0/ Buongiorno, #medtwitter! We bring to you a #tweetorial on ventilator management for all those folks who don’t normally manage ARDS who have stepped up to help in this pandemic.

All credit goes to @AvrahamCooperMD; the following tweetorial is his brainchild. Thanks, Avi!
1/ Many clinicians are being/will be called to manage ARDS on the ventilator.

Imagine that your patient has just been intubated. Let's walk through the steps of vent mgmt 101:
- Initial housekeeping
- Basic vent management decisions in ARDS
- Management of refractory hypoxemia
2/ First, confirm endotracheal tube position:
- Did capnography confirm tracheal placement?
- Are breath sounds bilateral?
- Is the tube placed appropriately on CXR? (typically 2-5 cm from carina)

Pic from SAEM https://bit.ly/3bJrTpa 
3/ Next, set the ventilator. You'll need to choose an initial setting.

Typically this will be assist control/volume control (AC/VC) which allows you to:
✔️ Maintain low tidal volume ventilation
✔️ Guarantee a respiratory rate

Pic from https://bit.ly/3462mny 
4/ You'll need to set minute ventilation (MV = tidal volume x respiratory rate)
-Try to approximate pre-intubation MV (not always possible)
-Use low tidal volume ventilation (4-8 ml/kg ideal body weight)
-Goal plateau pressure < 30 mmHg
-Goal pH > 7.2

6/ Now that the ventilator's set, choose a sedation strategy.
- Patients with moderate to severe ARDS usually need sedation to ensure vent synchrony
- Vent Dyssynchrony ⬇️ oxygenation and ⬆️ lung injury
- Whatever sedation you choose, achieve synchrony

7/ Some patients will oxygenate well with adequate PEEP and sedation.

Others will require additional therapies. Let's briefly review:
😮Inhaled pulmonary vasodilators
9/ Benefits of proning?
✔️Turning patients to the prone position optimizes V/Q matching and lung recruitment, and may dramatically improve hypoxemia.
✔️It has been shown to reduce mortality in those with PaO2:FiO2 < 150.

10/ What are ex. of inhaled pulmonary vasodilators?
1️⃣Epoprostenol or
2️⃣nitric oxide
- Preferentially vasodilate aerated lung units, ⬆️ V/Q matching and ⬆️ SpO2
- No impact on mortality or lung mechanics so should only be added for refractory hypoxemia

11/ Finally, when to call the veno-venous ECMO team.

There's no hard/fast rule but this is reserved for patients w/ refractory severe hypoxemia or respiratory acidosis despite conventional therapies.

A general rule is "it's better to call for ECMO too early than too late."
12/ To summarize:
✔️ Confirm tube position
✔️Low tidal volumes, adequate PEEP
✔️Tolerate respiratory acidosis
✔️ Sedate for synchrony
✔️ If still hypoxemic, prone and probably paralyze, inhaled vasodilators if refractory
✔️ Better to call for ECMO too early than too late
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