Development of a Lung Rescue Team to Improve Care of Subjects With Refractory Acute Respiratory Failure

Abstract

BACKGROUND: A lung-protective mechanical ventilation strategy has become the hallmark of ventilation management for patients with acute respiratory failure. However, some patients progress to more severe forms of acute respiratory failure with refractory hypoxemia. In such circumstances, individualized titration of mechanical ventilation according to the patient's specific respiratory and cardiovascular pathophysiology is desirable. A lung rescue team (LRT) was recently established at our institution to improve the medical care of patients with acute respiratory failure when conventional treatment fails. The aim of this report is to describe the consultation processes, the cardiopulmonary assessment, and the procedures of the LRT. METHODS: This was a retrospective review of the LRT management of patients with acute respiratory failure and refractory hypoxemia at Massachusetts General Hospital in Boston, Massachusetts. The LRT is composed of a critical care physician, the ICU respiratory therapist on duty, the ICU nurse on duty, and 2 critical care fellows. In the LRT approach, respiratory mechanics are evaluated through lung recruitment maneuvers and decremental PEEP trials by means of 3 tools: esophageal manometry, echocardiography, and electrical impedance tomography lung imaging. RESULTS: The LRT was consulted 89 times from 2014 to 2019 for evaluation and management of severely critically ill patients with acute respiratory failure and refractory hypoxemia on mechanical ventilation. The LRT was requested a median of 2 (interquartile range 1-6) d after intubation to optimize mechanical ventilation and to titrate PEEP in 77 (86%) subjects, to manage ventilation in 8 (9%) subjects on extracorporeal membrane oxygenation (ECMO), and to manage weaning strategy from mechanical ventilation in 4 (5%) subjects. The LRT found consolidations with atelectasis responsive to recruitment maneuvers in 79% (n 5 70) of consultations. The LRT findings translated into a change of care in 81% (n 5 72) of subjects. CONCLUSIONS: The LRT individualized the management of severe acute respiratory failure. The LRT consultations were shown to be effective, safe, and efficient, with an impact on decision-making in the ICU.

Implementation of Protocolized Care in ARDS Improves Outcomes

“…Other literature describing protocolized care in ARDS has focused on subjects on the severe end of the disease spectrum, showing benefits in terms of increasing use of adjunctive prone positioning and aiding in decision-making for patients with refractory hypoxemia. 36,37 To our knowledge, this is the first study that has investigated the protocolized implementation of evidence-based management with combined provider education to improve the utilization of different management domains and strategies for all patients with ARDS. Our results indicate that the implementation of optimal therapies with a strong evidence base in a protocolized, sequential manner can have a significant impact on patient survival and other outcomes in ARDS.…”

A lung rescue team improves survival in obesity with acute respiratory distress syndrome

“…The clinical decisions of the lung rescue team were based on multiple measurements of respiratory mechanics and hemodynamics; mechanical ventilation was accurately titrated using LRM and choosing the correct value of PEEP matching information from decremental PEEP trial, end-expiratory transpulmonary pressure measurements, and the use of electrical impedance tomography. Hemodynamics was carefully analyzed through standard hemodynamic parameters and right heart echocardiography with the aim to intensively study the interaction between lung and heart/vascular function [23].…”

Reply to Mezidi et al.: Assessment of Airway Closure and Expiratory Airflow Limitation to Set Positive End-Expiratory Pressure in Morbidly Obese Patients with Acute Respiratory Distress Syndrome

“…(1) The authors have raised several key pulmonary and hemodynamic questions on the ventilation of patients with obesity that should be investigated further. Our discussion here is limited and is focused on the apparent paradoxical hemodynamic response to lung recruitment in patients with severe obesity with an average BMI of 57±12 kg/m 2 epinephrine was decreased to 1 mcg/min, norepinephrine and vasopressin were unchanged (50 mcg/min and 0.08 U/min, respectively).…”