PMH: DM II

Recurrent ARDS

Idiopathic interstitial lung

disease

Asthma

Methadone dependence

Cocaine abuse

Hep C +

GERD

Depression

PTSD

5 hospitalizations and 4

intubations over the past 2

years for ARDS

Most have been related to crack

cocaine abuse, though at least

one was not

Patient is on 3-5liters of O2 at

home

Survival rates in ARDS have improved

significantly over the last 10 – 15 years

There are now more reports of patients

with recurrent ARDS

Still relatively rare

Mayo Clinic published results of Case/Control study

19 cases Patients with hx of 2 or

more episodes of ARDS (Case) compared to patients with only 1 episode of ARDS (Control)

Patients were matched 1:1:1 based on age, gender, predisposing factors for ARDS (sepsis, trauma, infection, etc)

No differences in alcohol use, smoking, or chronic opioid use between Cases and Controls

78.9% of the Cases had GERD

26.2%of the Controls had GERD

Am J Respir Crit Care Med 81;2010:A2594

No respiratory distress at rest

Diffuse wheezing on auscultation

Spo2 80-83% on 5 liter nasal cannula

Transferred to the HCMC ED for further

eval

WBC 21

Urine Screen positive for cocaine and

opiates

No blood gases noted???

Admitted to MICU with plan to treat with

steroids, nebs and Abx

Cough

Chest Pain

SOB

Hemoptysis

Exacerbation of Asthma

Pulmonary Edema

Interstitial Pneumonitis

BOOP

Eosinophilia

COPD

Patient had improved

with treatment…

Transferred to the

general medicine floor

RRT Called on Patient

SpO2 82% despite

High-flow O2

HR 130

RR 30

Transferred back to

MICU

Patient placed on BiPAP

20/10 , 1.0 FiO2

SpO2 89%

VBG 7.26/65/39/28

Patient refusing intubation

Inhaled Epoprostenol

(Flolan) added

Significant

desaturation with any

exertion

Patient C/O fatigue

and agrees to

intubation

ABG 7.27/69/143/30

Patient intubated by

CRNA

Desaturation to 50’s

during intubation

Patient’s ventilation

and oxygenation

labile

Patient has very poor

lung compliance

ABG post intubation:

7.02/126/84/31

Vent settings: A/C

20/300/100%/+18

PIP 54

Pplt 41

Low tidal

volumes/high PEEP

Recruit atelectatic

alveoli

Prevent alveolar

collapse

Control alveolar

distension to prevent

barotrauma

This does not appear

to be working…

ECMO established

standard of care for

pediatric and neonatal

respiratory failure

Not widely used in adults

‘74-’77 NIH sponsored

study of V-A ECMO vs.

conventional ventilation

with little improvement in

outcome

‘86 Gattinoni reported

improved survival among

ECCOR patients with

respiratory failure, but

similar to inverse I:E PCV

CESAR trial published in 2006

180 patients with severe ARDS randomly

referred to ECMO center or conventional

management

Group referred to ECMO center had

significantly increased survival without

disability at 6 months (63% vs. 47%)

Criticizied for lack of standardized

ventilator care

Provides extracorporeal

oxygenation and ventilation

for patients with primary

pulmonary failure

Single dual-lumen cannula

required

Ports in superior and

inferior vena cavae

Patient successfully cannulated for

ECMO in the OR

Vent strategy on ECMO: Keep the lung

open, prevent barotrauma

Patient placed on A/C PCV • Rate 20

• PIP 30

• PEEP 15

• Vte 145 mls

Patient stable on ECMO

Lung compliance slowly improving

Mild nosebleed

Mild kidney injury

Bronched every couple of days

Turn off the sweep gas Place vent settings for

full support Check pressures in

Volume ventilation, volume in pressure ventilation

Check Blood gas

Patient successfully removed from ECMO after 14 days

Patient placed on A/C

PCV: • RR 20

• PIP 32

• FiO2 0.8

• PEEP 12

• Exhaled Vte 300-350mls

• 7.30/49/91/24

2 DAYS AFTER ECMO

STOPPED

Vecuronium discontinued

successfully

Vent settings

• RR 20

• PIP 30

• PEEP 12

• FiO2 0.5

• 7.33/45/115/23

Patient extubated 24

days after admission

to the hospital

One week after

ECMO stopped

Patient discharged to

physical

rehabilitation center

for profound

weakness

Patient subsequently

sent through

inpatient chemical

dependency rehab

9 months after this

admission she was

admitted with a

similar presentation

She was intubated for

1 week

She was positive for

cocaine

54 y.o. Nursing home patient presents to

the ED with hypoxia, AMS and acute renal

failure

PMH: morbid obesity (BMI 58), OSA, DVT

(on coumadin)

SpO2 82% on 10 liter mask

ABG 7.29/69/76/32

BUN 33 Cr 2.8 K+6.4

Chest CT negative for PE

BiPAP

Kayexcelate

Ca gluconate/insulin/bicarb

2 liters saline IV

• Transported to the MICU

Patient remains anuric-dialysis catheter

placed

Patient remains altered: • VBG 7-17/96/48/33

Decision made to intubate

Defined as a BMI of 40 or greater

From 2000-2005 the prevalence of

morbid obesity increased by 50%

Obesity may not directly correlate with difficulty of intubation

Neck circumference does seem to directly

correlate with difficulty of intubation Decreased neck mobility can hinder

visualization with laryngoscope

Extraneous tissue in the airway can make bag-mask ventilation difficult

Blind Nasal Intubation

Glidescope

“Awake” Intubation

Back-up Airway (LMA/King)

Retrograde Intubation

Trans-tracheal needle ventilation

Cricothyrotomy

Tracheostomy

“AWAKE” INTUBATION

WITH BRONCHOSCOPY

BRONCHOSCOPIC

INTUBATION FAILED

Patient is lightly sedated

Patient is not chemically

paralyzed

Patient continues to breathe

spontaneously

Local anesthetic must be

used to overcome gag

reflex

Silicone coated,

anatomically curved airway

Distal end has an epiglottis

elevating bar that allows

blindpassage of an

endotracheal tube

Patient can usually be

ventilated temporarily

through the iLMA after

placement

Patient developed laryngospasm Patient was chemically paralyzed MDA and CRNA were unable to bag-

mask ventilate Patient developed subcutaneous

emphysema in the neck and chest Patient desaturated and became

bradycardic Plan to proceed to emergency

tracheostomy

Small incision is made in the cricothyroid membrae

Small tracheostomy tube or endotracheal tube is passed through incision

Must be able to identify landmarks in the neck

Must be converted to a tracheostomy to prevent sub-glottic stenosis

Contraindicated in tracheal perforation

Requires larger incision further down the airway

Tube placed between 2nd or 3rd tracheal rings

Open procedure allows for inspection of the trachea

Must be performed very quickly

Once incision was made tracheal perforation was noted by presence of air bubbles

First incision into trachea was unsuccessful in ventilating patient

Larger incision required to pass tube and adequately ventilate patient

Patient had developed a pneumothorax from tracheal perforation requiring chest tube placement

Patient had large amount of bleeding from incision leading into sternocleidomastoid muscle

Patient had a brief period of asysotle after prolonged hypoxia

Patient very unstable in ICU requiring

multiple blood products and pressors

Patient very difficult to oxygenate and

ventilate

Patient returned to OR for repair of

tracheal perforation as well as damage

from slash trach

Despite aggressive care including

dialysis, pressors, inhaled Epoprostenol,

maximal vent support patient made no

progress

Decision was made by family to withdraw

support after 8 days

Patient died within minutes of removal of

vent and blood pressure support