How does your facility treat ARDS?

Advanced Practice Columnist / Guide · Sep 19, 2013

80% is a high mortality rate if that's really what you are seeing in your ICU (national average is around 40%). I would be cautious in making this assumption. First, are these true ARDS cases by diagnostic criteria? Just to review, ARDS is diagnosed based on the following criteria:

1. Acute onset (within 7 days of an inciting event or trigger such as sepsis, trauma, pneumonia).

2. Bilateral opacities consistent with pulmonary edema on chest imaging.

3. The pulmonary edema on chest imaging could not be fully explained by cardiac failure or fluid overload.

4. Hypoxemia with a ratio of paO2 to FiO2 of 200-300 (mild ARDS), 100-200 (mod ARDS), or

*Studies show that patients in the severe ARDS category (paO2 to FiO2 ratio of

The mainstay in the treatment of ARDS is lung-protective ventilation with low tidal volume ventilatory settings. This minimizes stretch on already damaged lungs (volutrauma). There are many ways to accomplish this and there are protocols out there. What is your facility's approach in enforcing this? In our facility, we use the ARDSnet protocol. We have our own modified protocol based on that link using assist-control volume cycled mode.

Low tidal volume ventilation takes into account plateau pressures as an indicator of the risk of volutrauma. The goal is to rest the lung by delivering no more than 6 cc/kg of tidal volume based on the patient's predicted body weight (not actual body weight). High PEEP is encouraged and hypercapnia is permitted as long as the pH does not drop below 7.25 to 7.30.

This mode of ventilation is uncomfortable for the patient because you're forcing shallow and fast breaths on a patient whose instinct is to deep breathe. Thus, patients need to be adequately sedated and paralysis may be indicated in cases where ventilator dys-synchrony continues despite sedatives.

Other modalities used in ARDS are called rescue therapies. These are only used when lung protective ventilatory strategy has not worked. I will enumerate each one here:

1. Prone positioning - a new European study published in NEJM has renewed interest on this modality based on results that shows that it improves mortality. Not all facilities use proning as it requires manpower expertise and specialized Roto-prone beds. What's interesting is the European study (done in France and Spain) used regular beds for proning. See: https://allnurses.com/micu-sicu-nursing/ards-should-we-838596.html

2. Inhaled Nitric Oxide - a gaseous substance that acts as a vasodilator delivered to the lungs via the ventilator. In theory, it will improve ventilation-perfusion mismatch improving oxygenation and lowering pulmonary artery pressure. Unfortunately, studies on inhaled NO use have not been promising. It improved oxygenation in some cases but no improvement in mortality.

3. High Frequency Oscillatory Ventilation - we don't use this at our facility. Studies do not show a benefit in mortality.

4. ECMO - we have an ECMO service and have used ECMO in ARDS many times. It requires specialized expertise you only see in large hospitals and academic centers. We have great results with it. Another European study (UK) called CESAR have shown improvement in mortality with ECMO use in ARDS.

If perhaps your ICU has poor outcomes with ARDS, it may be best for patients who are initially diagnosed with it be transferred to a facility that can provide rescue therapies.

Spoiled1, MSN, RN · Sep 20, 2013

My hospital treats ARDS VERY similar to what Juan explains We prone, use the oscillator, nitric oxide, etc. We don't ECMO, or at least I've never seen it done.

ICUNurseStat · Sep 20, 2013

80% is definitely just a guess and hopefully it's high. We do not do ECMO but we have the capability to pronate, use an oscillator vent, and use nitric oxide. Unfortunately, it seems like our critical care/pulmonology docs would just rather not bother.

I can't disagree that maybe these patients should be transferred out rather than be treated by out apathetic physicians, but most of our patients are self pay and no one else will accept them. Don't even get me started on how much that upsets me!

TraumaSurfer · Sep 21, 2013

If you have only seen one HFOV (which have been very common in adults for about 10 years), chances are your doctors are not aggressive enough.

If you don't utilize the other therapies first like HFOV, NO and ARDSnet going straight to ECMO is really rather silly except in a few very, very rare situations.

