Multiprofessional Critical Care Review: Adult (2023)-Case Study Discussion 3 (ARDS & Pneumonia)

Case Study Discussion 3 (ARDS & Pneumonia)

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This document discusses the management of acute respiratory failure in patients with COVID-ARDS. The case presented is a 32-year-old female who is intubated and started on mechanical ventilation (MV), remdesivir, and dexamethasone. The initial ventilator settings include a tidal volume (Vt) of 360 cc, positive end-expiratory pressure (PEEP) of 12 cm H2O, and FiO2 of 80%. Over time, the Vt is decreased to 300 cc, PEEP is increased to 15 cm H2O, inhaled nitric oxide (NO) is added, and prone ventilation is initiated.<br /><br />After 12 hours, the patient's vital signs are stable, but the oxygenation remains at 92%. The FiO2 is increased to 100% while maintaining the same ventilator settings. The arterial blood gas shows improvement with a pH of 7.36, PaCO2 of 36 mmHg, PaO2 of 59 mmHg, and oxygen saturation of 89%.<br /><br />For a 36-year-old female with COVID-ARDS, the best evidence suggests administering cis-atracurium, instituting ECMO, starting high-frequency oscillatory ventilation (HFOV), placing the patient in the prone position, or increasing PEEP.<br /><br />In a case where the patient remains on the ventilator for 10 days, optimization of medical management is recommended. This includes attempting a spontaneous breathing trial (SBT) daily before liberation. If the patient fails the SBT, options include proceeding with a tracheostomy and daily face mask trials or tracheostomy with pressure support ventilation/continuous positive airway pressure (PSV/CPAP). Another option is extubating to high-flow nasal cannula (HFNC).<br /><br />The summary of management of acute respiratory failure includes the importance of lung protective ventilation with a plateau pressure (Pplat) less than 30 cm H2O and tidal volume 4-8 cc/kg of ideal body weight (IBW). High PEEP ventilation without prolonged recruitment breaths, prone ventilation, and a combination of low tidal volume and prone positioning are recommended approaches. Inhaled NO and HFOV are not recommended. Protocolized sedation and weaning are suggested. Early tracheostomy does not provide benefit, and tracheostomy mask trials are preferred over PSV.<br /><br />Overall, this document provides guidance on the management of acute respiratory failure in patients, particularly those with COVID-ARDS.

Keywords

acute respiratory failure

COVID-ARDS

management

intubation

mechanical ventilation

prone ventilation

oxygenation

cis-atracurium

ECMO

high-frequency oscillatory ventilation

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