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[jdh71]

Crap on your least favorite mode of mechanical ventilation!

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[jdh71]

APRV:

Things to remember about it!
1.APRV is a “pressure” mode of ventilation
–Are you setting a flow or a volume??? Well then . . . ???

2. You cannot control volume because patients control the flow
–What is the only variable definitely shown to decrease mortality in ARDS??

3. There is no way to know a Pplat or a Ptp

4. No data to support
–Better outcomes
–Or utility as a “salvage” mode

My then opinion!
1. It’s a crap mode of ventilation in general and wrong to use in ARDS and I promise I “understand it”
–There isn’t a secret club

2. It’s an “enabler”
–Allows us to feel ok about pressures and tolerances that we never would on conventional LTVV
–We happily violate the data (ARDSnet) to simply improve oxygenation

3. We should not be using it in cases of ARDS

 

[tartesos]

APRV:

Things to remember about it!
1.APRV is a “pressure” mode of ventilation
–Are you setting a flow or a volume??? Well then . . . ???

2. You cannot control volume because patients control the flow
–What is the only variable definitely shown to decrease mortality in ARDS??

3. There is no way to know a Pplat or a Ptp

4. No data to support
–Better outcomes
–Or utility as a “salvage” mode

My then opinion!
1. It’s a crap mode of ventilation in general and wrong to use in ARDS and I promise I “understand it”
–There isn’t a secret club

2. It’s an “enabler”
–Allows us to feel ok about pressures and tolerances that we never would on conventional LTVV
–We happily violate the data (ARDSnet) to simply improve oxygenation

3. We should not be using it in cases of ARDS

Some data/people say the same thing about pressure support on ards, volumes being somewhat less predictable can lead to more barotrauma, but not in my experience so far .

I agree with your points and agree it sucks balls.


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[tartesos]

Let's put simv out here. Just because.


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[jdh71]

Let's put simv out here. Just because.


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High five. Garbage mode.

 

[CCM-MD]

Worst mode of ventilation: negative pressure ventilation.

 

[tartesos]

Worst mode of ventilation: negative pressure ventilation.

Worked at the time though...


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[jdh71]

Some data/people say the same thing about pressure support on ards, volumes being somewhat less predictable can lead to more barotrauma, but not in my experience so far .

I agree with your points and agree it sucks balls.


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I don't use pressure control in ARDS either. Have synchrony issues? Paralyze them. That at least has some data.

 

[Mad Jack]

APRV:

Things to remember about it!
1.APRV is a “pressure” mode of ventilation
–Are you setting a flow or a volume??? Well then . . . ???

2. You cannot control volume because patients control the flow
–What is the only variable definitely shown to decrease mortality in ARDS??

3. There is no way to know a Pplat or a Ptp

4. No data to support
–Better outcomes
–Or utility as a “salvage” mode

My then opinion!
1. It’s a crap mode of ventilation in general and wrong to use in ARDS and I promise I “understand it”
–There isn’t a secret club

2. It’s an “enabler”
–Allows us to feel ok about pressures and tolerances that we never would on conventional LTVV
–We happily violate the data (ARDSnet) to simply improve oxygenation

3. We should not be using it in cases of ARDS

APRV works great in post-surgical patients that got a billion liters of fluid and you're trying to keep MAP up but Ppeak down. Other than that ARDSnet is superior, though there have been a couple of times we had patients that just couldn't tolerate ARDSnet but did fine on APRV (we're talking a number of patients you can count on one hand).

 

[Mad Jack]

Let's put simv out here. Just because.


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SIMV is the second worst mode, with the only thing that is worse being IMV.

 

[jdh71]

APRV works great in post-surgical patients that got a billion liters of fluid and you're trying to keep MAP up but Ppeak down. Other than that ARDSnet is superior, though there have been a couple of times we had patients that just couldn't tolerate ARDSnet but did fine on APRV (we're talking a number of patients you can count on one hand).

Surgeons. Lol.

APRV and all kind of other modes work post op. MAPs are neat. But meaningless end points.

Everyone has an anecdote of APRV in ARDS. The bottom line is that it violates all the principles that reasonably solid data has shown improves survival for better sats. It's wrong. And you are wrong if you are using it.

 

[Mad Jack]

Surgeons. Lol.

APRV and all kind of other modes work post op. MAPs are neat. But meaningless end points.

