Thread by @gretchemaben

Let's start day 3 of #CHEST2021 with tweet-ucation from "Severe-ARDS: New Frontiers in Management"! 1/

First up, Dr. Daniel Ouellette with "Optimization of PEEP" #CHEST2021 2/

You can continue to incrementally augment PEEP as long as the plateau pressure remains less than or equal to 28-30 cm H2O. #CHEST2021 3/

Esophageal manometry is useful for determining optimal targets for PEEP. #CHEST2021 4/

Patients with focal ARDS are at risk for over-distension using ARDSnet PEEP protocols. #CHEST2021 5/

Problems with current tools, #CHEST2021 6/

This study showed increased mortality when lung recruitment maneuvers were used. #CHEST2021  7/

BUT a JAMA meta-analysis also looked at this issue and found improved outcomes with LRMs... #CHEST2021 8/

Next up is Dr. Rodeo Abrencillo with "Driving Pressure in Severe ARDS" #CHEST2021 9/

Low TiVs, low plateau pressure, and high PEEP have all been suggested to lower mechanical stress on lung tissue. #CHEST2021 10/

The driving pressure is the plateau pressure minus the PEEP. #CHEST2021 11/

The driving pressure correlates strongest with mortality. #CHEST2021 12/

Lower TiV are good because they lower the driving pressure. #CHEST2021 13/

The driving pressure has a higher correlation with mortality than TiV. #CHEST2021 14/

The driving pressure has a higher correlation with mortality than the RR. #CHEST2021 15/

Lower tidal volumes are a/w a greater survival benefit in patients with a higher driving pressure. #CHEST2021 16/

This was a feasibility trial on a driving pressure-limited strategy in ARDS. #CHEST2021 17/

Limitations and challenges of driving pressure-limited management #CHEST2021 18/

Next up is Alice Gallo de Moraes (@GallodeMoraesMD) with "Prone Position in Severe ARDS"! 19/

What does prone positioning actually do? #CHEST2021 20/

This paper showed improved mortality with proning. #CHEST2021 21/

How about other body positions? In pigs with pleural effusions, Fowler's position had a higher FRC compared to horizontal positions. #CHEST2021 22/

External compression of the chest wall can lower plateau pressure. #CHEST2021 23/

Take home points #CHEST2021 24/

Last we have Dr. Daniel Brodie with "ECMO in COVID-19" #CHEST2021 25/

This study organized ECMO availability in Paris during COVID-19. 54% 90 day mortality. Mortality worse for older patents, at lower volume centers, and later ECMO cannulation after intubation. #CHEST2021 26/

This study had a 38.8% mortality rate. #CHEST2021 27/

This trial looked at a trial of ECMO vs no ECMO. The ECMO group had a lower mortality rate. #CHEST2021 28/

This cohort had a 37.4% mortality rate with ECMO. #CHEST2021 29/

Complications of ECMO. No difference in complications in COVID-19 vs other patients, except based on the time you are on ECMO. #CHEST2021 30/

Factors associated with an increased risk of in-hospital mortality include age, immunocompromised status, cardiac arrest, and chronic respiratory failure. #CHEST2021 31/

This study in Germany had higher mortality rates. #CHEST2021 32/

This meta-analysis showed a pooled in-hospital mortality of 37.1%. #CHEST2021 33/

Conclusions #CHEST2021 34/34