Nursebob’s MICU/CCU Survival Guide

Pulmonary Concepts in Critical Care

ARDS Protocol

Nursebob©

2/18/2006

1. Inclusion Criteria - Acute onset of…

A. P0₂ / F0₂ <250

B. Bilateral infiltrates consistent with pulmonary edema.

C. No clinical evidence of left atrial hypertension.

2. Ventilator set-up and adjustment.

A. Calculate ideal body weight

a. Male equal 50 plus 2.3 (height in inches - 60).

b. Female equal 45.5 plus 2.3 (height in inches - 60).

B. Select assist control mode.

C. Set initial Tidal Volume (TV) at 8 ml/kg body weight.

D. Reduce TV by 1 ml/kg at intervals < 2 hours until TV equals 6 ml/kg ideal body weight.

E. Set initial rate to approximate baseline minute ventilation (not > 35 bpm).

F. Adjust TV and respiratory rate to achieve pH and plateau pressure goals below.

G. Set inspiratory flow rate above patient demand (usually > 80 liters per minute).

3. Oxygenation goal

A. Pa0₂ 55-80 mm Hg or Sa02 88-95%.

B. Use incremental R02/PEEP combinations below to achieve goal.

Fi0₂ 0.3, 0.4, 0.4, 0.5, 0.5, 0.6, 0.7, 0.7.

PEEP 5, 5, 8, 8, 10, 10, 10, 12.

--------------------------------------------------

Fi02 0.7, 0.8, 0.9, 0.9, 0.9. 1.0, 1.0, 1.0, 1.0

PEEP 14, 14, 14, 16, 18, 18, 20, 22, 24

4. Plateau Pressure Goal

A. < 30 cm H20.

B. Check Pplat (0.5 second inspiratory pause), Sa02, RR, TV and pH (if available) at least q 4 hours and after each change in PEEP or TV.

a. If Pplat > 30 cm H20: decrease TV by 1 ml/kg steps (minimum equal 4 ml/kg).

b. If Pplat less than 25 cm H20: TV < 6 ml/kg, increase TV by 1 ml/kg until Pplat >25 cm H20 or TV equal 6 ml/kg.

c. If Pplat < 20 and breath stacking occurring: may increase TV in 1 ml/kg increments (maximum 8 ml/kg).

5. pH goal 7.30-7.45.

A. Acidosis management (pH < 7.30).

a. If pH 7.15 - 7.30: increase respiratory rate until pH > 7.30 or PaC02 < 25 (maximum respiratory rate 35).

b. If respiratory rate equals 35 and PaC02 < 25, may give sodium bicarbonate.

c. If pH less than 7.15, increase respiratory rate to 35.

d. If pH remains less than 7.15, and sodium bicarbonate is being infused, TV may be increased in 1 ml/kg steps until pH greater than 7.15.

(Pplat target may be exceeded).

B. Alkalosis management: (pH > 7.45).

a. Decrease ventilator rate if possible.

b. I:E ratio goal: 1:1.0 -1:3. Adjust flow rate to achieve goal.

c. If Fi02 equal 1.0 and PEEP = 24 cm H20, may adjust I:E to 1:1.

6. Definition of Weaning Tolerance:

A. Respiratory rate less than 35 (may exceed 35 for < 5 minutes).

B. SaO₂ > 88% (<15 minutes at < 88% may be tolerated).

C. Respiratory distress is absent (< 2 of the following)

a. Pulse > 120% of usual rate for > 5 minutes

b. Marked use of accessory muscles

c. Abdominal paradox

d. Diaphoresis

e. Marked complaints of Dyspenia

7. Conduct CPAP trial when:

A. FiO₂ < 0.4 and PEEP < 8

B. PEEP and R 0₂ < values of previous days

C. Patient has acceptable spontaneous breathing efforts

a. May decrease vent rate by 50% for 5 minutes to detect effort

D. Systolic blood pressure > 90 mm Hg without vasopressor support.

8. Conducting the trial:

A. Set CPAP equal 5 cm H₂0, FIO₂ equal 0.4.

B. If respiratory < 35 for 5 minutes

a. Advance to pressure support weaning below.

C. If respiratory rate > 35 in < 5 minutes

a. May repeat trial after appropriate interventions

-Suctioning

-Analgesia

-Angiolysis

D. If CPAP trial not tolerated, return to previous AC settings.

9. Pressure support weaning procedure:

A. Set PEEP = 5 cm H₂0 and Fi0₂ = 0.5.

B. Set initial PS based on respiratory rate during CPAP trial.

a. If CPAP respiratory rate < 25: set PS = 5 cm H₂0 and go to third step.

b. If CPAP respiratory rate is 25 to 30: set PS = 20 cm H₂0

-Then reduce by 5 cm H20 at < 5 minute intervals until respiratory rate equal 26 -35, then go to step C a.

c. If initial PS not tolerated, return to previous AC settings.

C. Reducing PS (no reductions made after 1700 hours).

a. Reduce PS by 5 cm H20 q 1 to 3 hours, then go to step C d.

b. If PS > 10 cm H₂0 not tolerated

-Return to previous AC settings

-Re-initiate last tolerated PS level next a.m. and go to step C a.

c. If PS = 5 cm H₂0 not tolerated

-Return to PS = 10 cm H20. If tolerated

-5 or 10 cm H₂0 may be used overnight with future attempts to wean the next morning.

d. If PS = 5 cm H₂0 tolerated > 2 hours

-Assess for the ability to sustain unassisted breathing below.

10. Unassisted breathing trial:

A. Place on T-tube or trach collar or CPAP < 5 cm H₂0.

B. Assess for tolerance as below for 2 hours.

C. If tolerated, consider extubation.

a. If not tolerated, resume PS = 5 cm H20.
D. Definition of Unassisted Breathing Tolerance:

a. Respiratory rate < 35 and:

b. Sa0₂ > 90% and/or pa0₂ > 60 mm Hg and:

c. Spontaneous TV > 4 ml/kg BW and:

d. Respiratory distress is absent (less than two of the following):

- Pulse > 120% of usual rate for greater than 5 minutes

- Marked use of accessory muscles

- Abdominal paradox

- Diaphoresis

- Marked complaints of Dyspenia.