Everyone has an anecdote of APRV in ARDS. The bottom line is that it violates all the principles that reasonably solid data has shown improves survival for better sats. It's wrong. And you are wrong if you are using it.

I'm just saying, we've had a few patients over the years that were literally bordering on death- sats 78% or lower- on ARDSnet that we'd try every mode on just as a last resort. Sometimes the mode that would work qould be APRV. We were ARDSnet all the way, and would try to switch patients back daily to see if they'd tolerate it.

 

[jdh71]

I'm just saying, we've had a few patients over the years that were literally bordering on death- sats 78% or lower- on ARDSnet that we'd try every mode on just as a last resort. Sometimes the mode that would work qould be APRV. We were ARDSnet all the way, and would try to switch patients back daily to see if they'd tolerate it.

Show me the data that oxygen saturation correlates with survival.

Sats of 78% are not incompatible with life. They are lower than we like but it's not a reason to abandon ARDSnet. If you have not paralyzed, proned, and or added inhaled vasodilators (the first two have data, the last allows you to remain in a mode where you control volume) then it was incorrect to try something lacking any data so you can feel better about sats which have no survival benefit data.

 

[Mad Jack]

Show me the data that oxygen saturation correlates with survival.

Sats of 78% are not incompatible with life. They are lower than we like but it's not a reason to abandon ARDSnet. If you have not paralyzed, proned, and or added inhaled vasodilators (the first two have data, the last allows you to remain in a mode where you control volume) then it was incorrect to try something lacking any data so you can feel better about sats which have no survival benefit data.

No one has ever studied sats that low versus the conventionally accepted lower limit of normal. ARDSnet pushes for a sat of 88-95%. If you can't maintain that sat, you're off protocol and no longer following the evidence, and just as off the research as anyone else. The research I've read on StO2 shows that once you drop below 70-75% oxygen saturation at the tissue level, tissue damage begins to occur, but StO2 is a new tool that is yet to be fully explored in large multicenter trials, so we'll see how it bears out. I prefer 85% at a minimum if given the option, but I'm just a lowly RT/MS4.

 

[jdh71]

No one has ever studied sats that low versus the conventionally accepted lower limit of normal. ARDSnet pushes for a sat of 88-95%. If you can't maintain that sat, you're off protocol and no longer following the evidence, and just as off the research as anyone else. The research I've read on StO2 shows that once you drop below 70-75% oxygen saturation at the tissue level, tissue damage begins to occur, but StO2 is a new tool that is yet to be fully explored in large multicenter trials, so we'll see how it bears out. I prefer 85% at a minimum if given the option, but I'm just a lowly RT/MS4.

There is no data those sats even in ARDS show survival benefit. I know their recommendations because I'm a pulmonary and critical care doc who does this kind of thing regularly.

Show me the data. If you have it. I will stand corrected.

But its all largely irrelevant to my points above which stand irrefuted. Even with low sats APRV is not even remotely the next step in management of severe ARDS.

 

[Mad Jack]

There is no data those sats even in ARDS show survival benefit. I know their recommendations because I'm a pulmonary and critical care doc who does this kind of thing regularly.

Show me the data. If you have it. I will stand correctly.

But its all largely irrelevant to my points above which stand irrefuted. Even with low sats APRV is not even remotely the next step in management of severe ARDS.

I was saying it's basically only worth using in patients who are tanking and not otherwise doing well. If they're at the limits of ARDSnet, it's worth trying. ARDSnet is hands down the gold standard for patients that fall within its parameters.

In non-ARDS patients (post-surg) we had pretty good results, as their big issue was fluid overload and dyssynchrony, in that setting it was great.

 

[jdh71]

I was saying it's basically only worth using in patients who are tanking and not otherwise doing well. If they're at the limits of ARDSnet, it's worth trying. ARDSnet is hands down the gold standard for patients that fall within its parameters.

In non-ARDS patients (post-surg) we had pretty good results, as their big issue was fluid overload and dyssynchrony, in that setting it was great.

I see zero reason to even use it then.

 

[Mad Jack]

I see zero reason to even use it then.

It required less sedation and led to faster turnover in our post-op pulmonary edema patients. All that matters in the SICU is bed turnover, so it's what we used.

 

[jdh71]

It required less sedation and led to faster turnover in our post-op pulmonary edema patients. All that matters in the SICU is bed turnover, so it's what we used.

