SCCM Resource Library-The Really Injured Lungs: Management of Acute Respiratory Failure in the Injured Patient

Video Transcription

Good afternoon, today we'll be talking about the really injured lungs and the management of acute respiratory failure in the injured patient.  My subject is turn them upside down, not always easy peasy. My name is Samantha Gambles-Farr, and I'm a nurse practitioner intensivist at UC San Diego.  I have no disclosures at this time. The objectives of this talk, at the end of this presentation, you will be able to describe  the history of prone ventilation, name an absolute and relative contraindication to pronation, discuss the effects of prone ventilation on functional residual capacity, effect on  perfusion, effect on ventilation, and describe the POSERA trial, as well as we will do an in-depth description of how to appropriately pronate a patient.  My colleagues previously have talked about the treatment of ARDS in great length. Because of that, I will do a brief description of what we will be looking to do for our patients.  The treatment of underlying diseases is the most important treatment of ARDS. That means that if your patient is septic, you want to treat that sepsis.  You want to provide lung protective ventilation, which includes low tidal volume and adequate PEEP, and then you want to avoid a positive fluid balance.  In some severe cases, which include low pH and high CO2 and airway pressures, standard therapy may fail.  That is where rescue therapy is needed, and those two rescue therapies include ECMO and pronation of the patient.  The history of prone ventilation started initially in 1974 and can be attributed to Brian et al., which first suggested studies based on sedation and paralysis of the diaphragm.  Next, we have 1976 with Feen and Brown, in which they did five case reports looking at the mean ABG data for patients as it relates to prone ventilation.  Finally, the first, as far as historical perspectives of prone ventilation, Douglas et al. in 1977  looked at six patients and looked at their individual PA2 levels, how they looked in supine and pronation, and how they looked in the early and latter course of their treatments.  Prone positioning has been thought to improve perfusion to the lungs by bettering VQ mismatching.  The diaphragm drops and the heart shifts forward, which improves lung recruitment, and then lung protective measures. This is primarily indicated by moderate to severe ARDS cases.  We want to pronate our patients very early, within the first 48 hours, and then the duration of the patient being pronated is typically between 12 to 16 hours.  There are several relative contraindications for patients, and this is truly something  that each provider and each team has to evaluate for patients, as you have to really use caution when you're looking at these patients.  In this particular circumstance, multiple traumas pose a very difficult time for people to evaluate whether the patient should be pronated, because most of these patients may  have pelvic fractures, chest fractures. They may have some type of pelvic device that is present.  If you have patients who have severe facial fractures, if they have a head injury and they have increased ICPs, have a bolt, have an EBD present, if your patient has a history  of frequent seizures, if they have raised intraocular pressure, if they've had a recent trach in the last 24 hours, if they have any type of cardiovascular system instability,  if they've had a prior poor intolerance to being pronated previously and understanding that that relative contraindication needs to be taken with a grain of salt, as patients  typically need time once they're initially pronated to recover from the actual event. Morbid obesity, and then typically patients who are in their second and third trimester  because of the obvious implication it relates to abdominal size, are usually relative contraindications.  Absolute contraindications include spinal cord instability, unstable facial fractures, a lot of burns and open abdomen for obvious reasons, post-cardiac surgery because of the  pressure it puts on that wound, and then if you have central cannulation of VA ECMO, not typically VV ECMO, and then if your patient is on BIVAC support.  The effect on functional residual capacity. In a supine position, functional residual capacity decreases due to the compression of the lungs.  In a prone position, particularly with the abdomen unsupported, the abdominal weight shifts and the diaphragm caudally moves, and this increases functional residual capacity.  In the obese and the anesthetized paralyzed patient, prone positioning results in improved  functional residual capacity, oxygenation, and in the end helps within exploratory, expiratory of rely recruitment.  In this picture, you can actually see healthy lungs and the distribution and the perfusion that's affected by gravity.  You can see the apex, typically the apex in the middle of the lungs get the more ventilation,  therefore you think about perfusion is V and ventilation is V and perfusion is Q, and so V is greater than Q in the apex in the middle of the lungs, and at the base, you have more  perfusion than you have ventilation. The effect on perfusion is that regional lung ventilation is determined by the pleural pressure gradient.  Patients in the supine position typically have non-dependent ventral lung, has more negative pleural pressure, and it's then compared to the dependent dorsal lung region, and thus  this determines regional ventilation with the ventral lung receiving more ventilation. Looking at large pleural pressure gradients results in over, whenever your patient is  supinated, you can have patients that have over distention of the ventral ventral ventilation, and by pronating them, this eliminates the compression of the lungs by the heart.  You can see there in that picture a patient upright and then a patient that's been pronated, and you can see the perfusion of the anterior and the base of the lungs improves in the  prone patient. The effect on ventilation is determined by the pleural pressure gradient. It's interesting to note that the prone position has been shown to induce redistribution of  the lung density, indicating more of a uniform regional ventilation. This suggests that additional mechanisms may be important in improving gas exchange.  The prone position eliminates compression of the lungs by the heart as the diaphragm drops and the heart shifts forward.  This could result in improved compliance, lower airway pressures, improved tidal volumes and minute volumes, and thus decreasing CO2, which you can see in the picture that's clearly  denoted there. One of the most known trials in the last seven years, which was in 2013, was the PROSERVA trial.  Particularly, the clinical question is, does early application of proning a patient improve mortality and severe ARDS? This was a random control trial. It was computer generated.  It was stratified by the ICU. They used 27 centers in France and Spain, all with five years or greater in pronating patients.  The intervention was to prone patients for at least 16 consecutive hours for 28 days or until they meet a standardized improvement. The outcome was standardized.  The strengths of the study was that standardized ventilation and weaning strategies with use of PEEP and FiO2 tables.  They did appropriate power calculation and tension and treat analysis. However, the weaknesses of the study was that 2,015 patients were not screened for inclusion  in the trial, differences in baseline characteristics, different SOFA scores. These are all things that were strengths and setbacks of the study, but the authors concluded  that patients with severe ARDS had improved mortality with early and long proning sessions. Oh, the mechanics of it all.  This is something that's very important to think about when you're thinking about pronating patients.  This is honestly one of the barriers as to why we don't pronate patients more often. In this picture, you can see that there is a picture of a rotoprone bed.  