ARDS indications CC

Question 1

Prone position indications

Answer 1

• Moderate to severe ARDS (FIO2 ≥ 0.6 and P/F ratio < 150 mmHg or 20 kPa)
• Early in disease (<48 h and after 12–24 h optimisation of mechanical ventilation)

Question 2

Contraindications to permissive hypercapnia

Answer 2

• Patients with acute cerebral disease: Permissive hypercapnia is generally avoided in patients with cerebral disease (eg, mass lesions, trauma, and cerebral edema) or a seizure disorder for several theoretical reasons outlined below. However, the data to support clinically impactful harm are poor
• Patients with coronary artery disease, heart failure, cardiac arrhythmias, or pulmonary hypertension with right ventricular dysfunction: Hypercapnia increases sympathomimetic output that may be poorly tolerated by patients who have cardiac disease. Beta blockade may limit the sympathomimetic effect of hypercapnia
• Patients with hypovolemia: Hypercapnia can induce systemic vasodilation, predisposing patients to hypotension (especially those who are hypovolemic). Hypovolemia should be corrected prior to the initiation of hypercapnic ventilatory strategies

Question 3

Contraindications to prone ventilation

Answer 3

• Acute bleeding (eg, hemorrhagic shock, massive hemoptysis)
• Multiple fractures or trauma (eg, unstable fractures of femur, pelvis, face)
• Spinal instability
• Raised intracranial pressure >30 mmHg or cerebral perfusion pressure <60 mmHg
• Tracheal surgery or sternotomy within two weeks

Question 4

Relative contraindications to prone ventilation

Answer 4

• Shock (eg, persistent mean arterial pressure <65 mmHg)
• Anterior chest tube(s) with air leaks
• Major abdominal surgery
• Recent pacemaker
• Clinical conditions limiting life expectancy (eg, oxygen or ventilator-dependent respiratory failure)
• Severe burns
• Recent lung transplant recipient

Question 5

Indications for Initiation of ECMO (VV-ECMO)

Answer 5

• Hypoxemic respiratory failure due to any cause
• Hypercarbic respiratory failure
• Bridge to lung transplantation
• Surgeries requiring apnea
• Severe air leak
• ARDS/hypoxemic respiratory failure: P/F ratio <150 with Murray Score 2–3 correlates with 50% mortality
• P/F ratio <100 with Murray score 3–4 despite optimal care correlates with 80% mortality risk (ELSO)
• Carbon dioxide retention on mechanical ventilation despite high ventilating pressure (plateau pressure >30 cm H2O) with or without pH <7.15
• To help prevent intubation in a patient expecting lung transplantation
• Any sudden cardiac or respiratory collapse that is unresponsive to optimal care can be considered

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Question 6

Indications for Initiation of ECMO (VA-ECMO)

Answer 6

• Refractory cardiogenic shock that persists despite adequate volume resuscitation or use of vasopressors & inotropes +/– intra-aortic balloon pump counterpulsation (ELSO), typical causes: massive PE, refractory cardiac arrest, fulminant myocarditis
• Bridge-to-heart transplantation or ventricular assist device placement
• Primary graft failure following heart transplantation
• Acute myocardial infarction
• Peripartum cardiomyopathy
• Septic shock with myocardial dysfunction can be an indication

Question 7

Contraindications for Initiation of Extracorporeal Life Support (ECMO) - Strong Contraindications

Answer 7

• Extended mechanical ventilation (usually more than 7 days)
• Central Nervous System (CNS) catastrophes, including significant anoxic brain injury, diffuse axonal injury, massive intracranial hemorrhage, or herniation
• Irreversible lung disease not amenable to lung transplantation
• Unrecoverable heart condition and not a candidate for heart transplant or Ventricular Assist Device (VAD)
• Chronic severe organ dysfunction such as emphysema, cirrhosis, or renal failure
• Non-compliance due to psychosocial, financial, or cognitive issues, particularly in cases requiring a bridge to device or transplant

MCQs

Question 8

Relative contraindications for initiation of extracorporeal life support (ECMO)

Answer 8

• Age over 70 years
• Immunocompromised state from solid-organ or stem-cell transplant, solid-organ or hematologic malignancy, chronic immunosuppressive therapy, HIV/AIDS, or inherited immunodeficiency syndromes
• Chronic CNS deficit or unknown CNS status
• High risk for anticoagulation
• Multisystem organ dysfunction syndrome
• Patient is not a candidate for lung or heart transplant or VAD due to poor social support, severe aortic insufficiency, or preexisting renal failure