Ventilator Management In Different Disease Entities
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Transcript of Ventilator Management In Different Disease Entities
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Ventilator ManagementVentilator Managementin Different Disease Entitiesin Different Disease Entities
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Mechanical VentilationMechanical Ventilation
Use of sophisticated life support Use of sophisticated life support technology aimed at maintaining tissue technology aimed at maintaining tissue oxygenation and removal of carbon oxygenation and removal of carbon dioxidedioxide
Support or replace the normal ventilatory Support or replace the normal ventilatory pump in moving air into and out of the pump in moving air into and out of the lungs – inadequate or absent spontaneous lungs – inadequate or absent spontaneous breathingbreathing
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Mechanical VentilationMechanical Ventilation
Not without risk – complications and Not without risk – complications and hazards an be life threateninghazards an be life threatening
Decision to initiate mechanical ventilationDecision to initiate mechanical ventilationSerious oneSerious oneSound clinical judgmentSound clinical judgmentClear understanding of the indications and Clear understanding of the indications and
associated goalsassociated goals
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Indications for Mechanical Indications for Mechanical Ventilatory SupportVentilatory Support
Respiratory failure Respiratory failure An inability of the heart and lungs to provide An inability of the heart and lungs to provide
adequate tissue oxygenation or removal of adequate tissue oxygenation or removal of carbon dioxidecarbon dioxide
Acute respiratory failureAcute respiratory failurePaO2 < 60 mm HgPaO2 < 60 mm HgSpO2 < 90% SpO2 < 90% With or without PaCO2 > 45 mm HgWith or without PaCO2 > 45 mm Hg
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Acute Respiratory FailureAcute Respiratory Failure
Hypoxemic respiratory failure – lung failureHypoxemic respiratory failure – lung failureHypercapnic respiratory failure – pump Hypercapnic respiratory failure – pump
failurefailureAcute ventilatory failureAcute ventilatory failure
A sudden increase in PaCO2 with a corresponding A sudden increase in PaCO2 with a corresponding decrease in pHdecrease in pH
Chronic ventilatory failureChronic ventilatory failureElevated PaCO2 with a normal or near normal pHElevated PaCO2 with a normal or near normal pH
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Initial Ventilator SetupInitial Ventilator SetupKey DecisionsKey Decisions
Indications for ventilatory support presentIndications for ventilatory support present Negative pressure versus positive pressure ventilationNegative pressure versus positive pressure ventilation Non-invasive versus invasive positive pressure ventilationNon-invasive versus invasive positive pressure ventilation Type and method of establishment of an airwayType and method of establishment of an airway Pressure versus volume ventilationPressure versus volume ventilation Partial or full ventilatory supportPartial or full ventilatory support Choice of ventilatorChoice of ventilator Mode of ventilationMode of ventilation
Assist-control ventilation versus SIMV (with or without pressure Assist-control ventilation versus SIMV (with or without pressure support)support)
Pressure supportPressure support Pressure controlPressure control Mixed or dual control modesMixed or dual control modes Other newer modes of adjunctsOther newer modes of adjuncts
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Indications for Mechanical Indications for Mechanical Ventilation in ARDS Ventilation in ARDS
HypoxemiaHypoxemiaApplication of PEEPApplication of PEEPDelivery of high FiO2Delivery of high FiO2
Increased work of breathingIncreased work of breathingUse of ventilator to reduce work of breathingUse of ventilator to reduce work of breathing
Impending or acute ventilatory failureImpending or acute ventilatory failureMaintenance of normal pH and/or PaCO2Maintenance of normal pH and/or PaCO2
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Ventilator Settings for ALI or ARDSVentilator Settings for ALI or ARDSARDSnet ApproachARDSnet Approach
Maintaining a low tidal volume Maintaining a low tidal volume
Monitoring plateau pressureMonitoring plateau pressure
Setting PEEP based on the FiO2 Setting PEEP based on the FiO2
requirementrequirement
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Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network
Calculate predicted body weightCalculate predicted body weight Male :Male :
PBW (kg) = 50 ± 2.3 [(height in inches)-60] PBW (kg) = 50 ± 2.3 [(height in inches)-60] = 50 ± 0.91[(height in cm) –152.4]= 50 ± 0.91[(height in cm) –152.4]
Female : Female : PBW (kg) = 45.5 ± 2.3 [(height in inches)-60] PBW (kg) = 45.5 ± 2.3 [(height in inches)-60] = 45.5 ± 0.91[(height in cm) –152.4]= 45.5 ± 0.91[(height in cm) –152.4]
Ventilator mode : Volume assist/control Ventilator mode : Volume assist/control until weaninguntil weaning
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Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network
Tidal Volume(Vt)Tidal Volume(Vt) Initial Vt : adjust Vt in steps of 1 ml/kg PBW Initial Vt : adjust Vt in steps of 1 ml/kg PBW
every 1-2 hours until Vt = 6 ml/kgevery 1-2 hours until Vt = 6 ml/kg Measure inspiratory plateau pressure (Pplat; Measure inspiratory plateau pressure (Pplat;