Rotoprones are very large in size, they're very bulky. Depending on the size and how many patients you actually have that need to be pronated,  this can be a very severe undertaking with a bed this large, which is why in recent years people have started the art and the craft of pronating patients in standard patient  beds and utilizing staff and teaching them how to pronate patients in the bed. All the information that I'm about to talk to you right now in looking at best practices  as it relates to pronating patients came from the Intensive Care Society. They produced a manual in 2019 that gave guidance for prone positioning of adults in critical care.  One of the things that the best studies or best practices of this Intensive Care Society validated was a pre-procedure prep.  Just like everything that we do, we think about our ABCs. You want to look at the patient's airway, you want to look at their breathing, their  cardiovascular system, their neurological status, which means their sedation and their paralytics.  You want to attend to their skin and their eyes, and then you want to look at the lines and tubes. The information or the equipment that you need is listed there.  That says low air mattress, an airway trolley, endotracheal tube tapes, ointments, slide sheets, and pillows, and things of that sort. You're going to assemble your team.  The best practices is a minimum of five people. You may want a sixth person that is the overall eyes looking at the actual procedure of how  the patient is being pronated and to ensure that no tubes are being pulled because the people who are actually doing the labor are focused on the actual labor of the procedure  while that sixth person can actually concentrate and make sure that everything is going as smoothly as possible.  The person at the head of the bed is typically a provider or someone who's looking at the airway, and then you have your team who can consist of anyone who's going to assist in  pronating the patient. The patient should be laid flat in a neutral position. All the lines, typically we put all the lines, the anterior EKG load are removed.  Pillow from the patient's head is removed. This is where some patients' traumas can be specifically excluded because if they have  an unstable airway or neck or anything like that, you cannot turn them in proning and so they're excluded from the criteria.  You're then going to place pillows on the patient, and then you're just going to leave the head and neck exposed, and then you want to make sure that you get the patients, you're  going to make sure that the pillows are placed across their chest, making sure that the stomach is exposed, and then you have pillows over their knees as well.  You're then going to cover them with the sheet. You're going to wrap the patient, and you can see on either side, they've actually rolled  the sides up, and then there's a sheet underneath the patient, which is typically used for pulling  the patient up and adjusting the patient, which makes it easier to turn the patient on with the sheet. You're going to horizontally move the patient closest to the ventilator.  I'm sorry, the horizontal move should be away from the ventilator and in the opposite direction to which the patient will be turned.  You're then going to laterally turn the patient, and you can see how it's very important to notice how their hands are placed in this slide.  Staff on either side should adjust their hand positions on the rolled up sheet so that now that they have the opposite edge to be compared in the horizontal move.  Then the pronation is completed. You want to make sure that the ET tube is not kinked, and then your patient is positioned.  You want to make sure that you check, do a pressure check. You want to check their ears, make sure the ET tube is not pressed against their lips  or mouth, any tubing against the skin, and then you want to make sure, especially in male patients, that their penis is actually hanging between their legs with the catheter  secured. Nursing care, very important is to make sure that this patient is adequately sedated, paralyzed,  ABGs, pressure checks every two hours, and then also pre-COVID time, we would educate the family, but of course, there are some ICUs that would allow a patient into a room  with ARDS. However, that's just up to your specific entity. Thank you so much for your attention. Like I said, my name is Samantha Gamble-Sparr.  My contact information is there as needed. I appreciate your time. Hello. I'm Heidi Engel, and I'm here to present Can They Move?  If They Can't Breathe, a discussion about physical therapy for the acutely injured lungs. My disclosures are I have a conflict of interest as a paid educational session provider on  ICU early mobility to the R. Joe Huntley Medical Equipment Company. My objectives for this talk are to help us recognize when patients requiring life-supporting  ICU management will benefit from physical therapy and help us discover the challenges and complexities of ICU mobility for these patients. So first question is why.  Why should this ICU patient move? And this is the one part of the question that really is well-established, and most of the research has been grounded in.  There are multiple meta-analyses, and we know that the 2018 PADIS Clinical Practice Guidelines  from the Society of Critical Care Medicine recommend early mobilization as a safe, feasible  intervention to help preserve muscle, reduce ventilation time, decrease ICU length of stay, and decrease delirium.  We also know from this study of a mixed population of patients in the ICU, some mechanically ventilated and some not, that if we have a patient sitting in a chair out of bed versus  a patient sitting in a chair out of bed and doing some exercise, that even in the very early phases of severe ARDS, these patients will begin to demonstrate better lung aeration  measured through electroimpedance. It's a fascinating study to look at and to think about how, just in the early phases,  what we will be able to do is improve the oxygenation of our patients if we perform out-of-bed mobility activity.  Think about considering how human adaption takes over in all situations. Our bodies, we are survivors, and we are survivors based on how very readily adaptable we are.  If this world of immobility, of sedation, of profound deep sedation is what our bodies adapt to, it's very hard to bring the internal world of sometimes hallucinations, delirium,  a brain that is entirely shut down, a body that is rapidly depleting, back into the external world.  How we bring these together really is by trying to keep our ICU patients in the external world as much as we possibly can. When should the physical therapy begin?  As soon as the acute admitting crisis is stabilized.  If the patient is trending in the recovering direction, we know that, especially in the Schweikart study, what the early randomized control trials showed was that the patients  who had the most benefit from mobilizing out-of-bed were the patients who started within two to three days of their ICU early admission. We know why.  Why is to help our patients oxygenate better. Why is also to help improve the overall recovery, get them out of the ICU and off the ventilator faster.  And then when, when the patient is ready to be part of the ICU liberation A to F bundle, E is just another element on the bundle of early mobility.  When the patient is trending in towards a recovery direction, when the acute admitting crisis has been stabilized, it is at that critical moment that we want to begin waking  them up and having them mobile and not have them adapted to a state of immobility and sedation.  And here's the bundle, just as a quick reminder that the patients will be assessed for pain.  They will be on a spontaneous, they will qualify for a spontaneous breathing trial on the ventilator.  We have the choice of analgesic sedation and then hopefully a target RAS of zero so the patient can be awake and completely off sedation to participate actively in activity.  