Acute respiratory distress syndrome mechanical ventilation therapy: Difference between revisions
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*'''Veno-venous (VV)-ECMO''': Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO<sub>2</sub> is removed and O<sub>2</sub> is introduced) before being returned to the body through an inflow cannula placed in another large vein (usually the right internal jugular vein or superior vena cava) | *'''Veno-venous (VV)-ECMO''': Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO<sub>2</sub> is removed and O<sub>2</sub> is introduced) before being returned to the body through an inflow cannula placed in another large vein (usually the right internal jugular vein or superior vena cava) | ||
:*Supports gas exchange but does not provide any hemodynamic support | :*Supports gas exchange but does not provide any hemodynamic support | ||
*'''Veno-arterial(VA)-ECMO''': Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO<sub>2</sub> is removed and O<sub>2</sub> is introduced) before being returned to the body through an inflow cannula placed in a large artery (usually the right femoral artery or right carotid artery) | *'''Veno-arterial (VA)-ECMO''': Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO<sub>2</sub> is removed and O<sub>2</sub> is introduced) before being returned to the body through an inflow cannula placed in a large artery (usually the right femoral artery or right carotid artery) | ||
ECMO works by removing venous blood (e.g., the right femoral vein, right internal jugular vein, or the right atrium) | ECMO works by removing venous blood (e.g., the right femoral vein, right internal jugular vein, or the right atrium) | ||
:*Supports gas exchange and provides hemodynamic support by bypassing the heart completely | :*Supports gas exchange and provides hemodynamic support by bypassing the heart completely | ||
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1], Associate Editor(s)-in-Chief: Brian Shaller, M.D. [2]
Overview
Most patients with ARDS will require endotracheal intubation and mechanical ventilation at some point during the course of their illness and recovery. A mechanical ventilation strategy using lower tidal volumes of 6 ml/kg predicted body weight and higher levels of positive end-expiratory pressure (PEEP) has been shown to be most effective at improving oxygenation and minimizing volutrauma (injury to the lungs resulting from overdistention).
Mechanical ventilation
- Lower tidal volume ventilation (6 ml/kg predicted body weight) is associated with reduced mortality and a greater number of ventilator-free days[1]
- Lower tidal volume ventilation should be continued even if the arterial partial pressure of carbon dioxide (PaCO2) rises (this is called permissive hypercapnia)
- Permissive hypercapnia usually results in a drop in blood pH, however, treatment of acidemia (e.g., intravenous administration of sodium bicarbonate or tromethamine) is not indicated if the pH remains at or above 7.15 to 7.20
- Predicted body weight (PBW) in kilograms (kg) may be calculated from height in inches (in) as follows:
- PBW (men) = 50 + 2.3 (height in inches – 60)
- PBW (women) = 45.5 + 2.3 (height in inches – 60)
- Higher positive end-expiratory pressure (PEEP) combined with lower tidal volume ventilation is associated with decreased mortality in patients with moderate or severe ARDS (PaO2/FIO2 ≤ 200)[2]
- Prone positioning for at least 16 consecutive hours each day is associated with improved 28-day and 90-day survival in patients with ARDS and a PaO2/FIO2 ratio < 150 on an FIO2 ≥ 60% and PEEP ≥ 5 mm Hg
- Prone positioning is thought to improve oxygenation by improving ventilation/perfusion (V/Q) mismatching via reduced shunting of blood through under-ventilated lung tissue
- Cisatracurium, when started within the first 48 hours of ARDS diagnosis and continued for 48 hours, has been associated with improved 90-day survival, a greater number of ventilator-free days, and a decreased incidence of volutrauma[3]
ARDS Network Mechanical Ventilation Protocol
In 1994 the National Institutes of Health (NIH) and National Heart, Lung, and Blood Institute (NHLBI) founded the ARDS Clinical Trial Network (often abbreviated as ARDSnet) – a consortium of over 40 hospitals that conduct clinical research trials aimed at improving care for patients with ARDS. In order to simplify the mechanical ventilation of patients with ARDS, the NIH-NHLBI ARDS Network has compiled a Mechanical Ventilation Protocol Summary that outlines the mechanical ventilation strategies associated with better outcomes in an easy-to-use format for ICU health care providers.[4]
Non-Invasive Positive Pressure Ventilation
Alternative Mechanical Ventilation Strategies