I will admit my cynical bias. But I believe nothing about the vents in an SICU unless I see it myself.

 

[Hamhock]

In non-ARDS patients (post-surg) we had pretty good results (with APRV), as their big issue was fluid overload and dyssynchrony, in that setting it was great.

This was the line from the RTs, neurosurgeons, and some of the trauma surgeons in a SICU I started working a some time ago. Within six months, using validated ventilator management (and some improved fluid management ), there as now been near cessation of calls for APRV.

With careful vent and medical management, I can get almost any MAP or ventilator outcome with ACVC that someone says APRV is needed for...I can guarantee it if you let me use ACPC (but then I have to stay at the bedside to make sure the patient's volumes don't go all over the place as compliance changes).

I agree with jdh here: APRV is unnecessary (and likely harmful) crap that no self-respecting critical care doc needs to use.

HH

 

[Hamhock]

Worst mode of ventilation: negative pressure ventilation.

Is it really the worst?
I've been wondering about that recently.
I wonder if it is actually the best.
HH

 

[sluggs]

None of you believe the data about the need to control plats in ARDS? There is now evidence that controlling for plats < 30 is at least as important, if not more important than just TV. APRV allows exquisite control of plats. There is no data to show APRV inferior to AC/VC and in fact it has only been data-studied significantly as a late rescue mode, not an early recruitment mode. Ac/VC is often poorly tolerated an even with 6cc/kg has poor outcomes in ARDS.

 

[tartesos]

None of you believe the data about the need to control plats in ARDS? There is now evidence that controlling for plats < 30 is at least as important, if not more important than just TV. APRV allows exquisite control of plats. There is no data to show APRV inferior to AC/VC and in fact it has only been data-studied significantly as a late rescue mode, not an early recruitment mode. Ac/VC is often poorly tolerated an even with 6cc/kg has poor outcomes in ARDS.

Mostly everything has poor outcomes in ARDS....

 

[jdh71]

None of you believe the data about the need to control plats in ARDS? There is now evidence that controlling for plats < 30 is at least as important, if not more important than just TV. APRV allows exquisite control of plats. There is no data to show APRV inferior to AC/VC and in fact it has only been data-studied significantly as a late rescue mode, not an early recruitment mode. Ac/VC is often poorly tolerated an even with 6cc/kg has poor outcomes in ARDS.

Tell me how to determine a safe Pplat (never mind accurate Ptp) in APRV if you are so worried about it in the spontaneously breathing patient. If you are going to paralyze them then why are you using APRV??

Again. If you are having problems with conventional or as I like to say the modes scientifically consistent with survival in ARDS and you haven't paralyzed, proned, or added inhaled vasodilators, your problem isn't an APRV deficiency. Your problem is a physician who gives zero ****s about the evidence showing better outcomes for patients in favor of higher sats.

 

[Mad Jack]

Tell me how to determine a safe Pplat (never mind accurate Ptp) in APRV if you are so worried about it in the spontaneously breathing patient. If you are going to paralyze them then why are you using APRV??

Again. If you are having problems with conventional or as I like to say the modes scientifically consistent with survival in ARDS and you haven't paralyzed, proned, or added inhaled vasodilators, your problem isn't an APRV deficiency. Your problem is a physician who gives zero ****s about the evidence showing better outcomes for patients in favor of higher sats.

I believe in proning, it's magic in many patients.

 

[deleted171991]

I don't use APRV (we used it in residency many years ago), but I can't understand why it has a bad rap.

1. It's spontaneous ventilation. I don't think that could produce more damage than controlled PPV.
2. It's mostly high CPAP (basically IRV BiPAP). Again, high PEEP is recommended even in the ARDSnet recipe, to decrease barotrauma.
3. As long as Pplat is less than the ARDSnet recommendations, why would it be worse than controlled ventilation on ARDSnet protocol, especially when the latter is obviously not working in that particular patient?
4. I am anesthesiologist. Hence I don't believe in recipes. I think there are different patient populations who have different physiologies and respond differently to various treatments. Hence we should never aim for one size fits all in medicine, but we should base our protocols on trial and error.

 

[Mad Jack]

I don't use APRV (we used it in residency many years ago), but I can't understand why it has a bad rap.