We want to assess their delirium and try our best to reduce as many of the delirogenic components of their care as we can so that we can mobilize them and have the family be  a part of an external grounding force for the patient whenever possible. There is also an expert consensus recommendation article from 2014, a very important lead author,  Hodgson, Carol Hodgson. And what this does help you do is to decide if the patient is ready to begin mobility or not.  It gives you this lovely breakdown of every potential hemodynamic situation and piece  of equipment that our patients might be encountering as critically ill person, including a patient in a trauma ICU.  And what it tells you is green is just go ahead, get this person up, not much need for contemplation, discussion, change of their medical care and go.  Yellow is more of a cautious, let's approach this slowly. Red is there's a significant reason why we may not mobilize this person today, but let's have a conversation about it.  And really the bottom line in always deciding is it time now to start mobilizing this patient  out of bed or not is about those bedside conversations, the interprofessional collaboration, the multidisciplinary teamwork.  That's really what drives when happening within a timeframe that it will be most effective for the patient's overall recovery.  It's always beginning the process very early with the end in mind, with the final outcome in mind.  And so now that we've thought about why improving the outcome and when as early as we possibly  can based on our conversations, now it's time to think about what modalities should be applied.  And this is really very important because there's a lot of research that has been done and a lot of trials that have been made to keep patients both in bed yet receive the  good benefits of early mobility out of bed. And what we've noticed in that research, including a recent study by Sue Verney that was published  in Thorax just this month, 2020, that lying in bed and using a gadget and being on a electrical  stim machine does not have very much response to the patient's overall outcome and achieve  some of the things we want in terms of reducing delirium and allowing them to return to their normal functional activities again.  And that's because skeletal muscle requires input from the brain, requires input from the nervous system.  That means the nervous system has to be able to actively engage the skeletal muscle. There needs to be weight bearing, a sense of gravity, and a sense of upright as normal.  Very often when I'm first getting a patient out of bed and they have been traumatized, they have been injured, their lungs are not working well, as you can see in this picture,  they can often be on a continuous dialysis machine and a ventilator and some other things, ECMO, nitric oxide, multiple tubes and wires and lines, what we need to be able to stress  in terms of why are we doing this for our panicked, traumatized patient is we want to empower them, we want to engage their brain, we want to have a sensory integrating experience  for their inflamed encephalopathic mind, but we also want to reiterate that upright is normal.  They will have adapted to thinking horizontal and gravity eliminated positions are normal. Their brain naturally adapts to its environment and its surroundings very readily.  When people first sit on the edge of the bed, there is panic. in order to address that panic, we need to reiterate upright is normal. Why are we doing this?  Because upright is normal. What will we do? We'll have you bear weight on your legs and engage those skeletal muscles. And the reason why we really want to engage  those large skeletal muscle groups, which is not what happens if someone's lying in bed and doing just bed exercises or passively moving or being passively moved,  is we know that the large skeletal muscles, and again, they require some weight-bearing sensation in order to really work adequately. This is where all of our metabolic efficiency,  this is where our cardiopulmonary efficiency comes from. If you want to train your heart and lungs, what you do is you go out and run. You don't add some special breathing component  or change your position just necessarily. So what will isoerodylmobility require? The sedation has to be off. It really needs to be a multisensory experience  in order to calm the anxiety of the patient, but also to integrate the brain and have the patient understand some sense of meaning of what's happening to them and what we're doing  and why we're helping them move out of bed. We want to adjust the ventilator to the patient and to their activity level as much as we possibly can.  We often have to increase the pressure support while the patient is being mobilized initially out of bed. And we have to trust in our patient's malleability  and adaption and help them adapt to what is normal, which is the upright interactive world again, with large skeletal muscles fully engaged. And in order to do this adequately,  the sedation has to be off. So even though a patient's eyes are open, and even though they appear comfortable while the sedation is still running,  the thought is if the patient is doing so well and they're comfortable, take the sedation away, turn it off, and make them prove they need it.  Now, often when people do not want to get their patients out of bed, the main objection is the problem being this patient is too sick. A really sick patient can't handle it.  And I bring you back to this study by Polly Bailey. It's from 2007. It is early activity is feasible and safe in a respiratory failure patient.  It was in critical care medicine, 2007. And I bring you back to this study all the time because if you look at how sick these patients are, if you look at they're in severe ARDS,  and you look at the types of activities that they ended up being capable of, on their last day before they left the ICU, the majority of these patients were able to walk  more than 100 feet. The majority of these patients all walked while they were still on the mechanical ventilator. And walking is very important because again,  it provides that sense of upright is normal, it engages the brain, and it also engages the large muscles of the legs, which is what really sufficiently improves  the cardiopulmonary system.  So that means we've gone through when, and we've gone through why, and we've gone through what, but now the greatest challenge of all,  always in creating early mobility for our patients to help them out of bed, is how. How do we get this done? How do we do this job and still not compromise ourselves  and our safety or our patients and their safety and their ability to really recover? So it requires as much interprofessional collaborative care  as you possibly can build in your team. It also requires a certain amount of containing your own fear of what might happen when we move this patient,  and fear of their potential to become agitated and confused.  But don't underestimate our patient's potential and recognize that really their pre-morbid resilience level is gonna have a huge impact on what they're able to accomplish.  So in terms of what activities you want to help them engage in, learn as much as you can about who they were, how active they were,  how long they've been requiring them to be sedated or lying in bed or potentially paralyzed,  and then build your activity gradually from there. We really want the demands of the large scale of the muscle on the body. That is what drives human efficiency.  And we have to be as flexible as we possibly can because every single patient is a unique encounter. Here, when we think of the resilience of the patient,  if it's in the first week of the ICU stay, the still admitting crisis is the most crucial component of making the decision of how will we get this job done. But as the weeks go on,  it's really about their physiologic reserve and their baseline and their physical performance history and age that will be the biggest component of how much we can push them  and how much they will be able to recover from this illness.  So think about it. Walking, we know, is a survival skill. We know that when we are one years old, we pull ourselves up on a piece of furniture  without anyone necessarily teaching it to us.  