0.5 second inspiratory pause) every 4 hours 0.5 second inspiratory pause) every 4 hours and after each change in PEEP or Vtand after each change in PEEP or Vt
If Pplat > 30 cm H2O, decrease Vt to 5 or 4 If Pplat > 30 cm H2O, decrease Vt to 5 or 4 ml/kgml/kg
If Pplat < 25 cm H2O, and Vt,6ml/kg, increase If Pplat < 25 cm H2O, and Vt,6ml/kg, increase Vt by 1 ml/kg PBWVt by 1 ml/kg PBW
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Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network
Respiratory Rate (RR)Respiratory Rate (RR)With initial change in Vt, adjust RR to With initial change in Vt, adjust RR to
maintain minute ventilationmaintain minute ventilationMake subsequent adjustments to RR to Make subsequent adjustments to RR to
maintain pH 7.30-7.45, but do not maintain pH 7.30-7.45, but do not exceed RR = 35/min and do not increase exceed RR = 35/min and do not increase set rate if PaCO2 <25 mm Hgset rate if PaCO2 <25 mm Hg
I:E ratio : Acceptable range = 1:1 – I:E ratio : Acceptable range = 1:1 – 1:3 (no inverse ratio)1:3 (no inverse ratio)
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Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network
FiO2, PEEP and arterial oxygenation: Maintain PaO2 55-FiO2, PEEP and arterial oxygenation: Maintain PaO2 55-80 mm Hg or SpO2 88%-95%80 mm Hg or SpO2 88%-95%
Use only the following PEEP/FiO2 combinations:Use only the following PEEP/FiO2 combinations: FiO2 PEEP (cm H2O)FiO2 PEEP (cm H2O) 0.3-0.4 50.3-0.4 5 0.4 80.4 8 0.5 8-100.5 8-10 0.6 100.6 10 0.7 10-140.7 10-14 0.8 140.8 14 0.9 16-180.9 16-18 1 18-251 18-25
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Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network
Acidosis managementAcidosis management If pH<7.30, increase RR until pH>1 7.30 or ≧If pH<7.30, increase RR until pH>1 7.30 or ≧
RR=35/minRR=35/min If pH remains <7.30 with RR = 35, consider If pH remains <7.30 with RR = 35, consider
bicarbonate infusionbicarbonate infusion If pH <7.15, Vt may be increased (Pplat may If pH <7.15, Vt may be increased (Pplat may
exceed 30 cm H2O)exceed 30 cm H2O) Alkalosis managementAlkalosis management
If pH > 7.45 and patient not triggering If pH > 7.45 and patient not triggering ventilator, decrease set RR but not below ventilator, decrease set RR but not below 6/min6/min
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Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network
WeaningWeaning Initiate weaning by pressure support when all Initiate weaning by pressure support when all
of the following criteria are present:of the following criteria are present:FiO2 <0.4 and PEEP<8cm H2OFiO2 <0.4 and PEEP<8cm H2ONot receiving neuromuscular blocking agentsNot receiving neuromuscular blocking agentsInspiratory efforts are apparent (ventilator rate may Inspiratory efforts are apparent (ventilator rate may
be decreased to 50%of baseline level for up to 5 be decreased to 50%of baseline level for up to 5 minutes to detect inspiratory effort)minutes to detect inspiratory effort)
Systolic arterial pressure > 90 mm Hg without Systolic arterial pressure > 90 mm Hg without vasopressor supportvasopressor support
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Traditional Tidal Volume Traditional Tidal Volume NIH ARDS NetworkNIH ARDS Network
Volume assist controlVolume assist control Tidal Volume(Vt) : 12 ml/kg predicted Tidal Volume(Vt) : 12 ml/kg predicted
body weightbody weight Plateau pressure : < 50 cm H2OPlateau pressure : < 50 cm H2O Ventilator rate setting needed to achieve Ventilator rate setting needed to achieve
a pH goal of 7.3-7.45 : 6-35 breath/mina pH goal of 7.3-7.45 : 6-35 breath/min I;E ratio : 1:1 – 1:3I;E ratio : 1:1 – 1:3
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Patients Excluded in Patients Excluded in NIH ARDS Network StudyNIH ARDS Network Study
36 hours had elapsed since they met the first 36 hours had elapsed since they met the first three criteriathree criteria
Younger than 18 years of ageYounger than 18 years of age Participated in other trials within 30 days before Participated in other trials within 30 days before
the three criteria were metthe three criteria were met PregnantPregnant Neuromuscular disease that impair spontaneous Neuromuscular disease that impair spontaneous
breathingbreathing Sickle cell diseaseSickle cell disease Severe chronic respiratory diseaseSevere chronic respiratory disease
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Patients Excluded in Patients Excluded in NIH ARDS Network StudyNIH ARDS Network Study
Weighed more than 1 kg per centimeter of Weighed more than 1 kg per centimeter of heightheight
Burns over more than 30 percent of their BSABurns over more than 30 percent of their BSA Other conditions with an estimated 6-month Other conditions with an estimated 6-month
mortality rate > 50%mortality rate > 50% Undergone bone marrow or lung transplantationUndergone bone marrow or lung transplantation Chronic liver disease (as defined by Child-Pugh Chronic liver disease (as defined by Child-Pugh
class C)class C) Their attending physician refused or unwilling to Their attending physician refused or unwilling to
dull life supportdull life support
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Respiratory Values during the First 7 Respiratory Values during the First 7 days in NIH ARDS Network Studydays in NIH ARDS Network Study
Variable Day 1 Day 3 Day 7Variable Day 1 Day 3 Day 7
LVT TVT LVT TVT LVT TVTLVT TVT LVT TVT LVT TVT