Many wait too long before initiating a therapy like proning, Nitric Oxide, HFOV, ARDSnet guideline for PEEP and buffering. When they do try it too late they justify their reluctance toward a different modality by saying "see it didn't work" and go back to the way they have always done things. Your unit seems to have all the right tools except for the doctors. Time to start addressing this with their Peer Review group and ask for an internal audit if the mortality rate is really that high or if you have concerns about the care of a patient. You can also get the RTs involved hopefully and talk to their medical director. If their medical director is one of these reluctant docs or if the RTs also have the same attitude about not wanting to do something different, then the unit will continue to have a very high mortality rate.

Advanced Practice Columnist / Guide · Sep 21, 2013

Rescue therapies should be used early. They won't work if you lose the window. Typically, a patient who is refractory on ARSnet settings should be considered for rescue therapies within 24 hours including ECMO. However, not every facility can and should offer ECMO. It's a very complicated modality that only centers with experienced physicians and nursing staff should use it. A referral to a center who can cannulate for ECMO is required.

HLS2010 · Sep 23, 2013

our unit uses lung-protective ventilation aiming for a max of 6ml/kg tidal volumes on all patients unless contraindicated. we also use a mode of ventilation called APRV (airway pressure release ventilation) and since it's implementation and a greater awareness and knowledge we have reduced our need to prone or oscillate patients. we have good links to larger hospitals who provide ECMO as recent research has shown that this is preferable over oscillation.

Advanced Practice Columnist / Guide · Sep 24, 2013

our unit uses lung-protective ventilation aiming for a max of 6ml/kg tidal volumes on all patients unless contraindicated. we also use a mode of ventilation called APRV (airway pressure release ventilation) and since it's implementation and a greater awareness and knowledge we have reduced our need to prone or oscillate patients. we have good links to larger hospitals who provide ECMO as recent research has shown that this is preferable over oscillation.

Yes, there are studies on APRV use in ARDS and it is an alternative to ARDSnet. It has the benefit of allowing spontaneous breaths, thus, minimizing the need for deep sedation (and paralytics). It appears to be well tolerated despite the high PEEP levels. We've used it rarely despite RT's advocating for it (mainly because our intensivists are pro ARDSnet and we are a designated ARDS network member). It seems to work best in obese patients who needs more recruitment. As with all the other modalities, patient profile and selection seem to play a role on who will benefit.

detroitdano · Sep 25, 2013

I have never seen anyone proned a day in my life. We used the heck out of APRV and if that failed HFOV. I can't give you numbers but I have personally seen many people who looked like they'd never make it come back around with APRV. We rarely used HFOV but the few I have seen it used on also survived to at least get out of the ICU. For long-term mortality though, who knows.

beckster_01, BSN, RN · Sep 26, 2013

Lucky this thread is here because I came to AN this morning to ask a question about this topic. What is the ideal time frame to start RFOV? My example, a recent patient of mine developed ARDS post cardiac arrest while on Arctic Sun. At 2100 PaO2= 140, 2200 SpO2= 85, and by 0000 his SpO2 was 70 with correlating ABGs, we had increased his PEEP from 10 to 24 with absolutely no effect, Flolan at 100. Around 0200 I had mentioned an oscillator/pronation to RT and the MD, but they thought it was too late in the game, and that pronating is "old school." His prognosis was dim in the first place as he coded for over 30 minutes, had a pH if 6.8, unresponsive to 6 amps of bicarbonate, and was on 100mcg/kg of levo and maxed on vaso. But I would really like to know how this would've gone down in a hospital that uses alternate therapies more frequently. I have not seen an adult on an oscillator yet (although I heard they used them a lot during the swine flu outbreak before my time), and I have only seen one patient proned, who was a young OD.

TraumaSurfer · Sep 27, 2013

our unit uses lung-protective ventilation aiming for a max of 6ml/kg tidal volumes on all patients unless contraindicated. we also use a mode of ventilation called APRV (airway pressure release ventilation) and since it's implementation and a greater awareness and knowledge we have reduced our need to prone or oscillate patients. we have good links to larger hospitals who provide ECMO as recent research has shown that this is preferable over oscillation.