It's not really an exercise that we engage in. It's something that we do innately from the beginning of our lives onward because it is a survival skill.  However, when a brain is traumatized and delirious and has been sedated or in bed for a prolonged period of time, it really does forget how to program the muscles  in order to do these movements. And so remembering that timing is everything, that we will lose crucial time in the body understanding how to maintain this survival skill  if it's not what we provide in terms of a patient's ability while they're still attached to all this profound equipment.  And then really as you're looking at how are we getting this done, what you also wanna do is make sure you collect data. Make sure you are engaged in a type of data collection  that demonstrates not what you think you're providing to the patient, but some sort of gauge, mobility score, activity score on a consistent basis  because we know that exercise is only beneficial when it can be consistent. And the Society of Critical Care Medicine ICU Liberation Campaign has a minimum data set  that can help this occur. We also want feedback from the patient and the family members in terms of how did you feel about engaging this activity?  Did it help you understand what was reality? Did it help you connect with the outside world?  So in conclusion, we know that we wanna begin with the end in mind with these patients. We wanna know why we're doing this and explain this to our family members  and to the patients themselves when we can. Why? Because it's feasible, it's safe, and it makes recovery normal. We wanna know when, when as soon as possible,  ideally within two to four days of the ICU admission. What we want activities that engage the brain  with focused tasks and simple movements, but they have to provide meaning. Why do we wanna have this person get up and walk to get better? What do we want them to do walk?  Because walking is a survival skill. And we wanna remember that people don't rest for extubation. This is a ridiculous idea that gets promoted a lot  that really walking helps you clear secretions, open up your lungs and oxygenate better because upright really is normal. So I thank you for your time.  There are some interesting references here that I referred to in the talk in order to develop this information. And I hope you'll get your patients all out of bed and on their feet.  Good morning. It is my great pleasure to present to you today on the management of inhalation injury as part of this panel with my esteemed colleagues.  I have no financial disclosures that are relevant to this presentation and just wanna recognize my implicit biases, which include exposure to burn patients  since I was a young surgical resident.  Inhalation injury is actually fairly uncommon regardless of how frequently my residents think it occurs. There are approximately 450,000 burn injuries  treated per year in the United States with 40 to 50,000 requiring hospital admission. Of those only about 5% have an inhalation injury.  The mortality statistics are difficult to parse for inhalation related deaths given that severe cutaneous injury resulting in death cannot always be separated out.  It is worth noting, however, that inhalation injury itself is an independent predictor of death, especially in patients with cutaneous injury greater than 20% TBSA.  The pathophysiology of inhalation injury has several components. Exposure to fire and smoke causes injury via direct thermal effects,  as well as deposition of toxic particulate matter and respiratory irritants. These effects are pathologic at several distinct anatomic levels. The upper or supraglottic airway,  the lower or infraglottic airway or tracheobronchial system, the lung parenchyma and alveoli, and then remote organ systems.  Thermal injury to the upper airway manifests as erythema, edema, bronchorrhea, and occasionally ulceration. Work of breathing increases  due to increased airway resistance from edema, reduced airway compliance, and hypermetabolism also occur. These are due in part to destruction of the epithelial layer,  which triggers a cascade of inflammatory responses. Additionally, viscous mucoid secretions can result in upper airway obstruction with impaired ciliary clearance  being part of the contributing problem.  Direct thermal injury below the vocal cords is uncommon and predominantly affects the nasal cavity and oropharyngeal mucosa due to the efficient heat exchange in this region.  An exception is exposure to large volumes of steam or superheated vapors in industrial settings, though the resulting severe glottic edema is often fatal.  Most of the airway edema that happens is going to manifest in the first six to 24 hours after time of injury.  Direct thermal injury below the vocal cords, again, is uncommon.  And in the lower airway, chemical injury to the tracheobronchial system stimulates release of the bronchoconstrictors and vasodilators in the form of neuropeptides.  As in the upper airway, this can trigger an inflammatory response, edema formation, and significant mucous production. When mixed with soot,  denuding airways can create bronchial plugs that can result in life-threatening airway obstruction.  Parenchymal or alveolar injury is characterized by atelectasis from decreased and dysfunctional surfactants and the loss of hypoxic pulmonary vasoconstriction,  which leads to ventilation precision mismatch and hypoxia. This mismatch is worsened by the formation of nitric oxide, which causes vasodilation,  increasing blood flow to poorly ventilated bronchioles. As in more proximal structures, the alveolar capillary membrane damage from inhalation injury  triggers a cascade of inflammatory mediators and the generation of highly reactive free radicals, which predisposes patients to developing ARDS and pneumonia,  two of the most common pulmonary problems in the thermally injured patient.  The systemic effects of inhalation injury are often delayed and partly a result of reduced P to F ratio and cellular asphyxiation, which decrease oxygen delivery to the end organs.  Its effects can also be attributed to the circulation of lung-derived inflammatory mediators, which trigger a systemic hypermetabolic state.  Additionally, various toxins in the smoke can produce variable specific effects. The most well-known are those of cyanide, which inhibits mitochondrial cytochrome C oxidase  and carbon monoxide, which binds hemoglobin and decreases oxygen carrying capacity.  Ultimately, diagnosis of inhalation is a clinical one with hard and soft signs available to guide the practitioner relative to the care of the additional problems.  Soft signs include singed nasal hairs, burns to the face and neck, nausea, emesis, and carbonaceous debris in the sputum.  Hard signs include decreased oxygen saturation, cyanosis, stridor, increased work of breathing, and visible mucosal changes to the upper airway.  When possible, bronchoscopic evaluation can be useful to the diagnosis of inhalation injury also. Abbreviated injury scoring, seen above,  can be useful for description of the proximal airway and has been shown in some studies to correlate with mortality.  However, Moser and colleagues in the late 20 teens performed an assessment of binary AIS grade, three and four versus one and two, and found that while worse inhalation injury  did correlate with the development of ARDS and pneumonia, there was only a trend towards a mortality increase. Much of this has to do with a still subjective assessment  of a visual finding and does not take into account involvement of the distal airway, the toxins to which a patient was exposed, and the variable inflammatory response  patients will have to their injury.  To improve on bronchoscopic evaluation, adjuncts have been investigated, including CT imaging and, interestingly, optical coherence tomography.  CT imaging has been assessed using a scoring system where a composite score was assessed for each side of the thoracic cavity and used to compare to bronchoscopic findings  and other findings to identify relation to a composite endpoint using ventilator-free days, pneumonia, ARDS, and or mortality. Ultimately, CT alone was not significantly associated  with the composite endpoint, but did increase the odds ratio of the composite endpoint occurring when tied to the bronchoscopic evaluation.  