Tidal volume 6.2±0.9 11.8±0.8 6.2±1.1 11.8±0.8 6.5±1.4 11.4±1.4Tidal volume 6.2±0.9 11.8±0.8 6.2±1.1 11.8±0.8 6.5±1.4 11.4±1.4
Plateau pressure 25±7 33±9 26±7 34±9 26±7 37±9Plateau pressure 25±7 33±9 26±7 34±9 26±7 37±9
Peak insp pressure 32±8 39±10 33±9 40±10 33±9 44±10Peak insp pressure 32±8 39±10 33±9 40±10 33±9 44±10
Mean aw pressure 17±13 17±12 17±14 19±17 17±14 20±10Mean aw pressure 17±13 17±12 17±14 19±17 17±14 20±10
RR 29±7 16±6 30±7 17±7 30±7 20±7RR 29±7 16±6 30±7 17±7 30±7 20±7
Minute ventilation 12.9±3.6 12.6±4.5 13.4±3.5 13.4±4.8 13.7±3.8 14.9±5.3Minute ventilation 12.9±3.6 12.6±4.5 13.4±3.5 13.4±4.8 13.7±3.8 14.9±5.3
PEEP 9.4±3.6 8.6±3.6 9.2±3.6 8.6±4.2 8.1±3.4 9.1±4.2PEEP 9.4±3.6 8.6±3.6 9.2±3.6 8.6±4.2 8.1±3.4 9.1±4.2
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Main Outcome Variables inMain Outcome Variables inNIH ARDS Network NIH ARDS Network
Lower VT Traditional VT P ValueLower VT Traditional VT P ValueDeath before discharge home 31.0 39.8 0.007Death before discharge home 31.0 39.8 0.007 and breathing without and breathing without assistance (%)assistance (%)Weaning by day 28 (%) 65.7 55.0 <0.001Weaning by day 28 (%) 65.7 55.0 <0.001No. of ventilator-free days, 12 ± 11 10 ± 11 0.007No. of ventilator-free days, 12 ± 11 10 ± 11 0.007 days 1 to 28days 1 to 28Barotrauma, days 1 to 28 (%) 10 11 0.43Barotrauma, days 1 to 28 (%) 10 11 0.43No. of days without failure 15 ± 11 12 ± 11 0.006No. of days without failure 15 ± 11 12 ± 11 0.006 of non-pulmonary organsof non-pulmonary organs or systems, days 1 to 28or systems, days 1 to 28
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Clinical Trials of Traditional Versus Lower Tidal Volume VentilationStrategies in Acute Lung Injury and Acute Respiratory Distress Syndrome
Number of Tidal Volumes Tidal Volumes Mortality Patients as Reported per kg PBW (%) Randomized T L T L T L Stewart et al 120 10.8+ 7.2+ 12.2 8.1 47 50
Brochard et al 116 10.3 7.1 11.3 7.8 38 47
Brower et al 52 10.2 7.3 10.2 7.3 46 50
ARDS Network 861 11.8 6.2 11.8 6.2 40 31
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Evidence-Based Medicine Evidence-Based Medicine In Mechanical Ventilation in ARDSIn Mechanical Ventilation in ARDS
The ARDS network trial The ARDS network trial provided strong evidence that provided strong evidence that a lower tidal volume strategy a lower tidal volume strategy can improve clinical outcomes can improve clinical outcomes in patients with ALI or ARDSin patients with ALI or ARDS
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Summary of Alternative Ventilator Summary of Alternative Ventilator Strategies for ALI/ARDSStrategies for ALI/ARDS
Ventilatory No. ofStrategy Year How Studies Patients Comments Study
Low tidal 1999 Phase III 861 Mortality was reduced by ARDS volume 22% with a 6 ml/kg Network predicted body weight tidal volume. This is the first large randomized multicenter controlled trial to show a mortality benefit from a specific therapy in ALI/ARDS
Low tidal 2002 Phase III 549 There was no mortality ARDS volume with benefit to increase levels Network high PEEP of PEEP compared with the standard ARDS Network low tidal volume strategy
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Higher versus Lower Higher versus Lower Positive End-Expiratory Positive End-Expiratory
Pressures in Patients with Pressures in Patients with the Acute Respiratory the Acute Respiratory
Distress SyndromeDistress Syndrome
ARDS NetworkARDS NetworkNEJM 2002NEJM 2002
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MethodsMethods
October 1999-February 2002October 1999-February 200223 hospitals of the National Heart, Lung, 23 hospitals of the National Heart, Lung,
and Blood Instituteand Blood Institute (NHLBI) ARDS Clinical (NHLBI) ARDS Clinical Trials NetworkTrials Network
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PatientPatient
Intubation with MV due to Intubation with MV due to a sudden decrease in the ratio ofa sudden decrease in the ratio of the the
PaOPaO22/FiO/FiO22≦≦ 300300
a recent appearance of bilateral pulmonarya recent appearance of bilateral pulmonary
infiltrates consistent with the presence of infiltrates consistent with the presence of edemaedema
no clinicalno clinical evidence of left atrial hypertension evidence of left atrial hypertension (defined by PAWP 18 mmHg)≦(defined by PAWP 18 mmHg)≦
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Criteria of exclusionCriteria of exclusion
<13 y/o<13 y/o participatedparticipated in other trials involving ALI within the in other trials involving ALI within the
precedingpreceding 30 days; 30 days; Pregnant; Pregnant; IICPIICP severe neuromuscular disease, severe neuromuscular disease, sickle cell disease,sickle cell disease,
severe chronic respiratory disease, severe chronic respiratory disease,
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Criteria of exclusionCriteria of exclusion
BW>BW> 1 kg/cm, 1 kg/cm, Burns> 40 % BSA, Burns> 40 % BSA, Severe chronic liver disease, Severe chronic liver disease, VasculitisVasculitis with diffuse alveolar hemorrhage, with diffuse alveolar hemorrhage, A coexisting conditionA coexisting condition associated with an associated with an
estimated 6-month mortality rate >50 %; estimated 6-month mortality rate >50 %; Post- BMT or lung transplant;Post- BMT or lung transplant;
Their attending physician refused to allow Their attending physician refused to allow enrollment. enrollment.
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Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.
