Septic Pneumonia

[DartmouthDave]

You are also not going to be able to do an "ARDS" ventilation protocol in the field and doing just parts of it without full access to all the buffers and medicaton protocols for low volume high PEEP dump the BP and pH. If your volumes are too low when you back off on the PEEP, you will set the patient up for atelectasis which decreases the ability to oxygenate/ventilate and then re-expansion trauma later if the opening pressures are high. An iSTAT would also be nice to know where your pH is before you try to manage a ventilator for "ARDS". You may have to run THAM (preferred) or NaHCO2 but then her Na+ might be high or the metabolic condition may not warrant it as a buffering agent. THAM is more useful for the permissive hypercapnia.

http://www.survivingsepsis.org/SiteCollectionDocuments/2008%20Pocket%20Guides.pdf

Hello,

Oh, do an APACHE II score to see if Xigris may be needed.

I guess, in effect, the stuff laid out in the Surviving Sepsis document posted above.

One question, what is THAM? I assume it is an alternative buffering agent of some type.

Just wondering how the rest of this will play out once you arrived at the ED.

Cheers

[Eydawn]

Ok, at the risk of sounding stupid, what are the diagnostic criteria for Adult Respiratory Distress Syndrome? I actually know of a former classmate who died of this in MI but I never fully understood exactly what it is and how it differs from acute respiratory failure or a bacterial infection that goes completely wonky... I know I could JFGI, but I like Vent's explanations and references ;-)

I would agree that airway suctioning seems to be indicated here. Any time there is vomit, aspiration must be suspected, and the best thing you can do is get as much gunk out of there as possible.

I'm particularly interested in the link between pneumonia and ARDS, as one of my residents got returned to us with a positive diagnosis of pneumonia (confirmed via CXR) and a scrip for Levaquin... what is the link, and where does a severe case of pneumonia differ from ARDS?

Wendy

CO EMT-B

[ccmedoc]

Ok, at the risk of sounding stupid, ...

Wendy

CO EMT-B

I cannot recall you ever sounding stupid.....-just sayin..

I think your ARDS question is valid, and if Vent doesnt get to it, I will add to this after shift..I am on my half break for 16 hrs..

[VentMedic]

Oh, do an APACHE II score to see if Xigris may be needed.

At $10k per dose, not all hospitals will be on board for that. Also, the patient will have to meet the criteria for it as well.

http://www.xigris.com/Pages/organ-dysfunction-assessment-animation.aspx

One question, what is THAM? I assume it is an alternative buffering agent of some type.

THAM is a buffering agent that does not break down to CO2 which is ideal for permissive hypercapnia. However, it will require close glucose monitoring.

Good reading:

http://ajrccm.atsjournals.org/cgi/content/full/162/4/1361

http://ajrccm.atsjournals.org/cgi/content/full/161/4/1149

Just wondering how the rest of this will play out once you arrived at the ED.

Cheers

A lactate level may diagnose sepsis and a CXR may either indicate a PNA with or without a pattern for ARDS. Fluids and pressors may be initiated but the ED doctor will be wanting this patient out of his/her ED quickly and into an ICU bed where ScvO2 monitoring, an A-line and the ICU ventilators are.

Eydawn

Ok, at the risk of sounding stupid, what are the diagnostic criteria for Adult Respiratory Distress Syndrome?

Acute Respiratory Distress Syndrome (ARDS) is a syndrome of inflammation and increased permeability associated with a constellation of clinical, radiologic, and physiologic abnormalities unexplained by elevations in left atrial or pulmonary capillary pressure.

Criteria:

Identifiable associated condition

Acute onset

Pulmonary artery wedge pressure </=18 mm Hg or absence of clinical evidence of left atrial hypertension

Bilateral infiltrates on chest radiography

Acute respiratory distress syndrome (ARDS) is present if Pao2/Fio2 ratio </= 200

Acute lung injury (ALI) is present if Pao2/Fio2 ratio is </= 300

We will also do a BAL (bronchoalveolar lavage) to gather fluid for multiple diagnostic tests.

For H1N1 Flu Associated ARDS, patients seemed to experience a cytokine storm. Very, very nasty ARDS to deal with which is why the deaths but unknown why the young were so harshly affected.

Clinical conditions associated with ARDS

Direct lung injury

Pneumonia

Aspiration of gastric contents

Inhalation injury

Near drowning

Pulmonary contusion

Fat embolism

Reperfusion pulmonary edema post lung transplantation or pulmonary embolectomy

Indirect lung injury

Sepsis

Severe trauma

Acute pancreatitis

Cardiopulmonary bypass

Massive transfusions

Drug overdose

Good ARDS ppt.

http://www.ohsu.edu/radiology/med/chest/ards.ppt

Thus, you can have PNA with localized infiltrates and go home with a script. If you have require a ventilator and an RRT at your bedside 24/7 for severe hypoxia and diffuse infiltrates, you probably have ARDS that may have been precipitated by that PNA infection either bacterial or viral. ARDS also goes down the path of multisystem organ failure and is not just isolated to the lungs. This is the reason I pointed out the caution with being overly aggressive with the ventilator until BP MAP is tanked up with pressors and fluids. Something will shut down and it the additional ventilator settings hurried that along, it may be difficult to recover or resuscitate the patient.

