Management of Acute Respiratory Distress Syndrome
Acute respiratory distress syndrome is a form or hypoxemic respiratory failure associated with the presence of several antecedent risk factors, most notably sepsis. The Berlin criteria classify this condition as mild, moderate or severe based on the PaO2/
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Robert C. Hyzy
Case Presentation A 53 year old woman with a history of alcohol abuse, pancreatitis, hypertension and COPD presented with 3 days epigastric pain, nausea, vomiting and decreased oral intake in addition to respiratory symptoms which included a week of cough with white sputum. At the time of presentation to the hospital her alcohol level was 207, lipase was 838, white blood cell count was 12.8 K. She was started on IV hydration and received benzodiazepines for incipient alcohol withdrawal when her mental status became delirious. Over the course of the next 12 h her oxygenation progressively deteriorated and she was intubated. Post intubation chest x-ray and a representative image from the CT scan performed are below (Figs. 21.1 and 21.2). Question What approach should guide this patient’s ventilator management? Answer Lung Protective Ventilation All patients with the acute respiratory distress syndrome should be treated with lung protective
R.C. Hyzy Division of Pulmonary and Critical Care Medicine, University of Michigan, Ann Arbor, MI, USA e-mail: [email protected]
ventilation in order to avoid ventilator associated lung injury (VALI). This patient was started on assist control mechanical ventilation with a tidal volume of 350 ml and 100 % FiO2. Neuromuscular blockade with cisatracurium was initiated. The depth of paralysis was monitored with train of four nerve stimulation and the depth of sedation with midazolam and fentanyl was assessed via bispectral analysis. Over the next 12 h her PEEP was increased to 16 cm H2O and her FiO2 was decreased to 40 %. During this time the patients plateau airway pressure ranged between 26 and 28 cm H2O. She was treated with broad spectrum antibiotics, vancomycin, pip-tazo and azithromycin. Results of a culture obtained from a mini- BAL specimen failed to grow any pathogenic organisms. Cisatracurium was discontinued after 48 h. At that time, solu-medrol was begun at a dose of 1 mg/kg body weight. The patient had had already been on an insulin drip but the glucose target range was changed to less than 110 mg/dL from the usual less than 150 mg/dL at that time. Daily sedation holidays were instituted to assess mental functioning and a physical therapy consult was initiated to promote mobility. The patient remained hemodynamically stable with good renal function and diuresis with furosemide was initiated, resulting in a negative fluid balance of 2400 ml on the third ICU day and about 1–2 L/day subsequently. Gas exchange remained satisfactory such that on the fourth ICU day PEEP was decreased to 5 cm H2O. By that time the patient was able to march in place at the bedside and take
© Springer International Publishing Switzerland 2017 R.C. Hyzy (ed.), Evidence-Based Critical Care, DOI 10.1007/978-3-319-43341-7_21
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Fig. 21.2 Representative section of chest CT from patient in case study demonstrating bilateral alveolar infiltrates with mild compressive atelectasis in the dependent lung zones Fig. 21.1 Chest x-ray of patient with ARDS from case s
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