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Evidence-Based Medicine Evidence-Based Medicine In Mechanical Ventilation in ARDSIn Mechanical Ventilation in ARDS
with Higher PEEPwith Higher PEEP
The ARDS Network higher versus The ARDS Network higher versus lower PEEP trial provided strong lower PEEP trial provided strong evidence that there was no evidence that there was no mortality benefit to increase levels mortality benefit to increase levels of PEEP compared with the of PEEP compared with the standard ARDS Network low tidal standard ARDS Network low tidal volume strategyvolume strategy
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Algorithm for ventilator management of ARDS using the ARDSnet protocolCalculate predicted body weight
CMV (A/C). VCV. Set initial volume to 8 mL/kg, then 7 mL/kg after 1 hr, then 6 mL/kg after next hr. increase respiratory rate to maintain minute ventilation. I:E ratio 1:2. PEEP and FiO2 per FiO2/PEEP table
Pplat <30 cm H2O
Adjust FiO2 or PEEPper FiO2/PEEP table
↑rate
↑VT by 1 mL/kg
↑VT to 7-8 mL/kg
↓VT to 4 mL/kg
↓rate↑rateConsider HCO3 ↑VT
Evaluate for weaning
VT 4 mL/kg
Pplat <25 cm H2O
VT < 6 mL/kg
Severe dyspnea
PaO2 55-80SpO2 88-95
FiO2 0.4≦PEEP=8
pHpH<7.15
START
no no
nono
no
no
no
no yes
yes
yes
yes
yes
yes
yes
yes
7.30-7.45
>7.45<7.30
ARDS Network N Engl J Med 2000; 342:1301
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Chronic Pulmonary DiseasePatients with Chronic Pulmonary Disease
Acute on chronic ventilatory failure and Acute on chronic ventilatory failure and hypoxemiahypoxemia Elevated PaCO2 and resulting hypoxemiaElevated PaCO2 and resulting hypoxemia
Unloading work-of-breathingUnloading work-of-breathing Increased work-of-breathing due to increased resistanceIncreased work-of-breathing due to increased resistance
Resting ventilatory musclesResting ventilatory muscles Exhausted musclesExhausted muscles
Improving bronchial hygieneImproving bronchial hygiene Increased airway secretionsIncreased airway secretions
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Ventilator Strategy in Chronic Ventilator Strategy in Chronic Pulmonary Obstructive DiseasePulmonary Obstructive Disease
Primary concern : patient-ventilator Primary concern : patient-ventilator synchronysynchronyTo avoid unnecessary work of breathingTo avoid unnecessary work of breathingTo reduce anxietyTo reduce anxietyTo decrease ventilatory driveTo decrease ventilatory driveTo minimize auto-PEEPTo minimize auto-PEEP
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Algorithm for the ventilator management of the patient with COPD
(A/C), PCV or VCV, VT 8-10 mL/kg, Pplat < 30 cm H2O, rate 10/min, Ti 0.6-1.2 s, PEEP 5 cm H2O, FiO2 for SpO2 90-95%
Clear secretionsAdminister bronchodilators
↑PEEP if missed trigger efforts↓VT or rate
↓ FiO2↑ FiO2
↑rate↑VT
NPPVContinue
NPPV
CandidateFor
NPPV
Patienttolerates
Clinicallyimproved
PaO2mmHg
pHPplat <
25 cm H2OPplat >
30 cm H2O
↓rate ↓VT
Auto-PEEP
Auto-PEEP
START
yes yes yes yes
yes
yes
no
no
yes
no
yes
no
>75
55-75 mmHg
<55
7.30-7.45
<7.30>7.45
intubate
intubate intubate
Fumeaux T et al Intensive Care Med 2001;27:1868Gladwin MT et al Intensive Care Med 1998;24:898Nava S et al Ann Intern Med 1998; 128:721
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Chest TraumaPatients with Chest Trauma
Flail chest with paradoxical chest movement, Flail chest with paradoxical chest movement, tachypnea, hypoxemia, hypercarbiatachypnea, hypoxemia, hypercarbia
Pulmonary contusion with tachypnea and severe Pulmonary contusion with tachypnea and severe hypoxemia (PaO2< 60 mmHg) breathing 100% O2hypoxemia (PaO2< 60 mmHg) breathing 100% O2
Rib fracture with chest pain requiring large dose of Rib fracture with chest pain requiring large dose of narcotics for pain controlnarcotics for pain control
Post-operative thoracotomyPost-operative thoracotomy Hemodynamic instability, particularly with marginal Hemodynamic instability, particularly with marginal
respiratory reserve (hypoxemia and tachypnea)respiratory reserve (hypoxemia and tachypnea) Severe associated injuries ( head injury)Severe associated injuries ( head injury)
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Ventilator Strategy in PatientsVentilator Strategy in Patientswith Chest Traumawith Chest Trauma
Full ventilatory support initiallyFull ventilatory support initiallySedation, or paralysis may be necessary Sedation, or paralysis may be necessary
initiallyinitiallyBarotrauma is commonBarotrauma is commonTidal volumeTidal volume
8-10 ml/kg with satisfactory lung compliance8-10 ml/kg with satisfactory lung compliance4-8 ml/kg with pulmonary contusion and 4-8 ml/kg with pulmonary contusion and
ARDSARDS
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Algorithm for Mechanical Ventilation of the Patient with Chest TraumaSTART
CMV (A/C), VT 6 to 10 mL/kg, FiO2 1.0.rate 15/min, Ti 1 s, VCV or PCV, PEEP 5 cm H2O
Titrate FiO2 toSpO2 92-95%
Good lung down
↑PEEP
↓VT and↑rate
↑FiO2
MaintainCurrent settings
↓rate ↑rate
↑VT or↑rate
FiO2<0.6
Broncho-Pleuralfistula
ICP>20
Unilateraldisease
Pplat>30 cm H2O
PplatpH
no no no
no
yes
yesyes
yes
yes
Unilateraldisease
no
>25
≦25
>7.45
7.30-7,45
<7.30
Calhoon JH et al Chest Surg Clin N Am 1997;7:199Ferguson M et al 1996 2:449Gentilello LM et al Am J Respir Crit Care Med 2001 163:604
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Acute Head InjuryPatients with Acute Head Injury
Depression due to primary neurologic Depression due to primary neurologic injuryinjury
Associated injuries to the spine, chest Associated injuries to the spine, chest and abdomenand abdomen
Neurogenic pulmonary edemaNeurogenic pulmonary edemaTreatment with respiratory suppressant Treatment with respiratory suppressant
medications (barbiturate, sedatives, medications (barbiturate, sedatives, paralysis)paralysis)
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Algorithm for Mechanical Ventilation of the Patient with Head Injury
Unilateral lungdisease
CMV (A/C), PCV or VCV,VT 4 t0 8 mL/kg.FiO2 1.0,rate 20/min, Ti 1 s, PEEP 5 cm H2O
CMV (A/C), PCV or VCV,VT 8 t0 12 mL/kg.FiO2 1.0,rate 20/min, Ti 1 s, PEEP 5 cm H2O
Titrate FiO2 for SpO2 92%≧
PaCO2 Pplat > 30
PaO2
FiO2>0.6
