Type 1 Respiratory Failure

Epidemiology and Risk Factors

Causes can considered anatomically:

History:

Exam:

Bedside:

Laboratory:

Imaging:

Other:

Goals of management

Resuscitation:

Specific therapy:

Supportive care:

Disposition:

Preventative:

Extracorporeal CO₂ removal:

Lung protective ventilation is effective in ↓ VILI but causes respiratory acidosis
Extracorporeal CO₂ removal is less invasive than ECMO and can clear significant amounts of CO₂, but not provide significant oxygenation
REST (2021)
- 412 Britons in 51 NHS ICUs with invasive ventilation for early (<48 hours) moderate-severe (P/F <150) hypoxic respiratory failure
  - Without a PE, pleural effusion, or pneumothorax
  - With a CO₂ production that prevented ↓ V_T <3mL/kg
  - Without contraindications to anticoagulation
- 1120 patients gives 90% power to detect 9% ARR of death
  Stopped early by DSMB on basis of conditional power analysis and not safety concerns, although there are some safety concerns!
- Open-label randomisation to ECOR vs. usual care
  - ECOR group
    - 2-7 days of ECOR
    - Dual-lumen percutaneous catheter
    - Maximal flow (350-450mL/min) with sweep of 10L/min
    - V_T of 3mL/kg
    - Weaning of ECOR by protocol
  - Usual care
    Protocolised mechanical ventilation as per ARDSnet tables.
- No difference in primary outcome of 90 day mortality (41.5 vs 39.5%), or secondary outcomes of V_T or ventilator free days
- Intervention associated with ↑ adverse events, including ICH
  5 felt to be ECOR related, 3 deaths.
- Low patient numbers in most sites (4/51 had >10 patients)