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2021-10-05-micu-morning.md (2023B)

      1 # ARDS
      2 
      3 Noncardiogenic pulmonary edema.
      4 
      5 ## How to confirm "Noncardiogenic"?
      6 
      7 Gold standard would be RHC, 
      8 but typically defined clinically
      9 
     10 ## [Berlin Criteria](https://www.mdcalc.com/berlin-criteria-acute-respiratory-distress-syndrome#evidence)
     11 
     12 P/F ratio. 
     13 
     14 Severity ratings (for prognostication, do not influence tx)
     15 
     16 - <300 mild
     17 - 100-200 moderate
     18 - <100 severe
     19 
     20 PEEP >= 5.
     21 
     22 Acute: onset w/in 1wk of insult
     23 
     24 ## Etiologies
     25 
     26 Two major branches:
     27 Pulmonary vs extrapulmonary.
     28 
     29 Extrapulmonary: anything inflammatory (pancreatitis, sepsis)
     30 
     31 
     32 ## Mgmt
     33 
     34 ### Low-tidal volume ventilation: 6mL/kg of ideal body weight
     35 
     36 [NEJM 2000](https://www.nejm.org/doi/full/10.1056/nejm200005043421801)
     37 
     38 Finer points from this article:
     39 
     40 - 6 vs 12
     41 - plateau pressure targets differed
     42 - allowances for adjusting tidal volume based on ventilation needs
     43 - used pressure control, which has led to wider use of this mode
     44 
     45 ### Conservative fluid mgmt
     46 
     47 [NEJM 2006](https://www.nejm.org/doi/full/10.1056/nejmoa062200)
     48 
     49 - no mortality difference
     50 - improvements in ventilator-days and ICU days
     51 - CVP endpoint less than 4, almost never reached == never cease to diurese
     52 
     53 ### Proning
     54 
     55 [NEJM 2013](https://www.nejm.org/doi/full/10.1056/nejmoa1214103)
     56 
     57 - large reported mortality benefit
     58 - results called into question
     59 
     60 ### Paralysis
     61 
     62 [NEJM 2019](https://www.nejm.org/doi/full/10.1056/nejmoa1901686)
     63 
     64 - no mortality benefit
     65 - still will paralyse patients, but not early as part of routine practice
     66 
     67 ### Steroids (all-comers)
     68 
     69 [Lancet 2020](https://pubmed.ncbi.nlm.nih.gov/32043986/)
     70 
     71 - done just prior to COVID-19
     72 - long enrollment period, very strict enrollment criteria
     73 - possible improvement in ventilator-days and mortality
     74 
     75 ### VV Ecmo
     76 
     77 [NEJM 2018](https://www.nejm.org/doi/full/10.1056/NEJMoa1800385)
     78 
     79 ![EOLIA KM Curve](https://www.nejm.org/na101/home/literatum/publisher/mms/journals/content/nejm/2018/nejm_2018.378.issue-21/nejmoa1800385/20190311/images/img_medium/nejmoa1800385_f2.jpeg)
     80 
     81 - trial ended early for futility, but KM curves did diverge