Phase 3: RESULTS

Group 5: ARDS/ALI

• Clinical algorithm for the management of intubated patients presenting with ALI or ARDS
  
  
• Best Practice Recommendation Consensus
  • Recommendation 1
  • Recommendation 2
  • Note

RECOMMENDATION 1: Patients diagnosed with ARDS/ALI might be positioned in prone position as soon as possible following diagnosis to improve oxygenation. This position can be considered for all patients with PaO2:FiO2 < 300kPa but is more effective in patients with PaO2:FiO2<200kPa. Those patients where the PaO2:FiO2 fails to increased by at least 20mmHg after six hours are considered non responders and can be turned back to supine. In patients where the minimum improvement has been reached after six hours the prone positioning must continue for at least eight hours per day increasing to a maximum of 20 hours/24 hours. Greater benefit is derived from an extended time of prone positioning. Weak recommendation: The meta-analysis (Alsighir et al 2008) based on the results of 5 high quality RCT’s concluded that prone positioning significantly improves oxygenation. No effect was established on survival; time on the ventilator or incidence of ventilator associated pneumonia. Whether this improved oxygenation could affect long term outcome including quality of life is not clear, and concerns have been raised to the high burden of implementation based on moderate quality evidence: A well conducted meta analyses based on five high quality RCT’s. The evidence is downgraded due to imprecision of data (wide CI) Additional reference: Abroug et al (2008) The effect of prone positioning in acute respiratory distress syndrome or acute lung injury: a meta-analysis. Areas of uncertainty and recommendations for research. Intensive Care Med 34:1002–1011

POSTED COMMENTS:

• Would only consider prone position when PaO2:FIO2 is below 200. So do not agree with whole statement. Given the lack of data supporting improved survival

RECOMMENDATION 2: The routine suctioning of patients diagnosed with ARDS/ALI is not recommended and patients might only be suctioned when clinically indicated. The choice of suction system used must be based on required effect, with the closed suction system resulting in better maintenance of oxygenation level but clearing less volume of secretions when compared to a open suction system. VHI (two hyperinflations using the CPAP function of the ventilator to an airway pressure of 45cmH2O for 20 s, with an interval of 1 min in between) could be included in combination with suction to improve oxygenation after open endo tracheal suction procedure. Weak recommendation: The implementation of this recommendation is not associated with extra cost or an increased burden however potential harm of RM is not clear. On very low quality evidence: One randomized crossover study (Dyer et al 2003) downgraded due to imprecision of data and sample and high risk of bias. Additional reference: Lasocki et al 2006 Open and Closed-circuit Endotracheal Suctioning in Acute Lung Injury: Efficiency and Effects on Gas Exchange. Anesthesiology 104:39–47

POSTED COMMENTS:

• Clinical indications should be identified. So again I would not agree with the whole statement.

NOTE:

The routine use of manual techniques (percussion) and continuous lateral rotation is not recommended at this time (Davis et al 2001) MOTIVATION: Davis et al (2001) concluded that continuous lateral rotation in specialized bed did increase the volume of sputum cleared in patients diagnosed with ARDS compared with manual turning, but the addition of percussion did not further improve secretion removal. The quality of the study is downgraded to very low due to methodological quality; directness and precision. As these beds are not routinely used in units this study could be used as basis for better quality studies rather than the incorporation of this evidence into the management algorithm.