The 3 most important recent advances in treating respiratory failure

Bram Rochwerg

Dr Bram Rochwerg is an associate professor in the Division of Critical Care at McMaster University, researcher, and medical lead in the intensive care unit at the Juravinski Hospital.

If you were to name the 3 most important recent advances in the treatment of respiratory failure, what would they be?

Bram Rochwerg, MD, MSc: Hi, my name is Dr Bram Rochwerg. I’m an intensivist at McMaster University in Hamilton, Ontario, Canada, and I was asked what I believe are the biggest evolutions, or changes, in the management of patients with respiratory failure in the last 5 or 10 years.

I think there’s a few things that come to mind. One, I would say, is—at least in those who are prior to intubation—the increased use of a high-flow nasal cannula and the increasing evidence base we have to suggest that this decreases the risk for intubation. We’ve drastically increased the number of high-flow units that we have in my own intensive care unit (ICU) and we’re now using them [high-flow nasal cannulas] quite widely in the emergency department, on the wards, and in ICU patients. And this has changed a lot and given us a nice tool in our belt that we can use to help prevent intubation and improve outcomes of patients.

I think the other changes that I’ve really noticed come once patients already require intubation in the setting of acute respiratory distress syndrome (ARDS). Certainly, positive end-expiratory pressure (PEEP) titration is one of these things that have evolved a lot in the last little while and probably in the general direction of using more PEEP for patients. But even beyond that, in the last few years, I think it comes down to individualized PEEP and the different ways to individualize PEEP, including using open lung studies, esophageal balloon, electrical impedance tomography (EIT), and other devices. I think that’s seen a lot of generation and changes in the last little bit.

Paralysis is another adjuvant that has seen a lot of evolution and ups and downs. And still, I think, [there is] some uncertainty around the best use of paralysis in patients with refractory hypoxia or even severe ARDS and [as to] whether there’s benefit in infusion versus bolus dosing. Myself I’ve moved more towards trying to be judicious in my paralysis use, especially and still in those with serious or severe ARDS.

And in that same population, one [change] that’s dramatic and highlighted by what’s going on with coronavirus disease 2019 (COVID-19) is the use of proning. And early on in my career, we probably… I would seldomly prone. I find that proning patients with severe ARDS has become such a part of my practice and—definitely when working in the COVID-19 ICU in these last few weeks—we’ll often do proning rounds where up to half of our unit is flipped over back and forth from morning to evening. And this was obviously driven a lot by the PROSEVA study results and subsequent data from there that have shown benefits.

And there are exciting modalities that I think are going to change the way we practice in the coming years. We’ve seen the increasing availability and use of extracorporeal membrane oxygenation (ECMO) in this population, not just for refractory ARDS but even in severe ARDS, in order to achieve lung-protective ventilation. And I think that the use of ECMO is going to become more widespread. But not only that… The capabilities and ability to provide ECMO are going to become easier and not require as much in terms of resources to provide [it], as the machines get smaller and the ability to provide [ECMO is greater]… And cannulas get smaller and easier [to use]…

So, I think there’s been a lot of change, no doubt, but I anticipate [that] the next 5, 10, 15 years are not going to be different.

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