Acute Respiratory Failure can be from many causes including the patient too tired to work at breathing to compensate for lungs or better term "cardiopulmonary" system that is failing them. People with pending ARF may have normal blood gases or close to it right up to the point of the tube. One thing I hate to hear is "but the ABG is normal" when the patient is huffing at 40 breaths per minute and diaphoretic with a BP that is about to bottom out. For this patient breathing at a rate of 40, the term should be tachypnea rather than "hyperventilation" unless the ABG confirms a low PaCO2 which could be possible with sepsis (falling pH) or a PE.

By definition, respiratory failure is defined as a PaO2 value of less than 60 mm Hg while breathing air or a PaCO2 of more than 50 mm Hg. ARDS patients will do well to have a 60 mmHg on 100% oxygen. The act of respiration engages 3 processes: (1) transfer of oxygen across the alveolus, (2) transport of oxygen to the tissues, and (3) removal of carbon dioxide from blood into the alveolus and then into the environment. Respiratory failure may occur from malfunctioning of any of these processes.

Edited February 25, 2010 by VentMedic

[mobey]

How did you come up with the diagnosis of ARDS and what protocols to you have for field management?

ARDS is often an overused and misused term like "hyperventilation" or the statement "all COPD patients are CO2 retainers". Just like CO2 retainers, ARDS is a diagnosis that is not made very often.

Vent (and squint..... ya... I know your chompin at the bit)

I'll be 100% honest and risk looking incompetent.

I was simply trying to organize things in my mind to explain each system.

We have no "Protocols" so to speak that direct our Tx. It is up to the provider to provide the best care, there is no real flowchart type protocols in place.

The thing is, I NEVER treat without a DD. What I do, I do for a reason.

Having that said, I want an explanation for each symptom.

2 things really drove me toward the ARDS.

1. dried yellow vomit tells me the Pt probably aspirated a while ago allowing ARDS to develop.

2. The chest was VERY crackly. even after aggressive suctioning and PPV, there were still crackles throughout all lung fields, moreso in the bases, but very present in the apecies.

Since the pt had no cardiac Hx, and no renal failure reported, I ended up at the ARDS DD. Perhaps I am pulling the trigger a little fast with the diagnosis, but when you are on a scene with 3 other paramedics I think it is OK to toss in a DD like ARDS so everyone is on the same page.

When I make a field Diagnosis like this, I am not closing my mind to anything else, it is simply a diagnosis to guide treatment.

I only say "Hyperventilation" when the EtC02 is low and O2 is normal.

I only say C02 retainer when they have been diagnosed as such. Although I may say it, if I give them high flow for a few hrs and they quit breathing

To respond to some of the other posts.

No EJ visible/palpable. (I hate EJ in an intubated Pt anyway)

How do you feel about PEEP with a hypotensive pt and inability to rapidly infuse fluid?

What about Pt positioning? Supine, or fowlers?

[VentMedic]

Since the pt had no cardiac Hx, and no renal failure reported, I ended up at the ARDS DD. Perhaps I am pulling the trigger a little fast with the diagnosis, but when you are on a scene with 3 other paramedics I think it is OK to toss in a DD like ARDS so everyone is on the same page.

Do you have the ability to transport to a more appropriate facility if you make the DD as ARDS? What criteria do you use? It is a bitch to move ARDS patients once they get to a local little general with limited resources unless a specialized transport team is available. What do you do differently for ARDS that you wouldn't do for Acute Respiratory Failure?

Since as ETT is established, position would be to accomondate BP. Once in the ICU, they will probably be prone once the HFOV is started or whatever protocol short of ECMO.

Edited February 25, 2010 by VentMedic

[Aussieaid]

Considering the vomit around her and the rhonchi, aggressive sucitoning is probably what she needs.

Understand the whole consequence and benefit sequence for any ventilation maneuver since every knob turn affects more than just that one setting.

Too much damage which is difficult to reverse can be done by just doing a few bits and pieces of a protocol by buzz words such as "recruitment maneuvers" or "PEEP 'em" or "low tidal volumes" if you do not have an adequate way to monitor pressures (hemodynamic and airway such as plateau pressure) and CVP.

Just saying here...I am actually fairly comfortable with my knowledge base of ARDS, Sepsis and Ventilator management at my level.

I answered the OP's questions at the prehospital level and with the limited treatment strategies available to a regular ALS crew. Now what they do in the ER and ICU is a whole other level that I wasn't even going to start on.

I agree that aggressive suctioning is necessary especially with the aspiration and as he suctioned out about 200mls I don't think that he wasn't addressing this issue. However on the other hand the pt was cyanotic preintubation with no update on changes post intubation and no SpO2 readings given and it is going to be just as detrimental to the pt to keep suctioning too much and not allow the pt to recover or re-recruit ( just made that one up!) the collapsed alveoli. You know how long it can take to get someone's sats back up after just a couple of quick passes if they are really sick. Sometimes you have to trade off a little and allow them to recover even though they may still have more secretions. Sometimes you could hold a catheter down there continually and still not clear all the secretions. Watching how long some people take to suction out an ETT tube has made me hypoxic on many an occasion and I believe it is all about using appropriate judgment.

