ARDS and oscillators

[Bostonredsox]

new article last issue NEJM

high frequency oscillation in early acute respiratory distress syndrome

www.nejm.org/doi/full/10.1056/NEJMoa1215554

Thoughts? A bit discouraging to me. We do not have oscillators at my shop so I am constantly shipping my ARDS patients to Duke, UNC or UVA for HFOV. Perhaps I shouldn't be...

---

Members don't see this ad.

 

[Hernandez]

http://www.nejm.org/doi/full/10.1056/NEJMoa1215554?query=featured_home#t=article
http://www.nejm.org/doi/full/10.1056/NEJMoa1215716?query=featured_home#t=article
http://www.nejm.org/doi/full/10.1056/NEJMe1300103?query=featured_home

I'm still reading through the 2 (both OSCILLATE and OSCAR were published) articles and editorial that were published, that being said, this shows that it definitely should not be used routinely, but is there still a role in certain patients? I'm surprised Neil MacIntyre hasn't had an editorial yet. Only interesting point I see so far is oscillate had a very tight vent protocal, while Oscar did not, but oscillate preferred PCV with adherence to the peep titration tables (which ARMA only suggested to be used it didn't mandate) and Oscar simply listed conventional vent as local conventional beat practices.

It's a shame.....I love the washing machine sound it makes.....

 

[Bostonredsox]

Lol. It is a cool sound. Yeah what I am understanding is it should not be an automatic " he's progressed to ARDS we need to ship to teritiary care for HFOV". I assume, similar to the new IABP articles, although the net population did not improve, there were subgroups which did. Just need to be selective in who is placed in the washing machine

 

[Hernandez]

Lol. It is a cool sound. Yeah what I am understanding is it should not be an automatic " he's progressed to ARDS we need to ship to teritiary care for HFOV". I assume, similar to the new IABP articles, although the net population did not improve, there were subgroups which did. Just need to be selective in who is placed in the washing machine

Also, OSCILLATE excluded people fatter than 1kg/cm height......that's still lots of fat they could jiggle.

 

[VJWDO]

Here at Duke we oscillate alot. Dr. MacIntyre is kind of apathetic to the whole thing. In our last lecture by him he said his money was on the advancement of ECMO into easier to place catheters and smaller units. Eventually he thinks vents are going to go away completely. Pretty interesting thought.

 

[Bostonredsox]

Here at Duke we oscillate alot. Dr. MacIntyre is kind of apathetic to the whole thing. In our last lecture by him he said his money was on the advancement of ECMO into easier to place catheters and smaller units. Eventually he thinks vents are going to go away completely. Pretty interesting thought.

I ship alot of my ARDS down to you from across the border. Went over the paper with my attending, she seems to agree. She is from UNC and said her attendings were always under the impression the reason that the HFOV numbers were so good was the control patients in the studies got hosed with terrible vent protocols. Now that the controls are getting Low TV/High PEEP, the numbers are not so favorable, if at all. Makes sense to me.

 

[UltimateDO]

Currently putting together a protocol re: our success with ECMO in Iraq and Afghanistan for ARDS secondary to IED blast barotrauma. From the small n of my personal soldiers that I ended up flying out on ECMO, I am sold. Granted it is not like the all-comers that make it into the unit here stateside as to etiology, I would have bet a large amount of money that at least one of my guys would not have made it and all four out of my unit did. We should be able to get an n of 40-50 and at least paint a semi-decent picture, at least on the trauma side.

 

[PlutoBoy]

New data on HFOV

The use of HFOV had no significant effect on 30-day mortality in patients undergoing mechanical ventilation for ARDS.

http://www.nejm.org/doi/full/10.1056/NEJMoa1215716

Edit: Nevermind, already posted.

 

[Bostonredsox]

I just got the 2/28 issue of NEJM, has two new HFOV articles in it, the one you mentioned above and the N.D. Ferguson led trial, which I think may be OSCILLATE. Reading over them tonight.

 

[Hernandez]

I mentioned both already

 

[Bostonredsox]

I mentioned both already

yes I have realised they were the same now that I have read them. I dont have a subscription to SCCM or CHEST, too expensive as a resident, just NEJM, so I only read things like these earlier than their journal when someone posts an open link to them.

 

[Bostonredsox]

THis is going to seem ******ed I know, but can one of you guys explain how you perform the lung recruitment manuever they talk about in OSCILLATE? 40cm H20 for 40 sec at the bginning of ventilation to help with recruitment. Is this something you can set a standard vent to do for you?

 

[Hernandez]

Read the supplemental materials, they're methods are very detailed. There are many different types of recruitment maneuvers but they crank peep to 40 then throw on PSV/CPAP with psv of 0.

 

[McLovin]

Here at Duke we oscillate alot. Dr. MacIntyre is kind of apathetic to the whole thing. In our last lecture by him he said his money was on the advancement of ECMO into easier to place catheters and smaller units. Eventually he thinks vents are going to go away completely. Pretty interesting thought.

At the opposite end of the spectrum you have John Marini, who believes you can gix anything with enough vent adjustments, and that eventually everyone - including you and I - will be on a ventilator.

 

[jdh71]

At the opposite end of the spectrum you have John Marini, who believes you can gix anything with enough vent adjustments, and that eventually everyone - including you and I - will be on a ventilator.

Sure. But Marini isn't a big oscillator advocate.