1. It's spontaneous ventilation. I don't think that could produce more damage than controlled PPV.
2. It's mostly high CPAP (basically IRV BiPAP). Again, high PEEP is recommended even in the ARDSnet recipe, to decrease barotrauma.
3. As long as Pplat is less than the ARDSnet recommendations, why would it be worse than controlled ventilation on ARDSnet protocol, especially when the latter is obviously not working in that particular patient?
4. I am anesthesiologist. Hence I don't believe in recipes. I think there are different patient populations who have different physiologies and respond differently to various treatments. Hence we should never aim for one size fits all in medicine, but we should base our protocols on trial and error.

ARDS also isn't a singular disease, and I feel that while the average patient with ARDS may benefit from X, Y, or Z, not every patient will because it is not one disease process with one singular etiology.

 

[deleted171991]

I believe in proning, it's magic in many patients.

I agree. This shows that what we really need to do for our ARDS patients is:
1. Optimize V/Q mismatch, so we can expose the lungs to the lowest possible inspired O2 and pressures, with the lowest hemodynamic impact. Proning can really do that, and its effects can be jaw-dropping.
2. Wait.

Medicus curat, Natura sanat.

 

[sluggs]

APRV:

Things to remember about it!
1.APRV is a “pressure” mode of ventilation
–Are you setting a flow or a volume??? Well then . . . ???

2. You cannot control volume because patients control the flow
–What is the only variable definitely shown to decrease mortality in ARDS??

3. There is no way to know a Pplat or a Ptp

4. No data to support
–Better outcomes
–Or utility as a “salvage” mode

My then opinion!
1. It’s a crap mode of ventilation in general and wrong to use in ARDS and I promise I “understand it”
–There isn’t a secret club

2. It’s an “enabler”
–Allows us to feel ok about pressures and tolerances that we never would on conventional LTVV
–We happily violate the data (ARDSnet) to simply improve oxygenation

3. We should not be using it in cases of ARDS

I think that the above is an overly-simplistic view of ARDS, ARDSNET, VILI and APRV.

1. Volume control is not a very good physiologic mode of ventilation and can cause dis-synchrony and high plats. When volume is your fixed variable, pressure becomes a variable variable and you can have plateau pressures that are high even a 6cc/kg PBW, especially if you need high peep. In the "injured lung" the disease is distributed heterogeneously and you will also have very excessive high "micro-plateau/trans pulmonary pressure gradients" in the diseased areas of the lung. This is injurious, no doubt. Of course you can paralyze and prone, but this should be an intervention of last resort (albeit early last resort).
2. There is now some data that high plateau pressures are more injurious than high TVs.
3. The studied group in ARDSNET did not have great outcomes, they just did better than a group ventilated at 12 cc/KG PBW.
4. APRV is not shown superior to low TV strategy, when studied as a rescue mode-- no data studying it as and early intervention.
5. You can control plateau pressures by lowering your pHIGH in APRV.
6. The obvious goal to prevent VILI is early, safe liberation from the vent-- you can't get VILI if you are not on the vent!!

I use the following approach for ARDS/ALI:

If the P/F is > 150, sedate to Rass -1-- -2; keep them recruited with peep; let them breathe in psupp if they can take it, otherwise some assist mode with daily awake and breathe trials.

If P/F < 150, early rescue with diuresis, high PEEP to recruit, including APRV for 12-18 hours. If the P/F rescues (goes above 150) wean in APRV. If it does not "rescue" within 18 hours; start paralyzing and proning.

 

[jdh71]

I think that the above is an overly-simplistic view of ARDS, ARDSNET, VILI and APRV.

1. Volume control is not a very good physiologic mode of ventilation and can cause dis-synchrony and high plats. When volume is your fixed variable, pressure becomes a variable variable and you can have plateau pressures that are high even a 6cc/kg PBW, especially if you need high peep. In the "injured lung" the disease is distributed heterogeneously and you will also have very excessive high "micro-plateau/trans pulmonary pressure gradients" in the diseased areas of the lung. This is injurious, no doubt. Of course you can paralyze and prone, but this should be an intervention of last resort (albeit early last resort).
2. There is now some data that high plateau pressures are more injurious than high TVs.
3. The studied group in ARDSNET did not have great outcomes, they just did better than a group ventilated at 12 cc/KG PBW.
4. APRV is not shown superior to low TV strategy, when studied as a rescue mode-- no data studying it as and early intervention.
5. You can control plateau pressures by lowering your pHIGH in APRV.
6. The obvious goal to prevent VILI is early, safe liberation from the vent-- you can't get VILI if you are not on the vent!!

