when can you stop calling ards...ards

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VentdependenT

VentdependenT

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ARDS is the diagnosis de jour isnt it? well at least here it is.

So many MICU pts have crappy BASELINE pao2/fio2 dont they.

Ahh now the 300-400 tv RR 24 settings are rampant. air hungry pts abound, begging and SUCKING on the vent for more. dyssynchrony is pervasive.

When switched to ACPC Pi of 15 the patient pulls TV of 550-600, the RR drops from 25 to 16. The tachycardia is gone...BUT THE PT CAME IN 2D ago with ARDS!!!! KEEP THEM ON THE LOW VT or you arent following protocol!!!!

Look, if the lungs are compliant and the pa02/fio2 is >200 should i really be calling this and treating it as ARDS until the pao2/fio2 is >300?

What are our endpoints? wtf is so wrong with 8cc/kg TV in an improving patient?
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I am gonna take an unorthodox view here, but high tidal volumes per se, aren't the big driving force in lung injury-- IT IS HIGH VOLUMES ON VOLUME CONTROL. It is hitting the lungs with a BIG FORCED VOLUME that is injurious. ARDS NET using volume AC requires you to keep checking plateau pressures, and if your plats are high at 6 cc/kg, you should lower your TV further. If you use pressure control, you can limit your plats, as you can with pressure support or APRV. That is the whole reason that APRV is lung protective, despite the potential for the machine to show a "high volume" when you go from Phigh to Plow.
Take a patient who is intubated for "airway protection". (eg pentobarb coma for refractory seizure). If they are doing fine on Psupp 5/5, but pulling 9 cc/kg pbw, should you let them be, or force them into volume AC, possibly raising the plat pressure.
I believe that all patients, ARDS or not, should be ventilated in a way to limit plats.
I realize this is a dissent view, but I almost never see VILI in patients who I start ventilating like this.
OK... here comes the fire back...
 
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I kind of agree. What is the end point? If lungs are improving and compliance is improving and will tolerate bigger Vt then why not. I hate when people stick with a protocol just because someone else told them to. When was it mandated that we stop being allowed to think and use some common sense?

Vent, I don't have an answer for a ratio cutoff, but I feel like if CXR is improving, PaO2 is improving, and compliance is improving, then why not treat them like more normal lungs.
 
Any doctor that can be replaced by a computer running some kind of algorithm or protocol, should be.

If the patient doesn't need or require the small tidal volumes for pressure reasons, and they seem to be trying to kill themselves on current vent setting, and you'd need to really sedate and paralyze them just to stick with some "protocol", then I think you're an idiot and not a real doctor to continue blindly with some "protocol". This is why we train what we do, to know when to make exceptions.

Gotta engage your brain in these things.
 
VentdependenT said:
It has EVERYTHING to do with airway pressures and atelectasis. damn dude
Click to expand...

It doesn't play that big of a role in plats. I've seen more than a few super morbids in ARDS, it's rare if you actually calculate their ideal weight that 6mL/kg has a plat higher than 30cm. The problem I've seen at many joints is too many CC docs just eyeball it and don't actually run the math.

Atelectasis? Ok....so how do ya'll manage PEEP in an ARDS pt?

So I think my point stands, you have a lot of 5'0" males in ARDS? http://www.ardsnet.org/system/files/pbwtables_2005-02-02_0.pdf
 
I think you are arguing for the sake of arguing.

I think ards at my institution is overcalled and seeing airhungy people on tidal volumes of 400 with them breathing on the vent 30x a minute autopeeping is ridiculous. Once upon a time I thought ards had to do with changes in lung architecture, but now everyone with a ****ty film (oirtable cxr sucks btw) and a pao2 over fio2 of less than 300 gets put on 4-6cc/kg TV.

I look at the overall picture and dont blindly put peeps on such low volumes. I believe 8cc/kg IBW is fine with decent plats unless its obviously Ards. Im sorry, but these big fatties sloched in half at 30degrees with their guts destroying FRC and cranking up their plats is more common than not. But its hard to get elevated plats with baby sized TV unless significant autopeep occurs...because pt is airhungry...then you try blastin em with sedation and paralytics...all this is FINE if IT REALLY IS ARDS. BUT how LONG do you have to keep this up? answer that.

I think CT guidance and compliance at 8cckg/tv in accordance with some measure of EXPECTED oxygenation for that pt GIVEN his/her previous pulmonary issues should guide when we stop, and god forbid, when we start, pushing and maintaining high peeps and 4-6cc/kg TV. The CXR is not sensitive nor specific in all but the most classic and obvious cases.

I handle atelectasis with recruitment then adjusting peep, hopefully just like you do.
 
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TrustMe said:
I kind of agree. What is the end point? If lungs are improving and compliance is improving and will tolerate bigger Vt then why not. I hate when people stick with a protocol just because someone else told them to. When was it mandated that we stop being allowed to think and use some common sense?

Vent, I don't have an answer for a ratio cutoff, but I feel like if CXR is improving, PaO2 is improving, and compliance is improving, then why not treat them like more normal lungs.
Click to expand...

Thank you. I agree with ya.
 