I am going to quote Juan for the 6 ml/kg comment.

80
Low tidal volume ventilation takes into account plateau pressures as an indicator of the risk of volutrauma. The goal is to rest the lung by delivering no more than 6 cc/kg of tidal volume based on the patient's predicted body weight (not actual body weight). High PEEP is encouraged and hypercapnia is permitted as long as the pH does not drop below 7.25 to 7.30.
This mode of ventilation is uncomfortable for the patient because you're forcing shallow and fast breaths on a patient whose instinct is to deep breathe. Thus, patients need to be adequately sedated and paralysis may be indicated in cases where ventilator dys-synchrony continues despite sedatives.

Most hospitals now follow ARDsnet and start with at least 8 ml/kg and titrate to plateau pressure. A knee jerk blanket protocol does not work for all and should not be used on all. The 6 ml/kg was popular 15 years ago but the research over the past 10 years has shown it to be less effective. Today, everyone should be documenting plateau pressure on every patient and not just PIP which without an understanding of plateau pressure it is just a "call to suction" number rather than a diagnostic tool.

APRV has been around for a couple of decades but to many RNs and MDs are afraid to venture from the SIMV and paralytic mindset.

Modern ventilators along with physical and diagnostic assessment have the ability to give vital data to prevent lung injury. Unfortunately few use something as simple as the wave forms. Most just document the few number their flow sheet require and miss the signs of progression into something more severe. Many also don't document the gradients or take note of the PaO2/FiO2 ratio. Most probably are not aware of the newer definitions for ARDS which changes to provide better awareness and care.

Also, the number of actual ECMO cases are rather small around the world including the UK and the USA. The same size of the UK studies are also small.

Most of the data Juan used came from:

Extracorporeal membrane oxygenation (ECMO) in Patients with ARDS

It also states

ECMO has not clearly been demonstrated to improve outcome compared to standard of care management of adult ARDS,

Those hospitals which jump the gun to ECMO instead of HFOV, APRV, NO or Flolan may have another motive which does not necessarily serve for the interest of the patient.

Another issue is getting the patient to an ECMO center which are few and far between. Some states do not have a center which does adults. Unless a center can send a team and set up for mobile ECMO, the drive real fast bagging the patient in a poorly equipped ambulance is not feasible which unfortunately happens too often. These patients are usually diverted enroute midway to a tiny hospital to die in the ER.

A list of ECMO centers:

http://www.elso.med.umich.edu/Member.asp

More information

Home - Extracorporeal Life Support Organization

detroitdano · Sep 27, 2013

Lucky this thread is here because I came to AN this morning to ask a question about this topic. What is the ideal time frame to start RFOV? My example, a recent patient of mine developed ARDS post cardiac arrest while on Arctic Sun. At 2100 PaO2= 140, 2200 SpO2= 85, and by 0000 his SpO2 was 70 with correlating ABGs, we had increased his PEEP from 10 to 24 with absolutely no effect, Flolan at 100. Around 0200 I had mentioned an oscillator/pronation to RT and the MD, but they thought it was too late in the game, and that pronating is "old school." His prognosis was dim in the first place as he coded for over 30 minutes, had a pH if 6.8, unresponsive to 6 amps of bicarbonate, and was on 100mcg/kg of levo and maxed on vaso. But I would really like to know how this would've gone down in a hospital that uses alternate therapies more frequently. I have not seen an adult on an oscillator yet (although I heard they used them a lot during the swine flu outbreak before my time), and I have only seen one patient proned, who was a young OD.

Someone that sick is not meant for APRV. If his sole issue was arrest, then he didn't really have a direct lung insult. He was probably poorly oxygenating because of a bunk heart. I'm assuming things didn't end well for the poor fella.

We used the heck out of APRV during the H1N1 outbreak. Some people are just too far gone and even APRV is not a measure that will save them. Medicine can only do so much.