Category: Critical Care
Keywords: ARDS, respiratory failure, ventilator settings, critical care (PubMed Search)
Despite ongoing research and efforts to improve our care of patients with ARDS, it remains an entity with high morbidity and mortality. Early recognition of the disease process and appropriate management by emergency physicians can have profound effects on the patient's course, especially in centers where ICU boarding continues to be an issue.
Recognition of ARDS (Berlin criteria)
*An ABG should be obtained in the ED if physicians are unable to wean down FiO2 from high settings, if oxygenation by pulse ox is marginal, or if the patient is in a shock state.
Tenets of ARDS Management:
*IBW Males = 50 + 2.3 x [Height (in) - 60] / IBW Females = 45.5 + 2.3 x [Height (in) - 60]
Strategies for Refractory Hypoxemia in the ED: You can't prone the patient, but what else can you do?
1. Escalate PEEP in stepwise fashion
2. Recruitment maneuvers
3. Appropriate sedation and neuromuscular blockade
4. Inhaled pulmonary vasodilators (inhaled prostaglandins, nitric oxide) if known or suspected right heart failure or pulmonary hypertension
Bottom Line: Emergency physicians are the first line of defense against ARDS. Early recognition of the disease process and appropriate management is important to improve outcomes AND to help ICU physicians triage which patients need to be emergently proned or even who should potentially be referred for ECMO.
Fielding-Singh V, Matthay MA, Calfee CS. Beyond Low Tidal Volume Ventilation: Treatment Adjuncts for Severe Respiratory Failure in Acute Respiratory Distress Syndrome. Crit Care Me.. 2018;46(11):1820-31.