ICP ICP
ICP<20
FiO2>0.6
Maintainventilator settings
More aggressiveMedical therapy
Slowly ↓rate to initialsetting
↑rate ↓rate
↓VT
↑rate
↓FiO2
↑FiO2
↑PEEP
START
yes
yesno
no
no
yes<35>45
35 - 45
>100
70 - 100
<70nono
yes
>20
<20
>20<20
no
Berrouschot J et al Crit Care Med 2000 28:2956
yes
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Management of Intracranial PressureManagement of Intracranial Pressure
Hyperventilation : PaCO2 of 25- 30 mmHgHyperventilation : PaCO2 of 25- 30 mmHg Mean airway pressure : kept as low as possibleMean airway pressure : kept as low as possible Positioning : 30Positioning : 30° elevation of the head° elevation of the head Dehydration and osmotherapy : manitol and lasixDehydration and osmotherapy : manitol and lasix Sedation and paralysis : agitation, coughSedation and paralysis : agitation, cough Barbiturate therapyBarbiturate therapy Temperature controlTemperature control VentriculostomyVentriculostomy
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Indications for Mechanical Ventilation Indications for Mechanical Ventilation in Post-operative Patientsin Post-operative Patients
Apnea – unreversed anesthetic agentsApnea – unreversed anesthetic agents Iatrogenic hypothermiaIatrogenic hypothermiaNeed to reduce cardiopulmonary stressNeed to reduce cardiopulmonary stressPresence of altered pulmonary mechanicsPresence of altered pulmonary mechanics
Transplant recipientsTransplant recipientsMinimize post-operative cardiopulmonary Minimize post-operative cardiopulmonary
stressstressPre-existing lung disease compromising Pre-existing lung disease compromising
cardiopulmonary reservecardiopulmonary reserve
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Algorithm for Mechanical Ventilation of the Post-operative Patient
Ventilate consistentwith underlying
disease
Ventilate consistentwith negative lung
pathology
Consider extubation
Spontaneousbreathing
trial
Titrate FiO2For SpO2> 92%
CMV (A/C), VCV or PCV, VT 10 – 12mL/kg, rate 12/min, I;E:1:3PEEP 5 cm H2O, FiO2:1.0
Adjust rate and tidal volume for normal acid-base
↑PEEP
Prior lungdisease
Single lungtransplant
Tolerated
Spontaneous Breathing efforts.HemodunamicallyStable, FiO2 0.5≦
PEEP 5≦
FiO2
STARTyes
yes
no
no
yes
noyesno
≧0.6<0.6
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Initial Ventilator Settings for Postoperative Initial Ventilator Settings for Postoperative Patients with no Prior DiseasePatients with no Prior Disease
Setting Recommendation
Mode A/C (CMV)
Rate 10 - 16/min
Volume/pressure control Pressure or volume
Tidal volume 10-12 mL/kg IBW and plateau pressure
<30 cm H2O
Inspiratory time 1 s
PEEP ≤ 5 cm H2O
FiO2 Sufficient to maintain PaO2 > 80 mm Hg
Flow waveform Descending ramp
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Initial Ventilator Settings for Postoperative Initial Ventilator Settings for Postoperative Patients with Prior Obstructive Lung DiseasePatients with Prior Obstructive Lung Disease
Setting Recommendation
Mode A/C (CMV)
Rate 8 – 12 /min
Volume/pressure control Pressure or volume
Tidal volume 8-10 mL/kg IBW and plateau pressure
<30 cm H2O
Inspiratory time 0.6 – 1.2 s
PEEP 5 cm H2O; counterbalance auto-PEEP
FiO2 Sufficient to maintain PaO2 > 60 mm Hg
Flow waveform Descending ramp
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Initial Ventilator Settings for Postoperative Initial Ventilator Settings for Postoperative Patients with Prior Restrictive Lung DiseasePatients with Prior Restrictive Lung Disease
Setting Recommendation
Mode A/C (CMV)
Rate 15 –25 /min
Volume/pressure control Pressure or volume
Tidal volume < 8 mL/kg IBW and plateau pressure
<30 cm H2O
Inspiratory time 1 s
PEEP 5 cm H2O
FiO2 Sufficient to maintain PaO2 > 60 mm Hg
Flow waveform Descending ramp
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Respiratory Failure in Neuromuscular Respiratory Failure in Neuromuscular Diseases and Chest Wall DeformitiesDiseases and Chest Wall Deformities Rapid onsetRapid onset
Myasthenia gravisMyasthenia gravis Guillain-Barre syndromeGuillain-Barre syndrome High spinal cord injuryHigh spinal cord injury Prolonged paralysis following use of neuromuscular Prolonged paralysis following use of neuromuscular
blocking agents in ICUblocking agents in ICU Gradual onsetGradual onset
Muscular dystrophyMuscular dystrophy Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis Thoracic deformities (severe scoliosis, kyphosis, Thoracic deformities (severe scoliosis, kyphosis,
kyphoscoliosis) kyphoscoliosis) Post-polio syndromePost-polio syndrome
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Neuromuscular DiseasePatients with Neuromuscular Disease
Progressive ventilatory failureProgressive ventilatory failure
Acute ventilatory failureAcute ventilatory failure
Oxygenation is not usually an issue – except Oxygenation is not usually an issue – except
in patients with acquired critical illness in patients with acquired critical illness
neuromusculopathy following prolonged neuromusculopathy following prolonged
mechanical ventilationmechanical ventilation
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Algorithm for Mechanical Ventilation of the Patient with Neuromuscular Disease without Lung Disease
CMV (A/C), VCV, VT 15 mL/kg, FiO2 0.40Rate 10/min, Ti 1 s, PEEP 0 cm H2O
↓FiO2↑FiO2 ↑PEEP
In-Exsufflattor
↑VT
↑VT
↑rate
↑rate
In-Exsufflattor
Maintain therapy
↓rate or ↓VT
Considermechanical dead space
Secretionsor
atelectasis
dyspnea dyspnea
secretions
pHPplat
SpO2<95%
SpO2
START
yes
yes
yes
no
no
yes
no
no
noyes
>7.45
7.35-7.45
<7.35
>25
≦25
>95%<92%
92-95%
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Methods to Treat AtelectasisMethods to Treat Atelectasis
In-exsufflatorIn-exsufflator
Maximal insufflation capacityMaximal insufflation capacity
HyperinflationHyperinflation
Assisted coughAssisted cough
Peak cough flow > 160 L/minPeak cough flow > 160 L/min
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Mechanical Insufflation-ExsufflationMechanical Insufflation-ExsufflationArtificial cough machineArtificial cough machineStimulating cough by inflating the lung with Stimulating cough by inflating the lung with
