Trach timing for ARDS

[militarymd]

To those practicing CCM.

Patient with ARDS secondary to community acquired pneumonia....single organ failure...

on vent for 8 days....getting all modalities for ARDS..

Mean airway pressure in the low to mid 20's

FIO2 70% pO2 65 mmHg

Minute Ventilation about 10 liters /minute to maintain normocarbia

CXR stable in last several days.

Would you be referring the patient for a trach at this point?

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[DropkickMurphy]

To those practicing CCM.

Patient with ARDS secondary to community acquired pneumonia....single organ failure...

on vent for 8 days....getting all modalities for ARDS..

Mean airway pressure in the low to mid 20's

FIO2 70% pO2 65 mmHg

Minute Ventilation about 10 liters /minute to maintain normocarbia

CXR stable in last several days.

Would you be referring the patient for a trach at this point?

From an RT's standpoint, I would say to go ahead and trach them.

 

[Eidolon6]

We, as a practice, suck at predicting extubation, esp after ARDS. No "good" data on the subject but trends favor earlier vs later trach. I use 8-10 days....surgery minded folks use 48 hrs. Trach is probably not a bad consideration at this point.

 

[waterski232002]

What's the PEEP at? Might want to crank it up to keep the FIO2 from being so toxic...

 

[militarymd]

What's the PEEP at? Might want to crank it up to keep the FIO2 from being so toxic...

Peep is 13....

I personally don't care so much about peep as MEAN airway pressure.

 

[waterski232002]

Peep is 13....

I personally don't care so much about peep as MEAN airway pressure.

His lungs may... I'm curious how long it takes for pulmonary fibrosis to develop? Can anyone shed some insight?

 

[southerndoc]

We follow a strict ARDSnet protocol for managing ARDS patients.

To answer the original question, if the patient is improving, then it may not be a horrible idea to wait on the trach. However, if it looks like he/she is worsening or "holding steady," then a trach is probably a thought to consider.

Where I am a resident, the medical teams do not trach that easily. I've seen patients intubated for 2 weeks without being trached. Where I went to medical school, the surgical service would trach patients if they were on the vent for more than 4 days it seemed.

 

[militarymd]

His lungs may... I'm curious how long it takes for pulmonary fibrosis to develop? Can anyone shed some insight?

Peep is just one of several variables used to target higher MEAN airway pressures....which ultimately recruits alveoli ...and which ultimately improves oxygenation.....

That's why I don't care what someone's peep is.

 

[waterski232002]

Peep is just one of several variables used to target higher MEAN airway pressures....which ultimately recruits alveoli ...and which ultimately improves oxygenation.....

That's why I don't care what someone's peep is.

Yeah... but 70% FIO2 is toxic and pts should not be exposed to such a high oxygen fraction for extended periods of time. It's better to up the PEEP and decrease the FIO2 to 60% or less... Unless you don't care about putting your patient on a future lung transplant list.

 

[militarymd]

Yeah... but 70% FIO2 is toxic and pts should not be exposed to such a high oxygen fraction for extended periods of time. It's better to up the PEEP and decrease the FIO2 to 60% or less... Unless you don't care about putting your patient on a future lung transplant list.

First of all, this is not my patient. This patient belongs to a pulmonologist who believes that 70% FIO2 is fine....and it probably is.

Second, you can lower the FIO2 by increasing the MEAN airway pressure...increasing the PEEP is one of several ways of doing it....

I think you are stuck on PEEP..when the MEAN airway pressure is the number that you ultimately care about when attempting to decrease FIO2 requirement.

Oscillating vents don't have PEEP...just MEAN....or PEEP equals MEAN is another way of looking at it.

 

[markneil]

PEEP and FiO2 should be set as needed (100%), PCV, and trach the pt for a more secure and definitive airway.

 

[DropkickMurphy]

APRV.....

 

[toughlife]

To those practicing CCM.

Patient with ARDS secondary to community acquired pneumonia....single organ failure...

on vent for 8 days....getting all modalities for ARDS..

Mean airway pressure in the low to mid 20's

FIO2 70% pO2 65 mmHg

Minute Ventilation about 10 liters /minute to maintain normocarbia

CXR stable in last several days.

Would you be referring the patient for a trach at this point?

Why are we concerned about maintaining normocarbia in an ARDS patient?

What's the rate at?

 

[militarymd]

Why are we concerned about maintaining normocarbia in an ARDS patient?

What's the rate at?

I'm not...this isn't my patient.

 

[toughlife]

I'm not...this isn't my patient.

OK. Kinda ghetto management of an ARDS patient.

 

[militarymd]

OK. Kinda ghetto management of an ARDS patient.

No....this patient came to my OR suite for a trach.

 

[toughlife]

No....this patient came to my OR suite for a trach.

I was referring to the fact they were trying to maintain normocapnia which makes me wonder whether they were using LPV.

To the OR for a trach? They are done at the bedside.

 

[neutropeniaboy]

My opinion: case by case.

Data show laryngeal complications as early as 3 days after intubation, and that excludes atypical complications like arytenoid dislocation related to the act. I'm seeing a guy who has a vocal cord paralysis of his right cord and was intubated only 4 days.

You obviously have to look at the patient and his/her disease process. You should be requesting a trach right up front if you know your patient's not going to do well with whatever caused his RF.

A lot of nonsurgical caregivers seem to view trach as a dead end -- the last ditch effort. Hopefully more people will start seeing trachs as something that help progress patient recovery.

As for the issue of the OR v. ICU room. Anyone who makes it a practice of doing bedside trachs is, in my opinion, a fool. The OR has better lighting, better anesthesia, better equipment, more instruments, and staff better able to handle complications that arise. Yes, it's more expensive, timely, and you have to wait for the surgeons. Something tells me that once you get your first bad complication, your practice might be different.

 

[toughlife]

My opinion: case by case.

Data show laryngeal complications as early as 3 days after intubation, and that excludes atypical complications like arytenoid dislocation related to the act. I'm seeing a guy who has a vocal cord paralysis of his right cord and was intubated only 4 days.

You obviously have to look at the patient and his/her disease process. You should be requesting a trach right up front if you know your patient's not going to do well with whatever caused his RF.

A lot of nonsurgical caregivers seem to view trach as a dead end -- the last ditch effort. Hopefully more people will start seeing trachs as something that help progress patient recovery.

As for the issue of the OR v. ICU room. Anyone who makes it a practice of doing bedside trachs is, in my opinion, a fool. The OR has better lighting, better anesthesia, better equipment, more instruments, and staff better able to handle complications that arise. Yes, it's more expensive, timely, and you have to wait for the surgeons. Something tells me that once you get your first bad complication, your practice might be different.

In that case your ENT colleagues at my institution are fools since they do them at the bedside all the time.

 

[southerndoc]

In that case your ENT colleagues at my institution are fools since they do them at the bedside all the time.

As do our other surgeons.

I think bedside trachs are more common than trachs in the OR.

 

[Smurfette]

At the 3 institiutions my program rotates through, NONE do bedside trachs. This includes both gen surg and ENT. Few attendings do perc. trachs, almost everybody does them open.

It's a trade-off...sometimes it would be nice (and faster), but sometimes you just cannot predict which patients will be a bit tougher than average to do, and being in an OR means you have staff available who can react better to your needs, and who have that particular retractor or instrument you need in the room or quickly available....which may not be the case in the MICU.

Personally, I don't think one way is better than the other for simple, totally straight-forward trachs....but if you even think it may be difficult due to a thick, short neck or other pt issue, the OR is a safer bet. Just my 2 cents.

 

[markneil]

OR or not, trach the pt.