Thread by @MJGriksaitis, ‘How do I manage refractory hypoxaemia?’ Is the question to be answered [...]

‘How do I manage refractory hypoxaemia?’ Is the question to be answered by @ICheifetz

Firstly - what is refractory hypoxemia?

In general: failure to maintain saturation’s >88%

#WFPICCS20 #PedsICU

$‘How do I manage refractory hypoxaemia?’ Is the question to be answered by @ICheifetz Firstly - what is refractory hypoxemia? In general: failure to maintain saturation’s >88% #WFPICCS20 #PedsICU$

The PALICC recommendations for ventilation in #pARDS include:

- tidal volumes 3-6ml/kg for those with poor respiratory compliance & 5-8ml/kg for those with better compliance
- PEEP 10-15 titrated to Sats (and may need higher)
- Keep Pplat <28-32

#PedsICU #WFPICCS

For PEEP:
-no significant increase in stress or strain applied to lung if higher
-kids respond different: some have recruitable lungs & some don’t

In non-recruitable lungs applying

PEEP will

peak airway pressure

PEEP management needs to be bespoke

#PedsICU #WFPICCS20

For PEEP:-no significant increase in stress or strain applied to lung if higher-kids respond different: some have recruitable lungs & some don’t In non-recruitable lungs applying PEEP will peak airway pressure PEEP management needs to be bespoke #PedsICU #WFPICCS20

Driving pressure matters and seems to have a direct relationship with mortality

The driving pressure (delta P) > 15 is when mortality increases

So when dealing with refractory hypoxaemia aim to keep dP < or = 15

#PedsICU #WFPICCS20 #PedsAnes

$Driving pressure matters and seems to have a direct relationship with mortality The driving pressure (delta P) > 15 is when mortality increasesSo when dealing with refractory hypoxaemia aim to keep dP < or = 15 #PedsICU #WFPICCS20 #PedsAnes$

What about adjunct therapies in #pARDS?

The PARDIE data shows those with severe ARDS get more adjunct therapies.

NMB is the commonest used and has some evidence for it (also see @Martin_Kneyber talk - a thread I did earlier!)

#PedsICU #WFPICCS20

What about high frequency oscillation?

Adult data not supportive.

Some data that those with HFOV:
- benefit more if PF ratio < 100
- have longer length of ventilation
- no mortality benefit (RESTORE)

Lots of debate about this- are we using it correctly?

#PedsICU #WFPICCS20

Proning is a low cost intervention with evidence of improved outcomes in adult, but this has not been reproduced in children

The PARDIE data shows we use proning less in Europe/USA than LMIC... surely proning is safer/easier than #ECMO?

#PedsICU #ARDS #WFPICCS20

#ECMO for #ARDS is often used as a rescue therapy.

No data to demonstrate benefit for use of #ECLS but people will still often use it (as would I)

#WFPICCS20 #PedsICU

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