pressure, followed by a negative pressure pressure, followed by a negative pressure to produce a high expiratory flowto produce a high expiratory flow
Inspiratory pressure :25-35 cm H2O for 1-Inspiratory pressure :25-35 cm H2O for 1-2 seconds2 seconds
Expiratory pressure:-40 cm H2O for 1-2 Expiratory pressure:-40 cm H2O for 1-2 secondsseconds
Treatment periods: 5-6 breathsTreatment periods: 5-6 breaths
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Cardiovascular FailurePatients with Cardiovascular Failure
Increased work of the myocardiumIncreased work of the myocardium
Decrease myocardial work with MVDecrease myocardial work with MV
Increased work of breathingIncreased work of breathing
Reduce the work of breathing with MVReduce the work of breathing with MV
HypoxemiaHypoxemia
Reverse hypoxemia with MVReverse hypoxemia with MV
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Algorithm for Mechanical ventilation of the Patient with Cardiac Failure
Awake andcooperative
Patienttolerates
PaCO2>45 mm Hg
PaCO2.45 mm Hg
Acute MI
Pplat
pH
Hemodynamicstability
SpO2<92%;Pulmonary edema
CMV (A/C), VCV or PCV, VT 8-10mL/kg, Pplat < 30 cm H2O, I;E:1:2PEEP 5 cm H2O, FiO2 1.0
Mask CPAP,5-10 cm H2O, FiO2 1.0
Continue therapy,Definitive medical therapy
Titrate FiO2For SpO2>92%
↑PEEP
NPPV
Manipulate PEEP and FiO2
↑ rate
↓VT
↓ rate
STARTyes
yes
yes
yes
yes
no
no
yesno
no
no
no
intubate
intubate
<30
≧30
<7.35
7.35-7.45
>7.45
no
yes
Bersten AD et al New Engl J Med 1991 325:1825Poppas A et al Am J Respir Crit Care Med 2002 165:4
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with AsthmaPatients with Asthma
Acute ventilatory failureAcute ventilatory failure
Impending acute ventilatory Impending acute ventilatory
failurefailure
Severe hypoxemiaSevere hypoxemia
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Ventilator Strategy Ventilator Strategy in Patients with Acute Asthmain Patients with Acute Asthma
Major concern: auto-PEEPMajor concern: auto-PEEPTo minimize auto-PEEPTo minimize auto-PEEPPermissive hypercapniaPermissive hypercapniaUse of inhaled bronchodilators and Use of inhaled bronchodilators and
systemic steroids to reduce the airway systemic steroids to reduce the airway inflammation, edema, swelling and inflammation, edema, swelling and bronchospasmbronchospasm
Risk of barotrauma and hypotensionRisk of barotrauma and hypotension
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Algorithm for Mechanical Ventilation of Patient with AsthmaSTART
Decrease minute ventilation
CMV (A/C), PCV or VCV, VT 4-8 mL/kg, Pplat 30 cm H2O≦rate 8-20/min, Ti 1 s, PEEP 5 cm H2O, FiO2 1.0
SpO2
Auto-PEEP
Auto-PEEP
Pplat<25 cm H2OpHPplat>
30 cm H2O
Administer bronchodilators
↑VT ↑rate
↑FiO2↓FiO2
↓VT↓rate
yes
yes
yesyes
no
nono
92-95%
>95% <92%
>7.45 <7.30
7.30-7.45
Afzal M et al Clin Rev Allergy Immunol 2001 20:385Mansel JK et al Am J Med 1990 89:42Koh Y Int Aneshesiol Clin 2001 39:63
no
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Indications for Mechanical Indications for Mechanical Ventilation in Patients with Burn Ventilation in Patients with Burn
and Smoke Inhalationand Smoke Inhalation Smoke inhalation or pulmonary burn with Smoke inhalation or pulmonary burn with
respiratory failure (ARDS)respiratory failure (ARDS) Severe burn with chest wall restrictionSevere burn with chest wall restriction Respiratory depression due to inhalation of Respiratory depression due to inhalation of
systemic toxin (carbon monoxide)systemic toxin (carbon monoxide) Respiratory failure due to secondary infection – Respiratory failure due to secondary infection –
pneumonia, sepsispneumonia, sepsis Postoperative skin graft or escharotomyPostoperative skin graft or escharotomy
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Algorithm for Mechanical Ventilation of Patient with Burn and Inhalation Injury
CMV (A/C), PCV or VCV, VT 6 to 12 mL/kg, FiO2 1.0,rate 15/min, Ti 1 s
Consider:BronchodilatorsDiureticsSecretion clearancePEEPRecruitment maneuverProneInhaled nitric oxide
Treat with:Bronchodilators, diuretics
Titrate FiO2 forSpO2 92%≧
Maintainventilator settings
↑ rate
↑ VT
↑ FiO2
↓ VT
↓ rate
ConsiderVT ↑↓ FiO2
↓Chest wall compliance
Pplat>30 pH
PaO2
FiO2<0.6
FiO2<0.6
ABGresults
Pplat>30Cm H2O
yes
yes
yes
yes
yes
no
no
no
no
no
no
<7.30>7.45
7.30-7.45
>100<70
70-100
Continue 100% O2
CO poisoningyes
START
Fitzpatrick JC et al Respir Care Clin N Am 1997 3:21
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Indications for Mechanical Indications for Mechanical Ventilation in Patients with Ventilation in Patients with
Bronchopleural FistulaBronchopleural Fistula
Bronchopleural fistula is not by Bronchopleural fistula is not by itself an indication for mechanical itself an indication for mechanical ventilation, but may be necessary ventilation, but may be necessary in the following settings:in the following settings:ApneaApneaAcute ventilatory failureAcute ventilatory failureImpending acute ventilatory failureImpending acute ventilatory failureOxygen deficit Oxygen deficit
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Algorithm for Mechanical Ventilation of Patient with Bronchopleural Fistula
CMV (A/C), VCV or PCV, rate 6-20/minVT 4 – 8 mL/kg, Ti≤ 1 s
PEEP 3 cm H2O, FiO2:1.0
Exhaled VT
>75%Inhaled VT
Systemicaly evaluate changes in:Tidal volumeRespiratory RatePEEPInspiratory timePressure control vs. volume control
Titrate FiO2 for SpO2 92-95%
pH rate rate
Start
yes
no
7.25-7.45
>7.45<7.25
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Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Drug OverdosePatients with Drug Overdose
ApneaApnea
Acute respiratory failureAcute respiratory failure
Impending acute respiratory Impending acute respiratory
failurefailure
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Algorithm for Mechanical Ventilation of Patient with Drug Overdose
CMV (A/C), VCV or PCV,,rate 10/minVT 8 to 12 mL/kg, Ti 1 s,
PEEP 5 cm H2O, FiO2 1.0
SpontaneousBreathing
trial
Consider extubation
↑PEEP
Titrate FiO2for SpO2 > 92%
Adjust rate and tidal volume fornormal acid-base
FiO2
tolerated
Spontaneousbreathing effortshemodynamicallystable, FiO2 0.5≦
PEEP 5≦
START
yes
yes
nono
<0.60
≧0.60
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謝謝 !如有問題請發問 !