Recruitment maneuvers in this case may only be as basic as not going overboard on the suctioning and allowing the lungs adequate time to re-expand to provide adequate oxygenation and by adding a reasonable level of PEEP (i.e. 10 cm H2O). If you fail to do at least some basic strategies prehospital to provide adequate oxygenation then significant irreversible brain damage may already have occurred and all the sophisticated treatments and strategies you apply in the hospital are not going to be able to fix it.

PEEP may be one of the few tools that prehospital providers have available. Kind of hard to worry about ventilator strategies if all you have available is a DMR. With the sepsis the pt needs aggressive fluid resuscitation and it's ongoing which often leads to some pulmonary edema even before they are adequately resuscitated or inotropes are started. Add in the aspiration and with obviously sick lungs PEEP is going to be one of the fastest and most effective methods of oxygenating this pt. The PEEP is also used in conjunction with ongoing fluid resuscitation and inotropic support to provide adequate hemodynamic support. (Kind of why you often start inotropes when you start a kid on HFOV!)

Anyway I probably shouldn't have reacted here but....I'm just saying, you know!

[Kiwiology]

Our Technician (BLS) level have PEPP and do not have the independant ability to infuse so I dno ....

But that makes me wonder, why would you risk decreasing MAP in the presense of PEEP or hyperventilation? Is the old hyperinflation trick we are taught to avoid with asthma?

[VentMedic]

Recruitment maneuvers in this case may only be as basic as not going overboard on the suctioning and allowing the lungs adequate time to re-expand to provide adequate oxygenation and by adding a reasonable level of PEEP (i.e. 10 cm H2O). If you fail to do at least some basic strategies prehospital to provide adequate oxygenation then significant irreversible brain damage may already have occurred and all the sophisticated treatments and strategies you apply in the hospital are not going to be able to fix it.

PEEP may be one of the few tools that prehospital providers have available. Kind of hard to worry about ventilator strategies if all you have available is a DMR. With the sepsis the pt needs aggressive fluid resuscitation and it's ongoing which often leads to some pulmonary edema even before they are adequately resuscitated or inotropes are started. Add in the aspiration and with obviously sick lungs PEEP is going to be one of the fastest and most effective methods of oxygenating this pt. The PEEP is also used in conjunction with ongoing fluid resuscitation and inotropic support to provide adequate hemodynamic support. (Kind of why you often start inotropes when you start a kid on HFOV!)

Anyway I probably shouldn't have reacted here but....I'm just saying, you know!

PEEP too early and you may not gain any ground with a sepsis patient. Sometimes you have to be patient and address the sepsis first since the ScvO2 will be extremely low. Oxygen will help get that back up but the BP MAP will have to be climbing as well. Anything to compromise shutting down more organs will definitely lead to death. Thus, patience and careful monitoring before jumping in with a full respiratory press that could dump the BP MAP to never, never land and never to return. Depending on the oxygenation level, we may even start at a PEEP of 0 until the BP MAP is increasing. However, if you don't have the circulatory support, it doesn't matter how much O2 or PEEP you use. The fact that this person is an asthmatic also might make one consider her lung volumes and compliance.

Too often some become focused on the SpO2 or just the respiratory part and will crank down the PEEP valve while forgetting all about the circulatory part or lack the protocols for an aggressive sepsis resuscitation.

If I did raise the PEEP on this person when the BP MAP is stable it would be because of her obesity more than just the lung sounds. Otherwise, a PEEP of 10 is not commonly used in the ICUs, EDs or on specialty CCTs. Most transport ventilators have a difficult time delivering higher PEEPs to any degree of accuracy or effectiveness and most have insufficient monitoring systems.

Aggressive recruitment maneuvers are also not indicated for all patients. Dust and Tnuiqs will probably remember the days when every patient on a ventilator got "Sigh" breaths and we know where that got us. I mastered chest tubes during those days.

BTW, HFOV is not just for kids anymore. HFV has been used for over 25 years in adults and HFOV has been used for at least 10 years.

Also, one of my favorite amusements is taking a newly patched CCEMT-P into the ICU and letting them have a peak at a septic ARDS patient with HFOV, Nitric Oxide and proned along with all the med drips. Or, I introduce them to ECLS or ECMO. Hopefully then they will understand "critical care" is not just a weekend cert.

Edited February 26, 2010 by VentMedic

[mobey]

Do you have the ability to transport to a more appropriate facility if you make the DD as ARDS?

An intubated Pt almost always goes to the University hospital round these parts. We don't really have certain hospitals that specialize in specific illness.

To be general: Really sick pts go to the BIG hospital, moderatly go to one of the middle sized, and not-so sick go to the small rural hospitals.

Any of these DD would have landed her at the BIG hospital.

Intubated sepsis

Intubated CVA

ARDS secondary to aspiration

Respiratory failure

Intubated Pneumonia

Unknown Resp problem (Intubated)

As you can see, I really could not go wrong with the system set up the way it is here.