Abstract
Introduction: Lung protective ventilation therapy with low tidal volume-high PEEP is the standard treatment for the patients with acute respiratory distress syndrome (ARDS). Oscillators are occasionally used for salvage ventilation in cases where poor compliance restricts the use of traditional ventilation with ARDS. In addition to ventilator therapy, prone positioning has been used to improve oxygenation. We presented a challenging case of ARDS, which failed medical management extracorporeal membrane oxygenation (ECMO) support and oscillatory ventilation. Prone positioning was initiated which improved oxygenation, respiratory compliance and posterior atelectasis. Case presentation: A 41-year-old morbid obese female developed ARDS due to influenza pneumonia. The patient remained hypoxic despite optimum medical and ventilator management and required veno-venous extracorporeal membrane oxygenation (VV ECMO). CT scan of the chest showed ARDS with posterior consolidation. Despite ARDSnet ventilation support, antiviral therapy and ECMO support, there was no clinical improvement. High frequency oscillatory ventilation was initiated on ECMO day #13, which resulted in no respiratory improvement over the next 5 days. On ECMO day #18, the patient was placed on a Rotaprone® bed Therapy, utilizing a proning strategy of 16 hours a day. The clinical improvements observed were resolving of the consolidation on CXR, improvements in ventilatory parameters and decreased oxygen requirements. The patient was successfully weaned off ECMO on POD#25 (8 days post prone bed). Conclusions: Prone position improved oxygen saturation and pulmonary compliance in severe ARDS requiring ECMO and it might facilitate early weaning.
Highlights
Lung protective ventilation therapy with low tidal volume-high positive expiratory pressure (PEEP) is the standard treatment for the patients with acute respiratory distress syndrome (ARDS)
High frequency oscillatory ventilation was initiated on extracorporeal membrane oxygenation (ECMO) day #13, which resulted in no respiratory improvement over the 5 days
Patients with severe ARDS are managed with lung protective mechanical ventilation strategies which include low tidal volumes calculated to predicted body weight, high positive expiratory pressure (PEEP) with low targeting plateau pressure < 30 cm H2O
Summary
Acute Respiratory distress syndrome (ARDS) has recently been re-defined by the Berlin criteria as severe hypoxemia, decreased lung compliance, and diffuse bilateral infiltration on chest X-ray. Patients with severe ARDS are managed with lung protective mechanical ventilation strategies which include low tidal volumes calculated to predicted body weight, high positive expiratory pressure (PEEP) with low targeting plateau pressure < 30 cm H2O. These respiratory settings have been used primarily for the patient with severe ARDS [1] and shown improved survival. Young et al showed that oscillators should not be routinely used for ARDS, but it could be considered as a salvage modality [2] In addition to these ventilator managements, prone position has been used in ARDS to improve oxygenation [3]. This repots were approved our institutional review board (IRB, #11D185) and consents were waived due to retrospective care report, per IRB
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