謝謝 !如有問題請發問 !
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Ventilator Setting for ALI or ARDSVentilator Setting for ALI or ARDSOpen Lung ApproachOpen Lung Approach
Maintaining a low plateau Maintaining a low plateau pressurepressure
Monitoring tidal volumeMonitoring tidal volumeUsing recruitment maneuvers and Using recruitment maneuvers and
high levels of PEEP to maximize high levels of PEEP to maximize alveolar recruimentalveolar recruiment
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Algorithm for ventilator management of ARDS using the open lung approach
Consider prone positionConsider accepting lower level of oxygenationConsider inhaled nitric oxide
CMV (A/C). PCV to achieve VT of 4-8 mL/kg, Ti to Avoid auto-PEEP. Rate 20/min. FiO2 1.0. PEEP 10 cm H2O
Recruitment maneuver PEEP 20 cm H2OFiO2 to maintain SpO2 90-95%Decrease PEEP to maintain SpO2 90-95%
↑ pressure control if Pplat < 30 cm H2O↑rate (avoid auto-PEEP)Consider accepting lower pH
Recruitment maneuver↑ increase PEEP↑increase FiO2
Maintain ventilator settings
↓FiO2↓ PEEP if FiO2 < 0.05
↓pressure control↓ rate
SpO2
SpO2
pH
<90%
≧90%
90-95%
>95%<90%
7.25-7.45
<7.25 >7.45
START
Amato MBP et al. N Engl J Med 1998 338:347
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The ARDSnet protocol for ventilation of The ARDSnet protocol for ventilation of patients with ALI and ARDSpatients with ALI and ARDS
Initial ventilator tidal volume and rate Initial ventilator tidal volume and rate adjustmentadjustment Calculate predicted body weightCalculate predicted body weight
Male = 50 + 2.3 [ht (in) – 60 ] kgMale = 50 + 2.3 [ht (in) – 60 ] kg Female = 45.5 + 2.3 [ht (in) – 60 ] kgFemale = 45.5 + 2.3 [ht (in) – 60 ] kg
Mode : volume Assist-ControlMode : volume Assist-Control Set initial tidal volume to 8 mL/kg PBWSet initial tidal volume to 8 mL/kg PBW Reduce tidal volume to 7 mL/kg PBW after 1-2 hrs Reduce tidal volume to 7 mL/kg PBW after 1-2 hrs
and then to 6 mL/kg PBW after a further 1-2 hrsand then to 6 mL/kg PBW after a further 1-2 hrs Set initial ventilator rate to maintain baseline Set initial ventilator rate to maintain baseline
minute ventilation (not > 35 /min)minute ventilation (not > 35 /min)ARDS Network N Engl J Med 2000; 342:1301
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The ARDSnet protocol for ventilation of The ARDSnet protocol for ventilation of patients with ALI and ARDSpatients with ALI and ARDS
Subsequent tidal volume adjustmentsSubsequent tidal volume adjustments Plateau pressure goal : Plateau pressure goal : ≤ 30 cm H2O≤ 30 cm H2O Check inspiratory plateau pressure (PCheck inspiratory plateau pressure (Pplatplat) with 0.5 s ) with 0.5 s
pause at least every 4 hrs and after each change in pause at least every 4 hrs and after each change in PEEP and tidal volumePEEP and tidal volume
If PIf Pplatplat >30 cm H2O, decrease tidal volume by 1 mL/kg PBW, >30 cm H2O, decrease tidal volume by 1 mL/kg PBW, if necessary to 4 mL/kg PBWif necessary to 4 mL/kg PBW
If PIf Pplatplat < 25 cm H2O and tidal volume < 6 mL/kg PBW, < 25 cm H2O and tidal volume < 6 mL/kg PBW, increase tidal volume by 1 mL/kg PBW until Pincrease tidal volume by 1 mL/kg PBW until Pplatplat >25 cm H2O >25 cm H2O and tidal volume =6 mL/kg and tidal volume =6 mL/kg
If breath stacking or severe dyspnea occurs, tidal volume may If breath stacking or severe dyspnea occurs, tidal volume may be increased (not required) to 7 or 8 mL/kg PBW 1f Pbe increased (not required) to 7 or 8 mL/kg PBW 1f Pplatplat < 25 < 25 cm remains ≤ 30 cm H2Ocm remains ≤ 30 cm H2O
ARDS Network N Engl J Med 2000; 342:1301
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The ARDSnet protocol for ventilation of The ARDSnet protocol for ventilation of patients with ALI and ARDSpatients with ALI and ARDS
Arterial oxygenationArterial oxygenationGoal : PaO2 55-80 mm Hg or SpO2 88 – Goal : PaO2 55-80 mm Hg or SpO2 88 –
95%95%Use these FiO2/PEEP combinations to Use these FiO2/PEEP combinations to
achieve oxygenation goalachieve oxygenation goal
--FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0
PEEP 5 5 8 8 10 10 10 12 14 14 16 16 18 20-24
ARDS Network N Engl J Med 2000; 342:1301
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Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.
