A 49yo man aspirates at the end of an otherwise uneventful cystoscopy. He develops a chemical pneumonitis & is transferred to ICU. Over the next 24hrs his condition deteriorates rapidly. He is intubated due to severe hypoxia, & has high ventilatory requirements. Despite optimal management, he has refractory hypoxaemia.
This patient has acute respiratory distress syndrome, or ARDS.
CXR: There is widespread air-space consolidation, & air-bronchograms. In this clinical context this is most likely to represent ARDS due to aspiration.
The patient has refractory hypoxia despite optimal ventilation…it’s time to bring out the rescue strategies. In this particular case, the patient was started on VV-ECMO.
Here is his CT scan.
Here is his CT scan. Again there is dense consolidation & almost no aerated lung. Note there has been R IJ cannulation for VV-ECMO.
The patient remains stable for a fortnight, then gradually seems to be improving. He is tracheostomised, CXR beginning to clear, & lung compliance improving. There is talk of weaning off VV-ECMO. Suddenly he becomes more hypoxic again with poor ventilation.
What has happened?
This CT shows a moderate sized R pneumothorax. There is less consolidation. There is evolving ground glass changes in the lungs, & some apical honeycombing. There are small bilateral pleural effusions. The R IJ ECMO line remains in situ.
“ARDS is an acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, & loss of aerated lung tissue, with hypoxaemia & bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space & decreased lung compliance.”
The Bottom Line is a must know web site that collates landmark literature relevant to the care of critically ill patients. Here is the link for articles about ARDS. Yes, that’s right, they summarise the game-changing articles for you.
LITFL summary of ARDS literature presented topic-by-topic. Where’s the evidence for proning? Protective lung ventilation? It’s all there, with helpful commentaries on each study.