Optical coherence tomography, which uses in vivo laser-based imaging to identify mucosal changes after tracheobronchial injury,  has really only been investigated to date in a swine model. However, OCT clearly identified early post-injury mucosal thickening, regardless of the ultimate ARDS development,  and demonstrated that mucosal thickening quantities could be correlated with P to F ratios, peak inspiratory pressures, and the volume of infused fluids  in a way that was suggestive of which model, which animals would develop ARDS and which did not.  Additionally, they identified that it was a fairly simple process to implement, meaning that it would have practical application in the management of our critically ill patients.  So what practical tools do we have and tips do we use when proceeding with an inhalation injury patient these days? The most important thing to keep in mind  is that the presence of an inhalation injury itself does not mandate an intubation. However, if a practitioner is concerned about the management of an airway  and doesn't have the resources for an extended time to manage the patient before proceeding with intubation, we will, of course, encourage our outlying facilities  to intubate first and send them to us for additional management.  Toxin management is fairly well described in the literature with the treatment for carbon monoxide toxicity being 100% FiO2, and the treatment for cyanide toxicity  being hydroxycobalamin. The identification of these two agents in play is variably done, however, as carbon monoxide is a data point that can arrive easily on the ABG,  but cyanide toxicity is usually a send-out lab that takes four to five days to come back. Therefore, treatment for cyanide toxicity is usually encouraged in the setting of patients  who have acidosis out of proportion to the rest of their data points and is done empirically with little to no identification of the total number of cyanide toxicity patients  in the United States at any given year. Toxin management is also fairly well described in the literature with the treatment for carbon monoxide toxicity  being the application of 100% FiO2, and the treatment for cyanide toxicity being the use of hydroxycobalamin. Unfortunately, we have no great data  on the incidence of cyanide toxicity concomitant with inhalation injury as routine measurements of cyanide levels is not easily done as it's usually a send-out lab  that takes four to five days to come back. Therefore, we typically proceed with hydroxycobalamin dosing in patients who are demonstrating an acidosis out of proportion  to their other findings on respiratory labs and exam.  Finally, ventilator management in these patients has to balance high minute ventilation requirements in patients with concomitant cutaneous injuries and a high metabolic state  with the idea of continuing lung protective strategy.  High tidal volumes may have benefit in the pulmonary clearance of sloughing mucosa, and it's important to keep in mind that ultimately whatever mode you use,  you're revisiting the airway for clearance of potentially life-threatening plugs and casts beginning at about 48 to 72 hours post-injury.  Additional standard of care and available options can be seen in this table here. It's worth noting that fluid resuscitation component of our burn management is often at odds  with the idea of keeping our lungs relatively dry, but this balances out over time relative to the survival potential for an appropriate burn resuscitation.  Options that are less routinely used but worth considering include the use of nebulized medications. Studied in the literature at various burn centers around the country  have been the use of heparin sulfate and N-acetylcysteine albuterol and bicarbonate, either independently or in various combinations. Here you see Miller's group et al  looking at a case control study showing improved survival in patients who received a nebulized heparin sulfate of 10,000 units combined with N-acetylcysteine and albuterol.  Unfortunately, the literature is not robust enough to support any one of these and different burn centers will have their own versions of how to apply this data.  Additionally, the role of ECMO in inhalation injury is extremely difficult to parse given the very low numbers and the potential use of ECMO in the larger burn population  confusing some of the data collection. What we do know is that from a survival standpoint, patients who can be on ECMO  who require less than 200 hours of ECMO tend to have a better chance of long-term survival than those who require longer than that.  So what's coming in the future? Things to pay attention to include the idea of mesenchymal cell infusions  and antioxidant delivery to impact the inflammatory responses of inhalation injury in our patients.  Here you see data demonstrating that swine treated with autologous stem cells show the least amount of diffuse alveolar damage mitigating ARDS and multi-organ system failure  in an extended model. The next most valuable is treatment with allergenic stem cells so such that if autologous stem cell harvest is not possible  there is a potential for allergenic stem cell infusion in order to impact long-term survival.  In an ovine model of injury specifically created to study the impact of oxidative and nitrosative stress after inhalation injury, here you can see that treatment with nebulized  vitamin E actually has significant benefit on the long-term P to F ratios in a treated population versus the control.  Both of these models is worth noting are still in animals and future clinical trials may start in the next decade as we see more data coming forth on the local  directed therapy for inhalation injury.  I would be remiss in this talk if I didn't mention long-term outcomes in our patients. Unfortunately we have very limited data in this patient population.  We think that airway obstruction may occur after long-term smoke inhalation extrapolating from patients who are long-term cigarette smokers.  And we think that the extent of obstruction may be related to the amount of smoke inhaled. We also have some data suggesting that psychosocial outcomes  such as an increased rate of PTSD and an association of two-year unemployment may with the presence of inhalation injury  are also possible. But long-term and extended tracking data is underway to further elucidate what other impact inhalation injury may have on our patients.  It is worth noting just by the way that markers of physical health, mental health and life satisfaction were not significantly associated with inhalation injury when compared  to an overall burn cohort. And with the idea being that overall burn patients have lower markers of those three components in long-term quality of life studies  than the baseline population.  Finally, the question becomes what's left to answer?  And in this small subsection of the acutely injured lung population I think that there's a lot of very interesting questions still to pursue.  Questions of anatomy, what does lung repair look like? What's the timeframe for it? How can we impact repair to the impact of the lung microbiome  on both the systemic outcomes of the patients and also again on lung repair? Clinical questions such as do we need to take into account inhalation injury  as we're doing fluid resuscitation? How do we do that? When should we be using ECMO in these patient populations? And then finally, long-term outcome questions  including what impact does inhalation injury have on things like exercise tolerance? Can it be extrapolated from the acute lung injury population  or is there a different components of this given the different triggers for acute lung injury in the smoke inhalation population?  Overall though, I would like to thank SCCM and my panelists for the opportunity to speak to you all today. I would like to thank my team, both my partners in burn surgery  and my nursing staff in the ICU, my physical therapists, my pharmacists, my nutritionists, all of them make coming to work an absolute joy  and make taking care of this population a real pleasure. Thank you.  