Severe ARDS can pose extraordinary problems for ICU clinicians and their patients. Conventional ventilation strategies often fail to ameliorate the severe hypoxemia exhibited by these patients, leading to high mortality rates.
A panel of pulmonologists and critical care experts will discuss the current state-of-the-art evidence for interventions to improve outcomes in these patients during the session, Severe ARDS: State-of-the-Art Management Strategies, Monday, from 8:30 am to 9:30 am, in Room 312 of the convention center.
“There are a lot of different conditions that can lead to ARDS, but the usual triggers for ARDS are infections,” said Session Chair, Daniel Ouellette, MD, MS, FCCP, Associate Professor of Medicine at Wayne State University School of Medicine and Chief of Pulmonary and Critical Care Medicine at Henry Ford Hospital in Detroit. “COVID-19 certainly was an important infection leading to ARDS, but other infections such as influenza or other viral infections, bacterial pneumonias, and other types of insults can lead to ARDS.”
Among the treatment strategies that have been proven effective, he said, is the use of positive end-expiratory pressure (PEEP).
“We’ve known for decades that the application of PEEP to mechanical ventilation can improve oxygenation, but what we’ve learned in the last 10 years or so is that mortality is also improved by the use of PEEP,” Dr. Ouellette said. “During this session, we will review strategies about the application of PEEP, how to determine how much is needed, and how it can improve outcomes.”
Another more recent intervention that has proven to be important, he said, is the use of prone ventilation.
“There are some challenges when the patient is placed in the prone position, in that treating their overall medical condition becomes more difficult,” Dr. Ouellette said. “It’s harder to maintain IVs, and the patient is at risk for things like pressure sores, but I think during the COVID pandemic, we learned how to get over all the obstacles. So, one of our speakers during the session will go over how and when to use prone positioning and what kind of improvements in outcomes can be expected.”
The importance of driving pressure in severe ARDS will also be discussed, he said.
“Driving pressure is an important measurement because when one looks at outcomes and mortality from being on mechanical ventilation with ARDS, the metric or measurement that’s most closely associated with survival is the driving pressure,” Dr. Ouellette said. “We know that the lower the driving pressure is, the better the patient’s mortality rate is going to be. What we strive to do on the ventilator is to invoke a variety of strategies that allow us to lower the driving pressure and keep it as low as we possibly can so that we can have improved patient outcomes.”
Despite these different strategies, some patients with ARDS who remain severely ill and are at extreme risk of dying may undergo extracorporeal membrane oxygenation (ECMO), he said. The final presentation of the session will review how to identify which patients with ARDS may benefit from ECMO.
“This strategy has been used increasingly frequently, especially during the COVID pandemic. Data has been hard to come by, though, about whether or not ECMO really improves mortality, but all of us who are involved in taking care of patients with ARDS have had patients who we know would not have survived if they hadn’t received ECMO,” Dr. Ouellette said. “ECMO is very challenging, and it requires a great deal of expertise in a specialty center, but in the best hands, it appears to be improving how patients do.”