Advanced Ventilator Training Module – Management of Refractory Hypoxemia in COVID-19

Lecture

Slides

REFRACTORY HYPOXEMIA SLIDES

 

References and Resources

FiO2 targets in ARDS

LOCO2 trial. Barrot et al. LOCO2 Investigators and REVA Research Network. Liberal or Conservative Oxygen Therapy for Acute Respiratory Distress Syndrome. N Engl J Med. 2020 Mar 12;382(11):999-1008PMID: 32160661.

IOTA. Chu et al. Mortality and morbidity in acutely ill adults treated with liberal versus conservative oxygen therapy (IOTA): a systematic review and meta-analysis. Lancet. 2018 Apr 28;391(10131):1693-1705. doi: 10.1016/S0140-6736(18)30479-3. Epub 2018 Apr 26. PMID: 29726345.

High vs Low PEEP in ARDS

Briel 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 – Journal of the American Medical Association, 303(9), 865–873.

Walkey et al. (2017). Higher PEEP versus lower PEEP strategies for patients with acute respiratory distress syndrome: A systematic review and meta-analysis. Annals of the American Thoracic Society, 14, S297–S303

COVID-19 associated ARDS

Marini JJ, Gattinoni L. Management of COVID-19 Respiratory Distress. JAMA. 2020;323(22):2329–2330. doi:10.1001/jama.2020.6825

 

MGH flare.  What we have learned about COVID-19: Pt 1.  

Proning in ARDS

PROSEVA. Guérin et al.  (2013). Prone Positioning in Severe Acute Respiratory Distress Syndrome. New England Journal of Medicine, 368(23), 2159–2168.

NMBA in ARDS

Low PEEP. ACURASYS trial. Papazian et al(2010). Neuromuscular Blockers in Early Acute Respiratory Distress Syndrome. New England Journal of Medicine, 363(12), 1107–1116.

High PEEP. ROSE trial. Early Neuromuscular Blockade in the Acute Respiratory Distress Syndrome. (2019). New England Journal of Medicine, 380(21), 1997–2008.

APRV TCAV

Evidence in ARDS: Zhou et al. Early application of airway pressure release ventilation may reduce the duration of mechanical ventilation in acute respiratory distress syndrome. Intensive Care Med. 2017 Nov;43(11):1648-1659. doi: 10.1007/s00134-017-4912-z. Epub 2017 Sep 22.

Review: Habashi NM. Other approaches to open-lung ventilation: airway pressure release ventilation. Crit Care Med. 2005 Mar;33(3 Suppl):S228-40. doi: 10.1097/01.ccm.0000155920.11893.37. PMID: 15753733.

Application:

www.aprvnetwork.org

www.emcrit.org/ibcc/covid-aprv/

Recruitment maneuvers in ARDS

Metaanaylsis: Goligher et al. (2017). Lung recruitment maneuvers for adult patients with acute respiratory distress syndrome: A systematic review and meta-analysis. Annals of the American Thoracic Society, 14(October), S304–S311.

RM followed by High PEEP table: Meade et al (2008). Ventilation strategy using low tidal volumes, recruitment maneuvers, and high positive end-expiratory pressure for acute lung injury and acute respiratory distress syndrome: A randomized controlled trial. JAMA – Journal of the American Medical Association, 299(6), 637–645.

RM followed by decremental PEEP – compliance method.  Kacmarek et al. Open Lung Approach for the Acute Respiratory Distress Syndrome: A Pilot, Randomized Controlled Trial. Critical care medicine. 2016;44(1):32-42.

RM followed by decremental PEEP – SpO2 method. Girgis K, Kacmarek RM. A decremental PEEP trial identifies the PEEP level that maintains oxygenation after lung recruitment. Respir Care. 2006 Oct;51(10):1132-9.

Optimizing PEEP

Review: Gattinoni et al. (2017). Positive end-expiratory pressure: How to set it at the individual level. Annals of Translational Medicine, 5(14), 1–10.

FOAM: www.derangedphysiology.com/main/required-reading/respiratory-medicine-and-ventilation/Chapter%205121/optimal-peep-open-lung

Salvage therapies in refractory hypoxemia

ECMO in ARDS Munshi et al. Venovenous extracorporeal membrane oxygenation for acute respiratory distress syndrome: a systematic review and meta-analysis. Lancet Respir Med. 2019 Feb;7(2):163-172.

Inhaled nitric oxide as rescue in ARDS Gebistorf F, Karam O, Wetterslev J, Afshari A (2016) Inhaled nitric oxide for acute respiratory distress syndrome (ARDS) in children and adults. Cochrane Database Syst Rev 6:CD002787

Analgesia and Sedation

Practice guidelines for Prevention and Management of Pain, Agitation/Sedation, Delirium, Immobility and Sleep Disruption in Adult Patients in the ICU (PADIS Guidelines) 2018. 

https://www.sccm.org/ICULiberation/Guidelines

Additional COVID-19 resources and Guidelines

https://www.sccm.org/SurvivingSepsisCampaign/Guidelines/COVID-19