A session blog from Day 1 of State of the Art, London December 2015. See the full list.
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Standing room only for this talk with many delegates waiting to get in and standing at the back. Luciano clearly a very popular speaker with many keen to hear his views. Charlotte chaired an interesting session aiming to explore Luciano’s gems of knowledge surrounding ARDS.
Why aren’t RCT helping?
He feels different the use of data can lead to different views. Starting off with an observation of reality deriving a general view which you subsequently try and prove experimentally.
Obviously well designed positive trials are very strong BUT If negative be careful to throw away original evidence. It becomes a question of definition.
In his own unit LG writes Acute resp failure due to ….because ARDS kills due to underlying disease not due to the ARDS entity itself and defining the ARDS misses the point.
Do you use diff nutrition?
Not really. Still waiting on better evidence.
Which ARDS treatment had greatest impact?
Lung protected ventilation is the result of limiting mechanical power and thus a product of tidal vol, pressure and frequency
TV is the easiest to measure, show and strongest indicator of mechanical power.
PEEP doesn’t increase power as the lung is not moving
What counts is movement i.e Tidal Volume
Why 6ml /kg?
6 better than 12, if ARDSNET had done 6 vs 10 would probably not have shown a difference.
The decision to have 12 was from a phone call as originally 6 to 10 might have been negative therefore 6 to 12 proves a concept for gentle vs aggressive ventilation thus decreasing pressure, volume and frequency you reduce mechanical power and go in right direction
Should we stop thinking of vent and do ECMO?
LG told us an interesting clinical vignette of a young girl from Paris on ECMO overnight who developed a cerebral bleed which she died from.
His thoughts are if you can choose between two options be wary of picking the one that can have irreversible complications.
ECMO not a panacea and is very invasive
Recruitable lung should we take off fluid?
Remove fluids when better or you lead to renal failure last drop comes from lungs so its not easy
Aim for even balance
Patients getting more obese, aims based on ideal body wt should we change this with super morbid obese?
In obese patient they have normal lung volume
Ideal body weight idea is size of lung is related to height
Do a CT at PEEP 5 and PEEP 45 measure what is recruitable
If no recruitment you can avoid higher vols.
This is just a summary of Luciano’s Q and A session please see ARDS 3 x 3 for more ARDS info.