ECMO for Respiratory Failure

ECMO for Respiratory Failure

A 40 year old lady was admitted under the medical team with pneumonia. She was normally well with no history of respiratory illnesses. On day two of her hospital admission she became more hypoxic necessitating continuous-positive-airway-pressure. Her condition rapidly worsened and her chest x-ray showed diffuse bilateral infiltrates. An echocardiogram demonstrated normal systolic function. She was intubated and ventilated. Despite sedation, ARDSnet ventilation, paralysis and then proning her, she remained severely hypoxaemic. A therapeutic bronchoscopy was performed prior to proning but did not improve her condition.

Should she be referred for consideration of ECMO and was is this evidence to support it’s use?

Read More »

Diagnosing Ventilator Acquired Pneumonia

Diagnosing Ventilator Acquired Pneumonia

A 65 year old woman developed a left lower lobe hospital acquired pneumonia following a elective laparoscopic procedure for which she was ventilated for 4 days. Twenty four hours post extubation, she developed hypoxic respiratory failure with bilateral patchy shadowing on chest X-ray. She was reintubated and subsequently grew Pseudomonas aeruginosa from tracheal aspirate.

How do we diagnose Ventilator Associated Pneumonia (VAP)?Read More »

Use of PEEP in ARDS

Use of PEEP in ARDS

A young woman was admitted with respiratory failure requiring invasive ventilation. She had bilateral lobar consolidation and positive urinary pneumococcal antigen. She was ventilated with protective lung strategies but required FiO2 of between 0.8-1.0. A PEEP of 18 was set. She was ventilated for over 2 weeks, and was tracheostomised but was discharged from the ICU after 3 weeks.

How is PEEP utilised in the ventilatory strategies in the management of Adult Respiratory Distress Syndrome?Read More »

Massive Pulmonary Embolism

Massive Pulmonary Embolism

A 48 year old lady was admitted to critical care whilst suffering from sepsis secondary to severe cellulitis of her leg. She was obese with a BMI of 38 and was managed with insulin and oral anti-hyperglycaemics for type 2 diabetes mellitus. A doppler scan was unable to exclude a DVT. She had a further deterioration 30 hours later. Her sinus tachycardia accelerated to 130 bpm, along with a drop in blood pressure to 100/40. Arterial blood gas demonstrated an increasing A-a gradient as his FiO2 increased. Although such changes can occur in sepsis, the acute onset led to concerns regarding venous thromboembolism and pulmonary emboli.

What are the options for prevention of venous thromboembolism and pulmonary embolism?
Proning for Refractory Hypoxaemia

Proning for Refractory Hypoxaemia

A 60 yr old woman was admitted to the ICU with a severe community acquired pneumonia and septic shock. She was invasively ventilated with a lung protective strategy, optimised PEEP and recruitment manouvres as needed. Her refractory hypoxia persisted and so she was probed for 16 hours a day for the first 5 days of her admission. She made slow but steady improvements and was discharged from the ICU 10 days later.

What is the current evidence for proning as a rescue therapy for refractory hypoxia?Read More »

ECMO for Severe Refractory Hypoxaemia

ECMO for Severe Refractory Hypoxaemia

An 60 year old woman developed ARDS secondary to pneumococcal meningitis. Despite optimal ventilatory management and restrictive fluid intake her oxygenation remained severely impaired. She was referred to the regional respiratory failure unit who established her on mobile ECMO for retrieval. She remained on ECMO for five days, weaned off the ventilator after three further days and made a full neurological recovery leaving hospital two weeks later.

Is there sufficient evidence to promote the use of Extracorporeal Membrane Oxygenation (ECMO) for the management of severe refractory hypoxia in the United Kingdom?Read More »

Pulmonary Vasculitis and Haemorrhage

Pulmonary Vasculitis and Haemorrhage: The Role of Plasmapharesis

A 65 year old woman investigated for malaise by her GP and found to have a creatinine of 993 and urea of 47.3. She was admitted to hospital to await renal assessment and commencement of dialysis, but became acutely breathless and hypoxic. CXR showed bilateral pulmonary consolidation. She was intubated due to her respiratory failure and frank blood was suctioned from her tracheal tube. Investigations for pulmonary-renal syndromes led to a positive cANCA and a presumptive diagnosis of Wegener’s granulomatosis. She was pulsed with methylprednisolone and commenced plasmapheresis. Despite this she continued to deteriorate and subsequently died.

What is the role of plasmapheresis in pulmonary vasculitides and pulmonary haemorrhage?

Read More »

The Role of ECMO in ARDS

The Role of ECMO in ARDS

A middle aged man with acute pancreatitis developed multiorgan failure and was admitted to the ICU and required ventilation and noradrenaline. He became progressively more hypoxic despite lung protective ventilation, paralysis, inverse ratios and a restrictive fluid regime. He developed bilateral pneumothoraces requiring chest drains. He was retrieved to the nearest refractory hypoxia centre and established on VV ECMO. On the third day of ECMO therapy he developed lateralising signs and was found to have had a large intracranial haemorrhage. Treatment was subsequently withdrawn.

Do patients with ARDS benefit from ECMO?Read More »

Nitric Oxide for Refractory Hypoxaemia in ARDS

Nitric Oxide for Refractory Hypoxaemia in ARDS

A 65 year old woman developed a hospital acquired pneumonia 24 hours after a multilevel spinal fixation. She became progressively more hypoxic and required intubation. She remained profoundly hypoxic despite FiO2 1.0, paralysis, lung protective ventilation and inverse ratios. She was established on inhaled nitric oxide therapy as anticoagulation for ECMO was felt to be contraindicated. This resulted in an rapid but modest increase in SpO2. Over the next days, her recovery was complicated by pneumothoraces requiring chest drains, but she remained on iNO for several days, and weaned off the ventilator at around day 10.

Does nitric oxide have a role to play in hypoxemia secondary to ARDS?Read More »

Mechanical Ventilation in patients with COPD

Predicting Outcomes of Mechanical Ventilation in patients with COPD

An elderly man with an infective exacerbation of COPD deteriorated during his medical admission with type 2 respiratory failure. He was commenced on ward-based non-invasive ventilation while establishing further history. He was on home nebulisers, was awaiting assessment for home oxygen, and was limited to household mobility only. He could not climb stairs. He had secondary polycythaemia. After discussion with the patient and family, a ward-based ceiling of care was set. He remained on NIV for several days before being weaned off and discharged to a rehabilitation facility after a two week admission.

Can we predict outcomes for patients with respiratory failure and COPD who require invasive ventilation?Read More »