Center Proposes New Approach for ARDS Care during Pandemics and Beyond
By Amesh Adalja, MD, FACP, November 23, 2012
Many young adults were infected with the novel 2009 H1N1 influenza virus during the pandemic. A significant proportion of those infected progressed to develop adult respiratory distress syndrome (ARDS), and many required sophisticated forms of mechanical ventilation to maintain oxygenation. For some, particularly young otherwise healthy individuals, “rescue therapies” such as extra-corporeal membrane oxygenation (ECMO), high frequency oscillating ventilation (HFOV), nitric oxide (NO), prone position ventilation, and inhaled prostaglandins were required. Many of these modalities are utilized by UPMC’s Department of Critical Care Medicine and at other tertiary/quaternary care centers, even as the benefit of those therapies are being debated by many intensive care unit physicians. There is mounting evidence, though, that even without use of rescue therapies, lower mortality rates are achieved in centers that treat high volumes of mechanically ventilated patients and have intensive care physicians present.
Following the experience with mechanical ventilation during the pandemic, my colleagues and I explored the possibility of developing a systematic approach to care for these patients that would match the sickest patients with the treatment centers most able to administer the required therapies. The full article, “A conceptual approach to improving care in pandemics and beyond: Severe lung injury centers,” is available in Journal of Critical Care; what follows is a brief summary of the concept.
After reviewing the relevant literature and conducting semi-structured interviews with experts in the field, we concluded that patients with severe ARDS and minimal co-morbid conditions would fare better if transferred as quickly as possible to centers with expertise in managing ARDS. We proposed that ARDS centers could be modeled after cardiac, stroke, and level I trauma centers. To qualify as an ARDS center, a facility could be required to, for instance, treat a high annual volume of mechanically ventilated patients, have around-the-clock intensive care physicians on staff and available, and be able to provide rescue therapies (ECMO, HFOV, NO, etc.)
Significant hurdles would have to be overcome to establish these centers. Rigorous evidence-based criteria for ARDS centers would be required, as would support of the Joint Commission, third party payers, and professional societies. Patient safety and transport would have to be worked out as well.
A Day-to-Day System
These hurdles are not insurmountable, though, and we believe this is an approach that deserves thoughtful consideration. We believe such centers could deliver great benefit during a pandemic and as an integral part of daily intensive care operations—regular transfer of patients to designated expert centers could reduce the current 25% mortality rate of ARDS.
Adalja AA, Watson M, Waldhorn RA, Toner ES. A conceptual approach to improving care in pandemics and beyond: Severe lung injury centers. J Crit Care 2012. http://www.jccjournal.org/article/S0883-9441%2812%2900326-7/abstract. Accessed November 19, 2012.