Several specialized modes of mechanical ventilation have been tested in ARDS, however, none has been proven to carry a morbidity or mortality benefit and should only be considered if oxygenation does not improve with a judicious trial of the first-line mechanical ventilation strategies as outlined by the ARDS Network.[5]
- High-frequency oscillatory ventilation (HFOV) may improve oxygenation in patients with moderate to severe ARDS and severe refractory hypoxemia, however, initiation of HFOV early in the course of ARDS (i.e., prior to low tidal volume/high PEEP mechanical ventilation) has been associated with increased mortality compared to lower tidal volume/high PEEP ventilation[6][7]
- Airway pressure release ventilation (APRV) appears to be safe in ARDS, and may be associated with reduced paralytic and sedative use as well as an increase in the number of ventilator-free days[8][9]
Extracorporeal Membrane Oxygenation (ECMO)
There is growing evidence to support the use of extracorporeal membrane oxygenation (ECMO) for severe ARDS that fails to improve despite judicious application of the ARDS Network low tidal volume/high PEEP ventilation strategy.[10][11] ECMO facilitates gas exchange in circumstances where adequate oxygenation and ventilation cannot be achieved through the lungs themselves. There are two main forms of ECMO, both of which have been used successfully in the treatment of severe ARDS:
- Veno-venous (VV)-ECMO: Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO2 is removed and O2 is introduced) before being returned to the body through an inflow cannula placed in another large vein (usually the right internal jugular vein or superior vena cava)
- Supports gas exchange but does not provide any hemodynamic support
- Veno-arterial (VA)-ECMO: Venous blood is removed through an outflow cannula placed in a large vein (usually the right femoral vein or inferior vena cava) and passed through an oxygenator where gas exchange occurs (CO2 is removed and O2 is introduced) before being returned to the body through an inflow cannula placed in a large artery (usually the right femoral artery or right carotid artery)
ECMO works by removing venous blood (e.g., the right femoral vein, right internal jugular vein, or the right atrium)
- Supports gas exchange and provides hemodynamic support by bypassing the heart completely
The use of ECMO in the treatment of ARDS is an ongoing area of research, and referral to a medical center with ample experience in the use of ECMO for ARDS should be considered for patients with ARDS who are failing traditional management strategies and may be candidates for ECMO.
References
- ↑ "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. 342 (18): 1301–8. 2000. doi:10.1056/NEJM200005043421801. PMID 10793162.
- ↑ Briel M, Meade M, Mercat A, Brower RG, Talmor D, Walter SD; et al. (2010). "Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis". JAMA. 303 (9): 865–73. doi:10.1001/jama.2010.218. PMID 20197533.
- ↑ Papazian L, Forel JM, Gacouin A, Penot-Ragon C, Perrin G, Loundou A; et al. (2010). "Neuromuscular blockers in early acute respiratory distress syndrome". N Engl J Med. 363 (12): 1107–16. doi:10.1056/NEJMoa1005372. PMID 20843245. Review in: Ann Intern Med. 2011 Jan 18;154(2):JC1-3
- ↑ NIH-NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. "http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf"
- ↑ NIH-NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary. "http://www.ardsnet.org/files/ventilator_protocol_2008-07.pdf"
- ↑ Derdak S, Mehta S, Stewart TE, Smith T, Rogers M, Buchman TG; et al. (2002). "High-frequency oscillatory ventilation for acute respiratory distress syndrome in adults: a randomized, controlled trial". Am J Respir Crit Care Med. 166 (6): 801–8. doi:10.1164/rccm.2108052. PMID 12231488.
- ↑ Ferguson ND, Cook DJ, Guyatt GH, Mehta S, Hand L, Austin P; et al. (2013). "High-frequency oscillation in early acute respiratory distress syndrome". N Engl J Med. 368 (9): 795–805. doi:10.1056/NEJMoa1215554. PMID 23339639.
- ↑ Daoud EG (2007). "Airway pressure release ventilation". Ann Thorac Med. 2 (4): 176–9. doi:10.4103/1817-1737.36556. PMC 2732103. PMID 19727373.
- ↑ Daoud EG, Farag HL, Chatburn RL (2012). "Airway pressure release ventilation: what do we know?". Respir Care. 57 (2): 282–92. doi:10.4187/respcare.01238. PMID 21762559.
- ↑ Gattinoni L, Pesenti A, Mascheroni D, Marcolin R, Fumagalli R, Rossi F; et al. (1986). "Low-frequency positive-pressure ventilation with extracorporeal CO2 removal in severe acute respiratory failure". JAMA. 256 (7): 881–6. PMID 3090285.
- ↑ Peek GJ, Mugford M, Tiruvoipati R, Wilson A, Allen E, Thalanany MM; et al. (2009). "Efficacy and economic assessment of conventional ventilatory support versus extracorporeal membrane oxygenation for severe adult respiratory failure (CESAR): a multicentre randomised controlled trial". Lancet. 374 (9698): 1351–63. doi:10.1016/S0140-6736(09)61069-2. PMID 19762075.