Severe ARDS for bedside percutaneous tracheostomy54-year-old man, 98 kg, ventilated for 10 days in ICU with ARDS after severe gallstone pancreatitis

The patient

The examiner asks

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1. Consider

   What are your considerations?

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   • A 54-year-old with severe ARDS from pancreatitis, on noradrenaline, for a planned bedside tracheostomy in ICU. Patient
   • His P/F is 90 on PEEP 14: severe by Berlin, 100 or less on PEEP 5 or more. Disease
   • Pancreatitis is an extrapulmonary cause; his lungs are injured by a systemic process that is still active.
   • A tracheostomy speeds weaning and cuts ventilator days, but won't lower his mortality or pneumonia risk. Surgery
   • It's elective, so on FiO2 0.8 I'd ask whether his oxygenation should improve first.

2. Prepare

   How do you prepare him?

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   • His ventilation stays protective: 6 mL/kg predicted weight, plateau no higher than 30. Disease
   • His driving pressure is 28 minus 14, so 14; I keep it at 15 or below.
   • Two anaesthetists: one on the airway and bronchoscope, one on drugs and the ventilator. Airway
   • Bronchoscope down his tube to guide the needle and confirm the new tube is in the trachea.
   • Reintubation kit open: videolaryngoscope, bougie and a fresh oral tube.
   • Cisatracurium continues, so he can't cough or fight the ventilator mid-procedure. Disease

3. Plan

   Take me through the procedure.

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   • FiO2 1.0 before we start, to give him an oxygen reserve. Disease
   • His PEEP keeps his alveoli open, so disconnections are avoided or kept as brief as possible.
   • Tube withdrawn under bronchoscopic view until the cuff sits just below the cords, never pulled back blind. Airway
   • Noradrenaline titrated to keep his MAP at 65 or more. Disease
   • After: plateau checked through the new tube, protective settings resumed, chest X-ray. After surgery

4. Crisis

   As the tube is pulled back, the cuff leaks loudly; SpO2 falls to 80%, tidal volumes halve, BP 98/56. What do you do?

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   • He has lost his PEEP through the leak: stop the procedure, FiO2 1.0. Crisis
   • Reposition the tube with the bronchoscope until the cuff seals, and confirm it is in the trachea. Airway
   • Restore PEEP 14 and check that volumes and the capnograph trace return. Crisis
   • Still low: a recruitment manoeuvre to about 40 cmH2O, accepting brief hypotension and desaturation.
   • If the leak can't be sealed, reintubate orally with the videolaryngoscope. Airway
   • We restart only when he is back at his baseline saturation. After surgery

5. Crisis

   Ten minutes after the tracheostomy is placed, peak pressure is 48 cmH2O, SpO2 78%, BP 72/40, HR 132, and the right chest is silent. What now?

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   • This is a right tension pneumothorax unless shown otherwise; the diagnosis is clinical. Crisis
   • Hand-ventilate on 100% and look down the tracheostomy to rule out a false passage.
   • No X-ray first: immediate needle decompression of his right chest.
   • Then a chest drain at the fifth intercostal space, just in front of the midaxillary line.
   • Noradrenaline up meanwhile; his pressure should recover quickly once the chest is drained.
   • Still hypoxic once drained: prone positioning, over 12 h each day. After surgery
   • P/F under 100 despite that, or plateau above 30: refer early for VV ECMO.