Good morning, everyone. My name is Jose Diaz-Gomez. I am the 50th anniversary Congress co-chair.  On behalf of my colleagues, Dr. Amlett and Dr. Taylor, I want to apologize because for  this session, we couldn't have the participation of Samantha Gumbels. She was a very last minute thing, but I'm assuming the responsibility as a moderator in this wonderful session.  So we have Dr. Laura Johnson. She's an associate professor of surgery in Georgetown MedStar Washington Hospital Center in Silver Spring. And we have Heidi Engel. She's a physical  therapist, a clinical specialist in physical therapy at the University of California San Francisco Medical Center. As you already saw in the past hour or so, there was a wonderful,  wonderful presentation, and I really want to start this discussion. I have the very first question for Dr. Engel as follows. I do work in an intensive care unit that we  have oftentimes patients on ECMO, mechanical circulatory support. And as you imagine, yes, there is a trend that all of us want to mobilize our patients. Can you tell us  briefly, how you envision that a team that never have had any experience on mobilization, how they should start doing so? How they can select the safest practice when they  are starting to build a team on mobilization? So when we started building our team at UCSF, we assembled a group of champions. So these  were people that were passionate about the idea of mobilizing ICU patients and had a level of experience that made them somewhat experts in this world that when we started,  nobody was mobilizing patients yet at all. And so we were entering kind of a new realm. And as an expert group of interprofessional champions, so we had a physician champion,  nurse practitioner champion, a respiratory therapy champion, nursing champions, physical therapy, occupational therapy. So we had a pharmacist. We had the entire group of  professionals in the ICU all together having this team of championship meeting to discuss  how we wanted to do this and to set parameters and how we were then going to bring this concept in how to get it done well and get it done right back to our fellow professionals who  would be doing this with us in the ICU. And of course, you don't pick your most complicated patient and you have to be careful not to end up perseverating on all the what ifs and  on the most complicated cases, you have to get your feet wet with some of the easier cases first. So we would tackle those easy cases and there's nothing like showing and  demonstrating to your colleagues how this works to make it inspirational for your colleagues to continue to have it work. In the special case of ECMO, it's I think when we mobilize  ECMO patients at UCSF, in my experience, it's very similar to what this presentation went  through on proning. So you really assemble the team in the room and you have a pre-procedural  check. You assign everyone almost a piece of equipment. Someone's got the vent, someone's got the ECMO cannulation. If there's also a continuous renal replacement therapy at the  same time, someone's got the various CBP lines, A lines and the CRT line, check, check, check.  We all know what we're going to do, where we're going. We engage the patient's mind. So bed  exercises, warm up, vigorous activity with their legs before we even sit them up on the side of the  bed. We want their cardiovascular system primed for what they're about to do. Sit up and try to  be actively engaged in activity. And from there, it's just making sure all the equipment is where  the patient is going to go, not where they are lying now in terms of slack on the entire system.  The mattress has to be firm. Their feet have to be able to be flat on a surface, the floor, something, and you take it from there. Great. That's a great question. And I know  you are a physical therapy specialist, but I'm pretty sure when you are doing this pruning, you are interested to see which ventilator settings, you know, you have in mind  as agreeing with the medical team to start doing the pruning. So there is a question here  in that regard. In the COVID era, what are the typical vent settings that you would consider  stopping the pruning, you know, the pruning with a PF ratio, for example, FIO2 60%, 10 of PEEP, what you have seen just to, you know, basically support a medical team saying, okay,  now we can stop pruning. There's a question on the audience. Is that for me? Yes. I don't know.  I know it's probably, it's a hard question, but. No, I want to, I mean, I want to explain how  pruning has worked at our institution. So at our facility, we were pruning patients prior to COVID,  which was such a blessing when COVID came along, right? We already had experienced professionals. And one of the things about the PROSIVA trial is, you know, as the physician  said, who gave the presentation, Dr. Gamble, that the people, the people who carried out the  pruning and the PROSIVA trial that we're basing everything on had five years or more experience  at pruning already. And it makes such a difference in terms of, you know, how that's going to work  and what kinds of outcomes you might potentially have. So we have a team of nursing and respiratory  therapy champions who have a whole protocol laid out and they have been pruning and doing  the pruning without the involvement of physical therapy directly even prior to COVID. So all I  end up being asked to do in the realm of pruning is after they position someone prone, they might  ask me to pass by the bedside and eyeball the position and tell them if I feel like the arm  position is in a good place for that particular patient so that we won't hurt their shoulder or  their elbow. Got it. And as you know, there has been this debate and it depending on resources  whether you are advising to have a roto-prone bed versus just a manual pruning. There are—  there is a question at any literature showing any differences with pruning by manual or placing  patient in a roto-res pruning bed itself? So I think we started on the pruning journal journey because Dr. Michael Mattei, who's a pulmonary researcher at UCSF, wanted to do a  study on pruning. Again, this is all pre-COVID. And we initially were pruning with the roto-prone bed  and it was very expensive, very challenging for the nurses to actually utilize the bed well.  And our ICU is still old. Our rooms are still from, you know, whatever, 1970. So fitting that  bed in the room, having the nurses, you know, be able to protect the skin and the position of the patient,  the cost of the bed, we abandoned the bed and it's all being done manually now. We also at the time had a physiotherapist from Switzerland who was very accustomed to pruning.  They had been doing it much longer than we had and she kind of looked at the bed and said,  why are you doing this? You just run in and flip the patient. So I think manual pruning is going to win out for a lot of very practical reasons. And it's like any manual skill.  You practice it. Once you get good at it, once your team gets their manual skill down,  it's not hard anymore. It's just the learning curve.  There is a question regarding, actually, Dr. Johnson can help us out and see what her practice is. Going back to Samantha's lecture, I'm curious how many centers are immobilizing  all prone patients with neuromuscular block agents? Can you comment on that?  Yes. I have to say in the burn unit, we're almost never using neuromuscular blocking agents unless  we're having patients with pretty significant combination events, dyssynchrony issues and  peak airway pressure problems that are sort of riding even above our upper limit of tolerance.  