When do you employ recruitment maneuvers?

[Bobblehead]

In someone admitted for severe CAP, now ventilated and relatively hemodynamically stable where in your algorithm do would you fit recruitment maneuvers? Let's say you're looking at a situation of inadequate ventilation (pCO2 = 60) and inadequate saturation (pO2=55) on AC 12 Vt 600 FiO2 100 PEEP 10? You've already played briefly with APRV, PRVC and PCV. In addition to adequate sedation, steroids, nebulizers, antibiotics what else would you toss into the mix?

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[Glp1del]

If after all of those interventions and oxygenation and ventilation remain a problem, the other interventions I would consider include:

1) Paralysis
2) Inhaled prostacyclin
3) Inhaled nitric oxide
4) Last resort would be evaluation by CT surgery for initiating ECMO.

 

[proman]

Is this ARDS? Is there evidence of bilateral pulmonary infiltrates, no evidence of heart failure, P/F <300? I'm guessing there would be in this patient. What's the pH? A PaO2 of 55 is not too low, and PaCO2 of 60, assuming a pH 7.30-7.45, is not too high. A PEEP if 10 is low, and you could go higher to improve lung recruitment. If your FiO2 is 1.0, then your PEEP should be at 20-24 per the ARDSnet protocol. Your minute ventilate could also be higher. The theory is to provide sufficient oxygenation to maintain cell function, adequate ventilation to maintain a reasonable pH with a lung protective vent stragety. Recruitment methods work for only about 2 hours after, and there is no evidence of mortality benefit. Heavy sedation +/- paralysis may be required.

 

[emt30119]

Just a couple more to add to the list that I have seen done.
P-flex test to find ideal PEEP
Continuous rotation or prone bed

 

[HomerSD]

I agree with proman, although I would vote to increase the PEEP first even if the patient was not in ARDS. Although there is much less literature to support lung protective ventilation in non-ARDS cases, I don't see the downside as long as the hypercapnia/resp acidosis isn't too severe. A pO2 of 55, while low, isn't far off my goal of a pO2 in the 60s for a patient with severe acute lung injury and the PEEP of 10 can be easily increased into the teens and twenties.

 

[bulgethetwine]

I agree with proman, although I would vote to increase the PEEP first even if the patient was not in ARDS. Although there is much less literature to support lung protective ventilation in non-ARDS cases, I don't see the downside as long as the hypercapnia/resp acidosis isn't too severe. A pO2 of 55, while low, isn't far off my goal of a pO2 in the 60s for a patient with severe acute lung injury and the PEEP of 10 can be easily increased into the teens and twenties.

I'm with Homer -- I think there is room on the increasing PEEP side.

It's a couple of days/week since this thread started -- what did you end up doing? Any clinical updates???

 

[Bobblehead]

I'm with Homer -- I think there is room on the increasing PEEP side.

It's a couple of days/week since this thread started -- what did you end up doing? Any clinical updates???

I'm not following the patient clinically but I may be able to check this weekend what the exact details are. From what I can tell he did not tolerate increased PEEP or APRV due to hypotension even after 12L of hydration. The next step was paralysis and PCV (vs. PCV without paralysis previously). I believe he's still intubated due to ARF and massive fluid overload requiring CVVHD.

 

[Bobblehead]

The final result was death from overwhelming multi-lobar pneumonia/respiratory failure/sepsis.