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Refractory ARDS — FRCA Final MCQ

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HardIntensive Care MedicineRefractory ARDSFRCA Final

An adult has potentially reversible pneumonia-related ARDS and has received invasive ventilation for 48 hours. Despite tidal volumes of 6 mL/kg predicted body weight, a plateau pressure of 28 cmH2O, PEEP of 16 cmH2O, neuromuscular blockade and 18 hours of prone positioning, the PaO2/FiO2 ratio has remained below 80 mmHg on an FiO2 of 1.0 for eight hours. There is no major comorbidity or recognised contraindication to extracorporeal support. Which rescue intervention has the strongest evidence for reducing mortality in this setting?

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Correct answer: E — Venovenous extracorporeal membrane oxygenation

Venovenous ECMO is the best-supported rescue intervention for a selected patient with potentially reversible, very severe ARDS despite optimised protective ventilation and proning. EOLIA showed a clinically important but not conventionally statistically significant reduction in 60-day mortality; subsequent individual-patient-data analysis of EOLIA and CESAR found lower 90-day mortality with ECMO (36% versus 48%; RR 0.75). UK guidance therefore supports urgent assessment by a specialist respiratory ECMO centre. Inhaled nitric oxide and inhaled prostacyclin may transiently improve ventilation–perfusion matching and oxygenation but have not demonstrated a mortality benefit. HFOV has no survival benefit and may increase mortality. APRV has physiological attractions and limited small-trial data, but the evidence is heterogeneous, at risk of bias and insufficient to establish it as a mortality-reducing rescue strategy.

Reference: Combes A, Peek GJ, Hajage D, et al. ECMO for severe ARDS: systematic review and individual patient data meta-analysis. Intensive Care Medicine. 2020;46:2048–2057. https://pubmed.ncbi.nlm.nih.gov/33021684/