Advanced Ventilator Training Module – Management of Refractory Hypoxemia in COVID-19
SlidesREFRACTORY 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.
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.
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.
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.
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.
Additional COVID-19 resources and Guidelines