Today on the podcast, we discuss how to set PEEP during ARDS and how ARDS can cause acute RV failure. Our guest is Matt Siuba, MD.
Matt Siuba
Critical care physician and APD for the CCM fellowship at Cleveland Clinic. Clinical expertise in hemodynamic monitoring, mechanical ventilation, and their intersection (The People's Ventricle). Member of the pulmonary vascular disease program. Trying to understand the factors leading to acute/acute on chronic PH and RV dysfunction in critical illness.
Matt's Maryland CC Project Lecture
The Paper on Selecting PEEP Setting During ARDS which I misattributed to Matt
Algorithm from that Paper
How do you choose your PEEP Setting?
Low PEEP vs. High PEEP table
Purpose of PEEP
Increase oxygenation
Increase Lung Homogeneity
Decrease PAP (U-Shaped Response)
Problems with PEEP
RV Dysfunction/failure
Hemodynamic Compromise
Best RV Function at FRC
Driving Pressure
- EMCrit 183 – Driving Pressure with Roy Brower
- The Amato Paper
- How Matt Measures Pplat to get a driving pressure
- 0.5 sec hold (as opposed to longer) as done in the ARDSnet trials
- Pt must be passive
- Driving pressure at 5 minutes after a vent change is probably what you are going to see for the next hour []
- Hour long lecture on Driving Pressure from Matt
Obesity/Low Chest Wall Compliance
Esoph mano vs. High PEEP table seemed to do the same
What are your feelings about APRV?
Doesn't have it as his shop
What do you do with Unilateral Lung Disease?
4.5-5 ml/kg Vt
Still need PEEP, maybe not to lower PEEP table but probably more than most people are using
May benefit from good lung down, but may still benefit from proning
Acute Cor Pulmonale
In patients with high driving pressure (≥ 18 cmH2O), severe hypoxemia or hypercapnia (≥ 48 cmH2O), perform echo to evaluate the RV
Treatment
Do not consider this a preload issue, rarely if ever will these patients need volume loading. Think less about the preload and more about the afterload.
Consider a neck line for CVP
Fix Hypoxia
Proning
Prone as indicated by the severity of ARDS as this will mirror severity of RV failure
RV Protective Ventilation
- Consider decreasing PEEP if you think it is increasing deadspace
- Consider decreasing PaCO2. 48 mmHg as a possible goal as >48 has been associated with RHF
Inotropes?
Probably not many cases that these will help
Only RCT was levosimendan
Inhaled Pulm Vasodilators
CO Monitoring
To monitor the effects of treatment along with TAPSE and CVP
ECMO & ECCO2R
RV Echo Starter Kit
Fantastic Paper on RV Echo for the Intensivist
Delta of TAPSE may be easiest way to track RV therapies
RV-PA Coupling
RV Uncoupling Predicts Mortality
TAPSE/PASP (mm/mmHg) Ratio
Normal ~ 1.2
Mortality increase < 0.64
Additional New Information
More on EMCrit
- EMCrit 272 – Right Heart Failure with Sara Crager
- EMCrit 273 – Inhaled Pulmonary Vasodilators & Q&A with Sara Crager
- EMCrit 373 – Mike Weinstock with another Critical Care Bounceback: “Asymptomatic Hypertension” - April 18, 2024
- EMCrit Wee – Ross Prager on 10 Heuristics for the New ICU Attending - April 13, 2024
- EMCrit 372 – FoundStab Intubation SOP - April 5, 2024
Hey Matt Siuba, insightful discussion on setting PEEP and righting the right ventricle in ARDS! Codex Executor enhances the scripting experience with its mobile executor, ensuring smooth and rapid execution of code. Kudos to the valuable insights shared! #CodexExecutor #ARDS #MedicalScience
This was a great discussion on setting a “best PEEP” in ARDS. Well done indeed. Will definitely use this with my residents.