Sixteen years at the bedside taught me this about ARDS

Working in a level I trauma center has allowed me to work with some of the best clinicians that I’ve ever come across.  It’s also allowed me the opportunity to gain invaluable experience. The specific trauma center where I worked afforded RTs a high degree of autonomy. We did everything; rapid response, intubations, arterial lines, balloon pumps, trauma’s, advance modes of mechanical ventilation, bedside trachs, etc. We were expected to know our stuff and if we didn’t let’s just say we’d find out.

If I learned anything, it’s that when a trauma patient is sick, they’re very sick. Their injuries require a different approach than the typical medical patient. Some say it’s more straight forward. Some say it’s more complex. Either way, acute respiratory distress syndrome (ARDS) is huge in this population. And once the kidneys start shutting down it becomes a race against time and fluid. I can admit, I’ve spent countless hours chasing blood gases. One change at a time and if that doesn’t work try something else. It’s all about precision. Whether it was SIMV, APRV or PC, it’s common for these patients to go into a refractory phase. There really isn’t a common approach when it comes to the vent. We do what works, when it works. I can admit, there have been many days in the ICU when I’ve spent what seemed like an entire shift getting vent settings right. We’ve all done it and still do it.

Which makes me think, when we get these extremely sick patients with pulmonary compromise why do we spend hours upon hours titrating the vent and drawing gases, but we often forget about arguably the most effective treatment for ARDS….proning? I can attest that at times in the ICU we are so busy and our patients are so critical that we often overlook proning. But why? Because it’s hard? Studies show it works. It’s safe. It’s non-invasive. It’s effective. We’re told, “when it doubt max it out”, but why not “when the PF ratio is getting lower flip them over”. Proning should be a standard of practice not only in trauma and surgery ICU’s, but in medical ICU’s too. Literature shows it. We should do it. That is if we are practicing evidence-based medicine. 

Think back to COVID: when everything else failed, what was the one therapy that worked? The underlying cause may differ—COVID, trauma, or medical disease—but ARDS is still ARDS.