Tuesday, July 1, 2014

ARDS: Early Ventilator Settings Matter

Author: Sean Weaver, DO MPH
Emergency Medicine Resident
University of Nevada, School of Medicine

The following blog post appeared initially at www.lasvegasemr.com/foam-blog and is reproduced with the permission of the author.

A 40y/o male with no known significant PMH presents with non-productive cough, SOB, DOE, diarrhea, and possibly fever though he is not sure. He has not had a similar illness in the past, denies any recent travel, no sick contacts and denies ever smoking.

Vitals: HR 102, RR 20, O2 sats: 90% on RA, BP: 116/56, Temp: 98ºF

Physical exam reveals an ill appearing male in mild distress. Mucous membranes are dry with a thrush like appearance isolated to the soft palate. Pulmonary exam reveals equal breath sounds bilaterally with some scattered rhonchi, dry crackles and occasional wheeze. ECG was unremarkable. Two view chest x ray was positive for diffuse prominence of the interstitium with interstitial infiltrates vs interstitial edema.

While awaiting admission patient becomes tachypneic and requires NRB mask. Patient stated that he was having difficulty breathing, felt tired and agreed to intubation.

Vitals: HR 103, RR 40, O2sats: 94 % on NRB, BP: 124/86

The patient is successfully intubated, placed on AC/VC w/ PEEP of 10, TV 500, RR 14 and FiO2 of 100% with orders to titrate to O2 sats >90%. An ABG was ordered for two hours post intubation.

Representative post intubation chest X-ray:

Chest x ray is representative of the patient’s portable chest X-ray after intubation.
This image is freely available on-line, courtesy the University of Washington (2004) copyright policy at the following link: http://courses.washington.edu/med620/mechanicalventilation/case3answers.html

Post intubation ABG: pH: 7.39; PCO2: 29; PO2: 112; FiO2: 100; SO2: 98

What is your diagnosis?

What interventions, specifically regarding the ventilator settings, could dramatically reduce the mortality risk in this patient?