I use the following approach for ARDS/ALI:

If the P/F is > 150, sedate to Rass -1-- -2; keep them recruited with peep; let them breathe in psupp if they can take it, otherwise some assist mode with daily awake and breathe trials.

If P/F < 150, early rescue with diuresis, high PEEP to recruit, including APRV for 12-18 hours. If the P/F rescues (goes above 150) wean in APRV. If it does not "rescue" within 18 hours; start paralyzing and proning.

However you need to rationalize crappy care bro. It's not between you and me.

 

[Laryngophed]

I don't use APRV (we used it in residency many years ago), but I can't understand why it has a bad rap.

1. It's spontaneous ventilation. I don't think that could produce more damage than controlled PPV.
2. It's mostly high CPAP (basically IRV BiPAP). Again, high PEEP is recommended even in the ARDSnet recipe, to decrease barotrauma.
3. As long as Pplat is less than the ARDSnet recommendations, why would it be worse than controlled ventilation on ARDSnet protocol, especially when the latter is obviously not working in that particular patient?
4. I am anesthesiologist. Hence I don't believe in recipes. I think there are different patient populations who have different physiologies and respond differently to various treatments. Hence we should never aim for one size fits all in medicine, but we should base our protocols on trial and error.

I'm liking this so hard.

I work in a place where one trauma surgeon refers to APRV as "PEEP for people afraid of PEEP" and one who uses it more regularly. At the point you are considering APRV, you've tried the conventional stuff, and sometimes you just do what you can to get a patient through a valley to see another day.

And I think after nearly finishing residency, I've proned more people than most any other physician, and it is great to just say "do it" in the ICU, it's another to live with the care that is required for a prone patient. And logistically that can be a nightmare on a busy unit. Yes, it is the right move by the data, but the places that acquired the data had all of the right equipment and seemingly endless amounts of nursing staff to care for a proned patient.

 

[bigtuna]

1. It's spontaneous ventilation. I don't think that could produce more damage than controlled PPV.

This is controversial to say the least and probably not true.

 

[Laryngophed]

This is controversial to say the least and probably not true.

Well, the first part is less controversial. The second part I can see.

 

[deleted171991]

This is controversial to say the least and probably not true.

One could argue that the Phigh can cause barotrauma (although I don't expect the plateau pressure to be higher than in the ARDSnet model), but I doubt that the patient's own negative pressure ventilation would ever produce more damage to the alveoli than PPV. Why? Because the positive-pressure ventilator does not have pulmonary stretch receptors. So, as long as it works, I don't see why APRV would be worse than some controlled ventilation method. (Again, I don't use it.)

I completely agree with what @Physio Doc 2 Be mentioned regarding people being afraid of using PEEP. I have seen it even with the ARDSnet protocol, or even just for good old cardiogenic pulmonary edema. Anyway, I am a big believer in "if it works, don't fix it" so, if one's patients do well on APRV, more power to them. Every patient's physiology is different (as in we don't really understand what goes on in their bodies at a very detailed level), so I prefer to go by trial and error until I find what works for that particular patient. I don't believe in the same protocol for everybody, especially when it's obvious that it's not working in a particular patient, and the more tools we have the higher the chances one may work.

 

[jdh71]

I'm liking this so hard.

I work in a place where one trauma surgeon refers to APRV as "PEEP for people afraid of PEEP" and one who uses it more regularly. At the point you are considering APRV, you've tried the conventional stuff, and sometimes you just do what you can to get a patient through a valley to see another day.

And I think after nearly finishing residency, I've proned more people than most any other physician, and it is great to just say "do it" in the ICU, it's another to live with the care that is required for a prone patient. And logistically that can be a nightmare on a busy unit. Yes, it is the right move by the data, but the places that acquired the data had all of the right equipment and seemingly endless amounts of nursing staff to care for a proned patient.

Who is afraid of PEEP?

What does the data say about PEEP (and recruitments) in ARDS?

 

[engineeredout]

Is anyone measuring transpleural PEEP with esophageal balloons to titrate their PEEP in your ARDS patients? Done it on a few patients and anecdotally seem to have good results - up titration of peep beyond what we would normally do, but improved oxygenation, improved CXR appearance. Most of these patients still die of course so hard to see from my limited cohort if there are any patient centered outcomes, but conceptually makes sense.

