The Science Journal of the American Association for Respiratory Care

2004 OPEN FORUM Abstracts

INITIAL RESULTS: FLEXIBLE PROTOCOL FOR ALI/ARDS INCORPORATING ARDSNET-TYPE PROTECTIVE STRATEGIES.

John W. Farnham, RRT; Michael S. Powers, MS, RRT. Respiratory Care Services, University of Tennessee Medical Center, 1924 Alcoa Highway, Knoxville, TN 37920.

Background:
Use of low tidal volume (VT) and low plateau pressure (Pplat) as strategies for improving outcomes in patients suffering from Acute Lung Injury (ALI) or Acute Respiratory Distress Syndrome (ARDS) has been shown to improve outcomes by the ARDS Network study and numerous subsequent studies. Different critical care clinicians have different preferred ways to manage these difficult patients during ventilatory support. Based on our successes with therapist driven protocols (TDP) for respiratory treatments and for ventilator management and liberation, we were asked to develop a protocol that would provide a systematic approach to management of ALI/ARDS, yet would allow the physicians flexibility in their choices of approach. The protocol was to maintain, in all options, the basic underlying ARDS Net philosophy of low VT and low Pplat.

Method:
An interdisciplinary team was formed to shepherd the development of the protocol. Membership included respiratory therapists, physicians who would be managing this cohort of patients, and a nurse representing the affected division of nursing so we would not lose touch with the necessary disciplines as we moved forward.
We developed a protocol that included a verbatim ARDSNet option, a pressure control (PC) option, and an airway pressure release option (APRV). While we fine tuned the protocol options to meet the physicians’ needs, we retrospectively looked at the previous year’s ALI/ARDS cases to determine outcomes of those cases. In application, the attending physician decides to enter the protocol, and decides which option to use. If deemed appropriate, the physician can change freely between the 3 options as is felt best for the patient. We developed a collection of data points we would use to monitor the process, and began using the protocol in May, 2004 in all adult critical care areas.

Results:
For the year prior to beginning use of the protocol our mortality rate had been 50.4%. As of the date of the writing of this abstract, the overall mortality rate since implementing the protocol is 39.3% in 33 patients, an improvement of 11.1% in almost two months. On 3 occasions, nitric oxide was used, 1 of those patients survived. One patient was proned, and did not survive. On 12 occasions, PC mode was used, on 22 occasions ARDSNet, and on 1 occasion, APRV. Three patients were treated using more than one strategy. Of those who died, 8 had been on ARDSNet, 3 on PC, and 2 on multiple modes.

Conclusions:
Clear improvement in survival has been demonstrated in a short period of time. The study cohort is too small to draw definitive conclusions of other aspects at this point. However, the set of data has great potential for interest to the community in that survival of different strategies can be compared, all being linked by having low VT and low Pplat in common. Not comparing differing applications is considered to be one weakness of the ARDSNet study. As time goes on and the total “N” of this study grows, more significant data on the various aspects being monitored will be available for evaluation. Further, as the skill with which this protocol is applied improves, it is reasonable to expect further improvement in mortality outcomes. The possibility of comparing, over time, whether or not ARDSNet ventilation truly is superior to other modes, so long as low VT and low Pplat are utilized, is a tremendous opportunity afforded with this study. Other details not elicited by the ARDSNet study may also be elicited. Preliminary results are quite promising, and long term follow up is indicated and planned.

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