VentdependenT said:
I think you are arguing for the sake of arguing.

I think ards at my institution is overcalled and seeing airhungy people on tidal volumes of 400 with them breathing on the vent 30x a minute autopeeping is ridiculous. Once upon a time I thought ards had to do with changes in lung architecture, but now everyone with a ****ty film (oirtable cxr sucks btw) and a pao2 over fio2 of less than 300 gets put on 4-6cc/kg TV.

I look at the overall picture and dont blindly put peeps on such low volumes. I believe 8cc/kg IBW is fine with decent plats unless its obviously Ards. Im sorry, but these big fatties sloched in half at 30degrees with their guts destroying FRC and cranking up their plats is more common than not. But its hard to get elevated plats with baby sized TV unless significant autopeep occurs...because pt is airhungry...then you try blastin em with sedation and paralytics...all this is FINE if IT REALLY IS ARDS. BUT how LONG do you have to keep this up? answer that.

I handle atelectasis with recruitment then adjusting peep, hopefully just like you do.
Click to expand...

I not being argumentative. I'm just making observations that I've noted other supposidly well CC Docs do commonly. I'm with you, I don't use 6cc/kg on everyone, nor is all pao2/fio2 ratios ARDS. But a) people need to actually measure the pts heights and b) calculate the TV instead of guesstimating it.

Re: fatties. Don't use just the bed incline to achieve 30 degrees, I've always had the nurses put about 5-10 degrees of reverse trendelenburg and then used the head incline for the remainder. Use gravity to help wth the gut fat.

And for pts with a TV of 400ml and a rr of 30, the minute ventilation is only 12 L/minute, if they're auto-peeping on that, their lungs are pretty ****ty. For that to be close to their MVV, they'd have an FEV1 of ~ 300cc, while I know that's kinda a bastardized way of looking at it, the dyschrony is likely the bigger issue than true auto-peep. Remember that you really need a passive exhalation to calculate PEEPi

Since you're calling me argumentative, let me ask this. If the pts compliance is improving, yet they're not stable enough to CPAP or extubate and still requiring such a high respiratory rate.....wouldn't it be possible that someone could infer that there was a persistant elevated dead space fraction that's causing resp issues? And wouldn't persistant dead space issue suggest a continued form of ARDS, perhaps the fibroprolif stage? And how do you know when it's safe to stop using protective strategies? Pull the ARMA trial sub group analysis and you'll find the chart That shows that even with pts with plats 30 with higher tidal volumes compared to low tidal volumes and less than 30, there still was a survival advantage.

AND remember that the ARMA protocal allowed for If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O.
 
Hernandez said:
I not being argumentative. I'm just making observations that I've noted other supposidly well CC Docs do commonly. I'm with you, I don't use 6cc/kg on everyone, nor is all pao2/fio2 ratios ARDS. But a) people need to actually measure the pts heights and b) calculate the TV instead of guesstimating it.

Re: fatties. Don't use just the bed incline to achieve 30 degrees, I've always had the nurses put about 5-10 degrees of reverse trendelenburg and then used the head incline for the remainder. Use gravity to help wth the gut fat.

And for pts with a TV of 400ml and a rr of 30, the minute ventilation is only 12 L/minute, if they're auto-peeping on that, their lungs are pretty ****ty. For that to be close to their MVV, they'd have an FEV1 of ~ 300cc, while I know that's kinda a bastardized way of looking at it, the dyschrony is likely the bigger issue than true auto-peep. Remember that you really need a passive exhalation to calculate PEEPi

Since you're calling me argumentative, let me ask this. If the pts compliance is improving, yet they're not stable enough to CPAP or extubate and still requiring such a high respiratory rate.....wouldn't it be possible that someone could infer that there was a persistant elevated dead space fraction that's causing resp issues? And wouldn't persistant dead space issue suggest a continued form of ARDS, perhaps the fibroprolif stage? And how do you know when it's safe to stop using protective strategies? Pull the ARMA trial sub group analysis and you'll find the chart That shows that even with pts with plats 30 with higher tidal volumes compared to low tidal volumes and less than 30, there still was a survival advantage.

AND remember that the ARMA protocal allowed for If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O.
Click to expand...

The last sentence here is important. VT can increase up to 8 so long as pplat is below 30. I see a lot of people forget this. Air hunger ensues as vent said because people are left on abysmal TVs even though their oxygenation and compliance is improved.

And I agree on the ratio. I had a hypoxic arrest in the floor the other day who's initial ratio was 64. Patient was put on 6ml/kg. after a few hours I picked up the patient. Still looked like hell. Repeat gas on 100%, peep 8 had pao2 of 103. Still crap ratio. There was some bilateral interstitial edema, not the classic ards film but ugly enough. Pt was very hypotensive, requiring Levo at an increasing dose nurse calling for a second pressor. Now things aren't adding up. I stuck the probe on him, RV is massive and immobile. Wicked TR. i get stat CT......you know where this is going.

Point is as others mentioned, not all pao2:fio2<200 are ards.

I ended up putting her on PC because her chest was so big she couldn't get TVs much above 500 without crossing my pressure settings. That translated to more of a 8-9ml/kg TV.
 
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