Acute hypoxic respiratory failure

Acute Respiratory Distress Syndrome (ARDS)
non-cardiogenic pulmonary edema characterized by acute onset (<7 days)

  • CC: Severe shortness of breath, hypoxia, respiratory distress

  • PP: Tachypnea, increased work of breathing, hypoxia refractory to oxygen, fever, cough, altered mental status, chest tightness

  • PN: No isolated volume overload symptoms

  • Pertinent SHx: Tobacco/vaping, EtOH use, drug use, aspiration risk,

  • Etiology:
    Sepsis, pneumonia, COVID-19, aspiration, pancreatitis, trauma, inhalational injury, transfusion reaction (TRALI), near drowning

  • Initial DATA: CBC, CMP, lactate, ABG/VBG, blood cultures, sputum cultures, procalcitonin, CXR, CT chest if needed, EKG, troponin/BNP, pulse ox, ventilator settings/ABGs

  • P/F [Mild >300, Mod >200, Severe >100] -> PaO2​​ (ABG) FiO2 (decimal)

  • Pending DATA:
    Blood/sputum cultures, MRSA nares, viral testing, CTA chest if PE concern, bronchoscopy/BAL studies, autoimmune workup if indicated

  • Course:

Plan

  • Low TV to prevent barotrauma

  • High PEEP to Prevent atelectasis

  • keep lateau Pressure<30 cmH2​O (Stiff lungs) -> Low TV (4–6) adjust PEEP 5-15

  • Treat underlying cause

  • consider proning P/F ratio <150 despite optimized ventilator settings/PEEP -> ~16 hours prone and 8 hours supine until oxygenation improves

  • consider to Diurese hypoxia despite vent optimization and Positive fluid balance (Lasix 40mg IV - repeat as needed)

  • consider Dexamethasone 20 mg daily x5 days (covid 6mg)

  • Serial ABGs and ventilator adjustments

  • Broad-spectrum antibiotics pending cultures if infectious concern

  • Daily SAT/SBT when appropriate

  • Consider paralysis if severe ventilator dyssynchrony

  • Escalate to ECMO evaluation if refractory hypoxemia P:F <80 survival