We tend to do more of an open lung approach to these patients. And so our numbers are higher  than I think in other places, but we are very rarely using paralytics. And I think throughout  the rest of the units here, as I've chatted with my colleagues in critical care, cardiac and in  surgical critical care, same thing. Most people have moved away from that, even in the proning  world. So I do want to go back to something Dr. Engel said about sort of the team approach to proning. I think it's critical that everybody buys in and that you really have people  focused on making sure that the patient is safe and that the team focuses on all of those  components as you're doing the proning operation. But I think that actually, as she said, the  move towards proning without the machines has actually been driven a lot in the last year by  COVID and the absence of machines for everybody. And I think it's shown us just how well we can mimic our colleagues in Europe and doing the same safe practice.  I agree. Thank you. I'll try to bring as many questions as I can. I have a question for a high esteem SCCN colleague. He said, we unfortunately got directed to getting two  bikes that can be used in the bed several years ago. They are expensive. Does collectors now,  and listening to your talk on the value of getting people upright, it makes total sense.  Is there a source that look objectively at the equipment that gets pushed by industry in an objective way consumer reports like, I guess, Dr. Engel?  Yeah. So there's not a consumer report study that I know of, but the one study I cited on my slides  allopathy 2020, where they did try to compare modalities versus just getting someone out of  bed somewhat. There's actually been a lot of recent studies that are randomized control trials  where people have wanted early mobility to be attaching electrical stim pads to people's legs  and bed bicycles. And you lie in bed with the electrical stimulation to the muscles and you're  rotating on this bicycle. And it turns out it has very little return on the investment of your  time and your money. It doesn't do very much for the patient at all, which to me makes complete  sense because really all we're trying to do is engage the brain first of all. And the brain is  not engaged in lying down bicycling. The brain is confused because it doesn't mimic anything you  ever do in life ever. So your skeletal muscle is 40% of your body mass. Your skeletal muscle is  part of your immune system, but your skeletal muscle also is in a constant conversation that  you're not privy to with your brain. And they work in conjunction with each other. And we want the  brain to get better. We want less delirium. We want the skeletal muscle to get better. It's part of  your overall suit of armor and ability to have a good immune response on top of everything else,  which is moving you through space and walking, which is a survival skill. The only way we trigger  all these things is if we do what we did when we were one year old and we pull ourselves up into an  upright vertical position, we understand where the force of gravity is and we try to put weight on  our legs and walk. So it hasn't surprised me because I also bought a bed bicycle in the very  early days and I was not impressed at all with what it did in terms of what I saw happen to  our patients. Unfortunately, I think the other downside of the bed bicycle is that the patients  who don't want to get out of bed, they really like it, which is a red flag right there by itself.  When your patient who doesn't like getting out of bed really likes a piece of equipment,  that's telling you something. So I would come by and the patients who hate getting out of bed would  go, no, no, I'm not getting up. Just bring that, that bicycle thing. I'll lie here and do that.  Amazing. Patients all around the country, same response to that. Yes.  By the way, Tarangal, they are really interested that you can share your proning protocol.  Oh, we have a written proning protocol that our clinical nurse specialist in the ICU wrote.  I, you know, I have it, I have it on file. I don't know how I would share it necessarily.  I think we can post in information that people are interested in attached to this session. So  we can make sure to post other things that people are interested in. Dr. Engel, we can talk to our SCCM coordinator to make that happen.  Perfect. So we have over two minutes left and Dr. Johnson, it was,  and there was an answer for this question on the chat, but basically, can you tell us in a couple  tell us in a couple of minutes about the treatment of cyanide toxicity and outcomes?  Yes. So I really appreciate Dr. Degree's question about late treatment. Is it apparently late to be  treating cyanide toxicity when patients arrive in the ER and the ICU? And I would argue that,  you know, not all EMS systems have the capacity to treat in the field. You know, in our area  of the country actually really only one, maybe one and a half now of our local EMS systems  have cyanokit or the hydroxycobalamin agent with them. And so it's often the case that these  patients will have BLS, maybe some ALS support for their respiratory failure on the way to the hospital. And then when they show up, it's incumbent upon us to at least think about  is what they're presenting with consistent with cyanide toxicity to the point where we can start  it. I would comment also that we have had two very strange patients situations over the years where  we've treated the cyanide toxicity early. And then at a later period within 24 to 48 hours,  almost as they're sloughing their mucosa and have raw surfaces again, have needed to retreat,  but that's very unusual. So it's something to think about, but should certainly be dealt with  in the ER, in the emergency department or the trauma base, depending on how your system is set  up. Thank you. And just taking a bunch of the last 30 seconds for Dr. Engel, what has been that case  that you feel you push the envelope so much on mobilization? Tell me what was like that specific patient that you decided to go on mobilization and somebody said, that's crazy.  Oh gosh, that happens actually more often than you might expect. And  we have incredible respiratory therapists, I have to say, who are very, we have a team that's very  pro-mobility. And when they're in the room with me and they are adjusting the ventilator as we go,  I feel very confident. And I have learned over the years that I will walk into a room, I will look at the setup, I will look at the patient and think, I'm not sure this is going  to work. And I forced myself to try it anyway. And 9.5 times out of 10, patients surprised me,  patients want to move, patients really respond well to movement. And if you can see very quickly,  if it's not working out and you just lie them back down. So you take everything one very specific  step at a time. It's all just like the proning and the pre-procedural and the teamwork. Every  single time you're checking every box and you're going every single step, you're not skipping steps,  you're not rushing, you're assessing the patient, you're looking at the monitor and your team is  adjusting the equipment to the patient, as opposed to just trying to force the patient to tolerate  whatever settings we have. If we need to turn up the pressers a little and everyone's okay with  that, we turn up the pressers a little. We need to take the prosthetics off, we take the prosthetics  off. Zero sedation is always my goal. That's the biggest thing. And then the respiratory therapist changes the vent with the patient's activity level. Wow, this is very enlightening  and has been a pleasure moderating the session. But let me recap real quick. Number one lesson I  learned, and I was just again joining you in the last hour. Number one, we need to make sure that  the brain is engaged. There's a very clear lesson. Number two, from Dr. Johnson, it seems to me that  team building and teamwork approach is the way to go. And number three, we must adapt. And I like  the way you go, you kind of go in the next step of personalized medicine and making sure we adapt to that patient's need. I want you to know that there were over 690 people  attending to this session here live stream. So I hope in social media, that is the traffic that  you guys deserve. And on behalf of my co-chairs and the SCCM staff, thank you for bringing us the next level learning about all these things. Thank you so much for such a wonderful  presentation. Thank you, Dr. Diaz. That was great. Great talking with you guys.

