balancing lung protection vs early mobilization (can you ... · delivered by helmet vs face mask on...
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Balancing lung protection vs
early mobilization (can you
have your cake and eat it too?)
Toronto 2106
Jesse Hall MD
University of Chicago
Section of Pulmonary and Critical Care Medicine
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Faculty Disclosures
Dr. Hall
• receives honoraria from the ACCP for their board review course and SEEK publications
• receives honoraria from McGraw-Hill and Taylor-Francis publishing
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A 39 year old woman with a history of well controlled asthma and hypertension came to the ED with a one day history of SOB, rigors, high fevers, and rust colored sputum. She received high flow nasal oxygen for low SpO2 and 2 liters of fluid for tachycardia and hypotension. A urinary antigen for pneumococcus was positive and abx were begun. Over two hours her work of breathing increases and her arterial saturations are 85-88%.
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9/22
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9/22
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Should intubation be
forestalled with NIV to
facilitate many things,
including
mobibilization?
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Brochard et al AJRCCM
Sept 2016
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Or…………….
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Available at www.jama.com
Patel BK and coauthors
Effect of Noninvasive Ventilation
Delivered by Helmet vs Face Mask on the
Rate of Endotracheal Intubation in
Patients With Acute Respiratory Distress
Syndrome: A Randomized Clinical Trial
Published online May 15, 2016
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9/22
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The patient was intubated in the ED without a consideration of additional NIV. On AC RR 30, TV 320, FiO2 1 and PEEP 5 cm H2O, her ABG was 7.31/46/58. Her PEEP was increased to 16 cm H2O and the ABG revealed 7.30/48/122. Pplat was 28.
She is beginning to breath over the set ventilator rate.
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Proning?
NMB?
Salvage therapy protocol?
Fentanyl alone for sedation
Furosemide 60 mg q 4h
Mobilize from bed
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Extubated
9/25, this is
CXR 9/26,
d/c to home
9/28
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Onset and offset of critical care
interventions
Days or weeks
‘turning on a dime at the right time’
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0 7 14 21 280
20
40
60
80
50 100
Control
Intervention
Number at Risk
Control 55 51 21 13 9 4 0
Intervention 49 40 21 13 8 2 1
048.0P
Hospital Days
%
Fu
ncti
on
all
y I
nd
ep
en
den
t
Lancet, May 2009
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37 year old male
cirrhosis,
aspiration with
ARDS
CXR 24 hours
after intubation
Assist Control
Tidal Volume 400
PEEP 12
FiO2=70
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If this patient had not tolerated diuresis
and had worsened and even required
ECMO, does that preclude mobilization?
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In summary, in weighing controlling ventilation
in ARDS to avoid VILI (or SILI) but not losing
the ability to mobilize and avoid ICU-AW
• Is there a window to avoid intubation and promote mobilization?—interesting, controversial area of competing goals
• While intubated—yes, but you need to not lock in unnecessary immobilization
• And with salvage therapies such as ECMO?-yes—but if patients in the recovery phase of ARDS remain on ECMO when can they take how deep a breath (see first bullet point)?