So the seasons are changing, autumn’s here and I think we’ve reached a natural point at which to change topics in journal club; otherwise we’ll have to start calling ourselves “ARDS club”…..
However before we jump ship to another subject I thought it worthwhile to highlight what I understand to be the current “best practice approach” to managing ARDS (in a DGH) and the evidence for doing so. Feel free to contradict and disagree!
Things that seem to work (and you should do in every ICU)
- Make the diagnosis! Sounds simply but it isn’t. Time and time again the literature shows that ARDS is underdiagnosed. This was part of the impetus I’m sure for the Berlin Criteria (http://lifeinthefastlane.com/ccc/acute-respiratory-distress-syndrome-ards-definitions/). If we don’t think of it we won’t treat it……
- Address the underlying trigger i.e. pneumonia, pancreatitis, burns etc….
- Low Tidal Volume Ventilation ( if you haven’t read this landmark paper please check it out here (http://www.nejm.org/doi/full/10.1056/NEJM200005043421801#t=article) it’s taken on almost mythical status now!
- Short courses of NDMR’s.
- Aim for neutral fluid balance.
Things to consider when you’re not winning.
- Discussion with an ECMO centre.
- Recruitment manoeuvres and optimising PEEP. I say “optimum” PEEP rather than just a blanket high PEEP as in the heterogeneous mess that is an ARDS lung we don’t have the luxury of a one size fits all approach. It’s summarised nicely here (http://lifeinthefastlane.com/ccc/open-lung-approach-to-ventilation/).
Things that probably don’t help but we wish they did…
- Nitric oxide.
- Omega 3.
Future areas of interest
- Permissive hypoxia?
Of course you could just read the GPICS manual…… (https://www.ficm.ac.uk/sites/default/files/GPICS%20-%20Ed.1%20%282015%29_0.pdf).
I guess ultimately my take home message is that we have to remember that ARDS is a pathological process rather than a defined disease entity. No two cases will ever be the same and even in the same patient the pathological process is constantly evolving and shifting focus from one lung unit to another, always trying to stay one step ahead of the clinician. ARDS is a formidable foe that frequently has sprinted off down the street before we’ve even managed to get our shoes on, however you better watch out ARDS because we’re coming to get you…….