 

[leviathan]

More recent evidence suggests it's the driving pressure not the Pplat or the PEEP or the tidal volume that actually matters. Although the ART trial seems to have made things more confusing.

 

[Hamhock]

Is anyone measuring transpleural PEEP with esophageal balloons to titrate their PEEP in your ARDS patients? Done it on a few patients and anecdotally seem to have good results - up titration of peep beyond what we would normally do, but improved oxygenation, improved CXR appearance. Most of these patients still die of course so hard to see from my limited cohort if there are any patient centered outcomes, but conceptually makes sense.

In one of the units I work in, we have started doing this...and I hope we do it more often (when I am on, "we are"). I have found early placement (but only when heavy sedation or NMB; so not all patients are candidates and I am not encouraging deep sedation or NMB) leads to early higher PEEPs, better oxygenation, and better CXR...especially in the obese. This early application makes sense to me when I consider the natural history and pathophysiology of ARDS.

The more I use the balloon, the crazier it seems to me when I see (1) low PEEP (esp on obese or wet patients) and (2) arbitrarily set starting PEEP.

HH

 

[bigtuna]

One could argue that the Phigh can cause barotrauma (although I don't expect the plateau pressure to be higher than in the ARDSnet model), but I doubt that the patient's own negative pressure ventilation would ever produce more damage to the alveoli than PPV. Why? Because the positive-pressure ventilator does not have pulmonary stretch receptors. So, as long as it works, I don't see why APRV would be worse than some controlled ventilation method. (Again, I don't use it.)

I completely agree with what @Physio Doc 2 Be mentioned regarding people being afraid of using PEEP. I have seen it even with the ARDSnet protocol, or even just for good old cardiogenic pulmonary edema. Anyway, I am a big believer in "if it works, don't fix it" so, if one's patients do well on APRV, more power to them. Every patient's physiology is different (as in we don't really understand what goes on in their bodies at a very detailed level), so I prefer to go by trial and error until I find what works for that particular patient. I don't believe in the same protocol for everybody, especially when it's obvious that it's not working in a particular patient, and the more tools we have the higher the chances one may work.

I wasn't arguing for or against APRV though I also don't use it frequently. I was just pointing out that it is pretty well accepted that VILI can occur with spontaneous modes of ventilation. If you look on pubmed there are lots of publications addressing this. I work in a regional ECMO center and anecdotally we have seen many pts on VV ECMO for severe ARDS that have very high respiratory drive that we feel have developed VILI on spontaneous modes of ventilation (including APRV).

Using the driving pressure to set initial PEEP seems to be an effective strategy and leads to using a higher initial PEEP than what would have traditionally been chosen.

 

[Mad Jack]

I love this subforum, it's such a ****ing nerd fight sometimes.

 

[deleted171991]

I love this subforum, it's such a ****ing nerd fight sometimes.

That's one of the reasons I love critical care. It attracts a lot of smart people.

 

[jdh71]

Is anyone measuring transpleural PEEP with esophageal balloons to titrate their PEEP in your ARDS patients? Done it on a few patients and anecdotally seem to have good results - up titration of peep beyond what we would normally do, but improved oxygenation, improved CXR appearance. Most of these patients still die of course so hard to see from my limited cohort if there are any patient centered outcomes, but conceptually makes sense.

I use esophageal manometry to find out Ptp for setting PEEP all the time, especially in the obese.

When you say "most" will die what are you saying? More than half of your patients who get ARDS are dying from ARDS?

 

[engineeredout]

I use esophageal manometry to find out Ptp for setting PEEP all the time, especially in the obese.

When you say "most" will die what are you saying? More than half of your patients who get ARDS are dying from ARDS?

We don't use the balloon monitoring much yet, largely because RTs/nursing are unfamiliar with it, thus provide tremendous amounts of flak (the all encompassing "I'm not comfortable with...") and citing lack of specifically defined 40 page policies. So the patients that we actually end up doing this in are usually in severe ARDS, failing everything else, already circling the drain of refractory hypoxia and multi organ systems failure, so yes most of these patients end up dying. Didn't mean to imply all our ARDS patients as a whole are dying.

 

[Mad Jack]

That's one of the reasons I love critical care. It attracts a lot of smart people.

And a lot of stubborn ones as well

 

[drmwvr]

Worst mode of ventilation: negative pressure ventilation.

Used in the OR every single day...