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The ARDSnet protocol for ventilation of The ARDSnet protocol for ventilation of patients with ALI and ARDSpatients with ALI and ARDS
Respiratory rate and arterial pHRespiratory rate and arterial pH Arterial pH Goal : 7.30 – 7.45Arterial pH Goal : 7.30 – 7.45 A. Acidosis managementA. Acidosis management
If pH 7.15 – 7.30If pH 7.15 – 7.30 Increase set rate until pH >7.30 or PaCO2 < 25 (max rate = 35/min)Increase set rate until pH >7.30 or PaCO2 < 25 (max rate = 35/min) If set rate = 35 /min and pH < 7.30, NaHCO3 may be given (not If set rate = 35 /min and pH < 7.30, NaHCO3 may be given (not
required)required) If pH < 7.15If pH < 7.15
Increase set respiratory rate to 35 /minIncrease set respiratory rate to 35 /min If set rate = 35 /min and pH < 7.15 and NaHCO3 has been considered, If set rate = 35 /min and pH < 7.15 and NaHCO3 has been considered,
tidal volume may be increased in 1 mL/kg PBW steps until pH > 7.15 tidal volume may be increased in 1 mL/kg PBW steps until pH > 7.15 (Pplat target may be exceeded)(Pplat target may be exceeded)
Alkalosis managementAlkalosis management Decrease set rate until patient rate > set rate. Minimum set rate = Decrease set rate until patient rate > set rate. Minimum set rate =
6 /min6 /min I:E Ratio Goal : 1:1 – 1:3I:E Ratio Goal : 1:1 – 1:3
Adjust flow and inspiratory flow waveform to achieve goalAdjust flow and inspiratory flow waveform to achieve goal
ARDS Network N Engl J Med 2000; 342:1301
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Recruitment ManeuversRecruitment Maneuvers
In the first 80 patients, higher-PEEPIn the first 80 patients, higher-PEEP
group, => assessed the safety and group, => assessed the safety and efficacy of recruitment maneuversefficacy of recruitment maneuvers
single sustained inflations of the lungs tosingle sustained inflations of the lungs to
higher airway pressures and volumes than higher airway pressures and volumes than are obtained duringare obtained during tidal ventilationtidal ventilation
An effort to improve arterial oxygenation.An effort to improve arterial oxygenation.
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Recruitment ManeuversRecruitment Maneuvers
One or two such maneuvers were One or two such maneuvers were conducted during the first fourconducted during the first four days, by days, by applying CPAP 35 to 40 cmH2O for 30 applying CPAP 35 to 40 cmH2O for 30 seconds. seconds.
The subsequentThe subsequent mean increase in arterial mean increase in arterial oxygenation was small and transient.oxygenation was small and transient.
Discontinued recruitment maneuvers for Discontinued recruitment maneuvers for the remainderthe remainder of the trial.of the trial.
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General Guideline for Initial Ventilator General Guideline for Initial Ventilator Settings for Adult PatientsSettings for Adult Patients
Tidal VolumeTidal Volume 8 to 12 mL/kg IBW8 to 12 mL/kg IBW Avoid over-distensionAvoid over-distension Prefer volume on the steep part of the pressure-volume Prefer volume on the steep part of the pressure-volume
curvecurve Maintain PMaintain Pplat plat at 30 cm H2O or lessat 30 cm H2O or less
10-12 mL/kg IBW is a good starting point for most of the 10-12 mL/kg IBW is a good starting point for most of the patientspatients
12 – 15 mL/kg IBW –neuromuscular diseases or post-12 – 15 mL/kg IBW –neuromuscular diseases or post-operative patients with normal lungs operative patients with normal lungs
8-10 mL/kg IBW in SIMV with adequate expiratory time 8-10 mL/kg IBW in SIMV with adequate expiratory time In ARDS patients, start with 8 mL/kg, reduce gradually to 6 In ARDS patients, start with 8 mL/kg, reduce gradually to 6
mL/kg to maintain PmL/kg to maintain Pplat plat at 30 cm H2O or lessat 30 cm H2O or less
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Alarm and Backup Ventilation Settings Alarm and Backup Ventilation Settings for Initial Ventilator Setup (Adult)for Initial Ventilator Setup (Adult)
Low pressure 8 cm H2O 0r 5-10 cm H2O below PIPLow pressure 8 cm H2O 0r 5-10 cm H2O below PIP
Low PEEP/CPAP 3-5 cm H2O below PEEPLow PEEP/CPAP 3-5 cm H2O below PEEP
High pressure limit 50 cm H2O High pressure limit 50 cm H2O
adjust to 10-20 cmH2O above PIPadjust to 10-20 cmH2O above PIP
Low exhaled tidal volume 100 mL or 10-15% below set VLow exhaled tidal volume 100 mL or 10-15% below set VTT
Low exhaled minute ventilation 2-5 L/min or 10-15% below backup minuteLow exhaled minute ventilation 2-5 L/min or 10-15% below backup minute
ventilationventilation
High minute ventilation 5 L/min or 10-15% above baseline High minute ventilation 5 L/min or 10-15% above baseline
minute ventilation minute ventilation
Oxygen percentage 5% above and below set O2 %Oxygen percentage 5% above and below set O2 %
Temperature 2°C above and below set temperatureTemperature 2°C above and below set temperature
High temperature not to exceed 37°CHigh temperature not to exceed 37°C
Apnea delay 20 secondsApnea delay 20 seconds
Apnea values Tidal volume and rate set to achieve full Apnea values Tidal volume and rate set to achieve full
ventilatory support with 100 % O2ventilatory support with 100 % O2