Professional Documents
Culture Documents
Acidosis management
If pH<7.30, increase RR until pH>1≧7.30 or
RR=35/min
If pH remains <7.30 with RR = 35, consider
bicarbonate infusion
If pH <7.15, Vt may be increased (Pplat may
exceed 30 cm H2O)
Alkalosis management
IfpH > 7.45 and patient not triggering
ventilator, decrease set RR but not below
6/min
Lower Tidal Volume Ventilation Strategy
NIH ARDS Network
Weaning
Initiate
weaning by pressure support when all
of the following criteria are present:
FiO2 <0.4 and PEEP<8cm H2O
Not receiving neuromuscular blocking agents
Inspiratory efforts are apparent (ventilator rate may
be decreased to 50%of baseline level for up to 5
minutes to detect inspiratory effort)
Systolic arterial pressure > 90 mm Hg without
vasopressor support
Traditional Tidal Volume
NIH ARDS Network
Volume assist control
Tidal Volume(Vt) : 12 ml/kg predicted
body weight
Plateau pressure : < 50 cm H2O
Ventilator rate setting needed to
achieve a pH goal of 7.3-7.45 : 6-35
breath/min
I;E ratio : 1:1 – 1:3
Patients Excluded in
NIH ARDS Network Study
36 hours had elapsed since they met the first
three criteria
Younger than 18 years of age
Participated in other trials within 30 days before
the three criteria were met
Pregnant
Neuromuscular disease that impair spontaneous
breathing
Sickle cell disease
Severe chronic respiratory disease
Patients Excluded in
NIH ARDS Network Study
Weighed more than 1 kg per centimeter of
height
Burns over more than 30 percent of their BSA
Other conditions with an estimated 6-month
mortality rate > 50%
Undergone bone marrow or lung transplantation
Chronic liver disease (as defined by Child-Pugh
class C)
Their attending physician refused or unwilling to
dull life support
Respiratory Values during the First 7
days in NIH ARDS Network Study
Variable Day 1 Day 3 Day 7
LVT 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±1.4
Plateau 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±10
Mean 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±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±5.3
PEEP 9.4±3.6 8.6±3.6 9.2±3.6 8.6±4.2 8.1±3.4 9.1±4.2
Main Outcome Variables in
NIH ARDS Network
Lower VT Traditional VT P Value
Death before discharge home 31.0 39.8 0.007
and breathing without
assistance (%)
Weaning by day 28 (%) 65.7 55.0 <0.001
No. of ventilator-free days, 12 ± 11 10 ± 11 0.007
days 1 to 28
Barotrauma, days 1 to 28 (%) 10 11 0.43
No. of days without failure 15 ± 11 12 ± 11 0.006
of non-pulmonary organs
or systems, days 1 to 28
Clinical Trials of Traditional Versus Lower Tidal Volume Ventilation
Strategies in Acute Lung Injury and Acute Respiratory Distress Syndrome
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
ARDS Network
NEJM 2002
Methods
October 1999-February 2002
23 hospitals of the National Heart, Lung,
and Blood Institute (NHLBI) ARDS Clinical
Trials Network
Patient
Intubation with MV due to
a sudden decrease in the ratio of the
PaO2/FiO2≦ 300
a recent appearance of bilateral pulmonary
infiltrates consistent with the presence of
edema
no clinical evidence of left atrial hypertension
(defined by PAWP≦18 mmHg)
Criteria of exclusion
<13 y/o
participated in other trials involving ALI within the
preceding 30 days;
Pregnant;
IICP
severe neuromuscular disease,
sickle cell disease,
severe chronic respiratory disease,
Criteria of exclusion
BW> 1 kg/cm,
Burns> 40 % BSA,
Severe chronic liver disease,
Vasculitis with diffuse alveolar hemorrhage,
A coexisting condition associated with an
estimated 6-month mortality rate >50 %;
Post- BMT or lung transplant;
Their attending physician refused to allow
enrollment.
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.
