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

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

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%.

9/22

9/22

Should intubation be

forestalled with NIV to

facilitate many things,

including

mobibilization?

Brochard et al AJRCCM

Sept 2016

Or…………….

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

9/22

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.

Proning?

NMB?

Salvage therapy protocol?

Fentanyl alone for sedation

Furosemide 60 mg q 4h

Mobilize from bed

Extubated

9/25, this is

CXR 9/26,

d/c to home

9/28

Onset and offset of critical care

interventions

Days or weeks

‘turning on a dime at the right time’

http://www.thelancet.com/journals/lancet/issue/current

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

37 year old male

cirrhosis,

aspiration with

ARDS

CXR 24 hours

after intubation

Assist Control

Tidal Volume 400

PEEP 12

FiO2=70

If this patient had not tolerated diuresis

and had worsened and even required

ECMO, does that preclude mobilization?

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)?