Video Summary

Good afternoon, today we'll be talking about the management of acute respiratory failure in injured patients. The lecture covers the history of prone ventilation, absolute and relative contraindications to pronation, the effects of prone ventilation on functional residual capacity, perfusion, and ventilation, and the PROSIVA trial. The speaker discusses the importance of treating the underlying disease causing the acute respiratory distress syndrome (ARDS) and providing lung protective ventilation with low tidal volume and adequate PEEP, as well as avoiding positive fluid balance. However, in severe cases that don't respond to standard therapy, rescue therapies like ECMO and pronation may be necessary. The history of prone ventilation dates back to the 1970s, and it has been found to improve perfusion and lung recruitment in moderate to severe ARDS cases. Prone ventilation should be initiated within 48 hours and maintained for 12 to 16 hours. However, there are relative contraindications that need to be considered, such as multiple trauma, severe facial fractures, head injuries with increased ICP, and cardiovascular instability. The effect of prone ventilation on functional residual capacity is that it increases it due to the caudal movement of the diaphragm. The effect on perfusion is that it improves regional ventilation by eliminating compression of the lungs by the heart. The effect on ventilation has been shown to improve gas exchange and decrease CO2 levels. The speaker also discusses the PROSERVA trial, which showed improved mortality with early and long-prone sessions in severe ARDS patients. The mechanics of pronation are also explained, and the importance of a team approach and proper patient positioning are emphasized. The use of neuromuscular blocking agents is not recommended in most cases, and the speaker emphasizes the importance of engaging both the brain and the skeletal muscles for successful mobilization. Finally, the speaker recommends starting with easier cases and gradually progressing to more complex situations. In conclusion, pronation and patient mobilization can improve outcomes in acute respiratory failure, and a team approach and careful patient selection are key to success.

Asset Subtitle

Pulmonary, Patient and Family Support, 2021

Asset Caption

The Society of Critical Care Medicine's Critical Care Congress features internationally renowned faculty and content sessions highlighting the most up-to-date, evidence-based developments in critical care medicine. This is a presentation from the 2021 Critical Care Congress held virtually from January 31-February 12, 2021.

Learning Objectives

Apply advanced ventilatory modes to the trauma and burn injury patient with severe respiratory failure
Determine when to use prone positioning and/or extracorporeal membrane oxygenation (ECMO) in the patient with severe lung injury
Discover optimal techniques and challenges of placing patients in the prone position, including those on continuous renal replacement therapy and ECMO
Recognize which patients with severe lung injury may participate in physical therapy and discuss the benefits of physical therapy

Turn Them Upside Down: Not Always Easy Peasy
Samantha Gambles Farr

Can They Move if They Can't Breathe?
Heidi J. Engel

Current Treatment of Inhalational Injury
Laura S. Johnson

Meta Tag

Content Type Presentation

Knowledge Area Pulmonary

Knowledge Area Patient and Family Support

Knowledge Level Intermediate

Knowledge Level Advanced

Membership Level Select

Tag Respiratory Failure

Tag Rehabilitation Medicine

Year 2021

Keywords

acute respiratory failure

prone ventilation

ARDS

lung protective ventilation

ECMO

pronation

functional residual capacity

perfusion

ventilation

patient mobilization

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