Chest
Volume 137, Issue 6, June 2010, Pages 1437-1448
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POSTGRADUATE EDUCATION CORNER
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Severe Hypoxemic Respiratory Failure: Part 2—Nonventilatory Strategies

https://doi.org/10.1378/chest.09-2416Get rights and content

ARDS is characterized by hypoxemic respiratory failure, which can be refractory and life-threatening. Modifications to traditional mechanical ventilation and nontraditional modes of ventilation are discussed in Part 1 of this two-part series. In this second article, we examine nonventilatory strategies that can influence oxygenation, with particular emphasis on their role in rescue from severe hypoxemia. A literature search was conducted and a narrative review written to summarize the use of adjunctive, nonventilatory interventions intended to improve oxygenation in ARDS. Several adjunctive interventions have been demonstrated to rapidly ameliorate severe hypoxemia in many patients with severe ARDS and therefore may be suitable as rescue therapy for hypoxemia that is refractory to prior optimization of mechanical ventilation. These include neuromuscular blockade, inhaled vasoactive agents, prone positioning, and extracorporeal life support. Although these interventions have been linked to physiologic improvement, including relief from severe hypoxemia, and some are associated with outcome benefits, such as shorter duration of mechanical ventilation, demonstration of survival benefit has been rare in clinical trials. Furthermore, some of these nonventilatory interventions carry additional risks and/or high cost; thus, when used as rescue therapy for hypoxemia, it is important that they be demonstrated to yield clinically significant improvement in gas exchange, which should be periodically reassessed. Additionally, various management strategies can produce a more gradual improvement in oxygenation in ARDS, such as conservative fluid management, intravenous corticosteroids, and nutritional modification. Although improvement in oxygenation has been reported with such strategies, demonstration of additional beneficial outcomes, such as reduced duration of mechanical ventilation or ICU length of stay, or improved survival in randomized controlled trials, as well as consideration of potential adverse effects should guide decisions on their use. Various nonventilatory interventions can positively impact oxygenation as well as outcomes of ARDS. These interventions may be considered for use, particularly for cases of refractory severe hypoxemia, with proper appreciation of potential costs and adverse effects.

Section snippets

Neuromuscular Blocking Agents

From 25% to 55% of patients with ALI enrolled in contemporary multicenter randomized controlled trials (RCTs) received neuromuscular blocking agents (NMBAs),1, 2, 3, 4 a prevalence that increases further with use of nonconventional modes of ventilation, such as high-frequency oscillatory ventilation.5 The most common reason for using an NMBA is to promote patient-ventilator synchrony and improve oxygenation.6 Data that directly examine the impact of NMBAs on oxygenation using an RCT design in

Conservative Fluid Management

Fluid administration increases hydrostatic pressure in the lungs and promotes fluid filtration and edema formation, particularly in states of increased microvascular permeability, such as ARDS.88, 89 Additionally, the administration of blood products can contribute to circulatory overload or pulmonary edema as a result of ALI (ie, transfusion-related ALI). Worsening pulmonary edema is associated with progressive hypoxemia. Patients with ARDS generally accumulate about 1 L of fluid per day with

Summary

Figure 1 summarizes a proposed algorithmic nonventilatory approach to management of severe hypoxemic respiratory failure. Severe refractory hypoxemia is a common challenge in the management of patients with ARDS. Adjustments to mechanical ventilation and nonventilatory interventions can produce improvements in oxygenation that may be life saving. The use of NMBAs, iNO, prone positioning, and/or ECLS may improve oxygenation in some patients. Given the risk of adverse effects and/or high cost of

Acknowledgments

Financial/nonfinancial disclosures: The authors have reported to CHEST the following conflicts of interest: Dr Hess has received royalties from Impact. He was a consultant for Respironics and Pari. He also has relationships with Cardinal (CaseFusion) and Ikaria. Drs Raoof, Esan, Goulet, and Sessler report that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

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