA, Hayden DL, Brower RG. Tidal volume reduction in patients with acute lung injury when plateau pressures are not high. Am J Respir Crit Care Med. 2005;172(10):1241-5.</a><br> * <a href="http://marylandccproject.org/wp-content/uploads/2014/04/Grasso.SI_.ajrccm2007.pdf">Grasso S, Stripoli T, De michele M, et al. ARDSnet ventilatory protocol and alveolar hyperinflation: role of positive end-expiratory pressure. Am J Respir Crit Care Med. 2007;176(8):761-7.</a><br> <br> <br>