Evidence-Based Medicine
In Mechanical Ventilation in ARDS
with Higher PEEP
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
no no ↓VT to
Pplat <
↑VT by 1 mL/kg VT 4 mL/kg 4 mL/kg
30 cm H2O
yes yes
yes Pplat < yes
VT < 6 mL/kg
25 cm H2O
no no
yes
↑VT to 7-8 mL/kg Severe dyspnea
no
Primaryconcern : patient-ventilator
synchrony
To avoid unnecessary work of breathing
To reduce anxiety
To decrease ventilatory drive
To minimize auto-PEEP
Algorithm for the ventilator management of the patient with
START COPD
Candidate yes yes yes yes
Patient Clinically Continue
For NPPV tolerates improved NPPV
NPPV
intubate intubate
intubate (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%
55-75 mmHg
no Pplat > Pplat < no
30 cm H2O pH 25 cm H2O
>7.45 <7.30
yes yes
↓rate ↓VT 7.30-7.45 ↑VT ↑rate
no Auto-PEEP
yes
no Clear secretions
Auto-PEEP
Administer bronchodilators
Titrate FiO2 to
SpO2 92-95%
Good lung down
yes
FiO2 no Broncho- no no
Pleural
ICP Unilateral
<0.6 fistula >20 disease ↑PEEP
no
yes
yes yes
↑FiO2
yes Pplat>
↓VT and
↑rate 30 cm H2O
no
7.30-7,45 ≦25
Maintain ↑VT or
Current ↑rate Calhoon JH et al Chest Surg Clin N Am 1997;7:199
settings Ferguson M et al 1996 2:449
Gentilello LM et al Am J Respir Crit Care Med 2001 163:604
Indications for Mechanical Ventilation in
Patients with Acute Head Injury
no
↑rate PaCO2 Pplat > 30 ↓rate
>45 <35
yes
35 - 45 ↓VT
Titrate FiO2
For SpO2> 92%
FiO2 ↑PEEP
≧0.6
<0.6
Adjust rate and tidal volume for
normal acid-base Consider extubation
yes
Spontaneous
Breathing efforts. Spontaneous
no yes breathing Tolerated no
Hemodunamically
Stable, FiO2≦0.5 trial
PEEP≦5
Initial Ventilator Settings for Postoperative
Patients with no Prior Disease
Setting Recommendation
Setting Recommendation
no
yes no Secretions <92% >95%
SpO2 SpO2
↑FiO2 <95% ↑PEEP or ↓FiO2
atelectasis
yes
92-95%
In-Exsufflattor
yes yes
↑VT dyspnea ↑rate dyspnea
no
no
↓rate or ↓VT
≦25 <7.35 >7.45 Consider
↑VT Pplat pH
mechanical
>25 dead space
7.35-7.45
↑rate no
secretions
yes
In-Exsufflattor
Maintain therapy
Methods to Treat Atelectasis
In-exsufflator
Assisted cough
Peak cough flow > 160 L/min
Mechanical Insufflation-Exsufflation
Artificial
cough machine
Stimulating cough by inflating the lung with
pressure, followed by a negative pressure
to produce a high expiratory flow
Inspiratory pressure :25-35 cm H2O for 1-
2 seconds
Expiratory pressure:-40 cm H2O for 1-2
seconds
Treatment periods: 5-6 breaths
Indications for Mechanical Ventilation in
Patients with Cardiovascular Failure
no intubate yes
CMV (A/C), VCV or PCV, VT 8-10 no Patient
intubate tolerates
mL/kg, Pplat < 30 cm H2O, I;E:1:2
PEEP 5 cm H2O, FiO2 1.0 yes
PaCO2> no
yes SpO2<92%; 45 mm Hg
↑PEEP Pulmonary edema
yes
no NPPV
Titrate FiO2
For SpO2>92%
yes PaCO2. no
≧30 45 mm Hg
↓VT Pplat
<30
>7.45 <7.35
↓ rate pH ↑ rate
7.35-7.45
Severe hypoxemia
Ventilator Strategy
in Patients with Acute Asthma
Major concern: auto-PEEP
To minimize auto-PEEP
Permissive hypercapnia
Use of inhaled bronchodilators and
systemic steroids to reduce the airway
inflammation, edema, swelling and
bronchospasm
Risk of barotrauma and hypotension
Algorithm for Mechanical Ventilation of Patient
with START
Asthma
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
>95% <92%
↓FiO2 SpO2 ↑FiO2
92-95%
no Pplat> >7.45 <7.30 Pplat< no
30 cm H2O pH 25 cm H2O
yes yes
↓rate 7.30-7.45
↓VT ↑VT ↑rate
no
Auto-PEEP
yes
no
Auto-PEEP Administer bronchodilators
ABG
results
Treat with:
<7.30 Bronchodilators,
no >7.45 diuretics
↓ rate Pplat>30 pH
yes
↓ VT 7.30-7.45 Pplat>30 no
↑ VT
Cm H2O
yes FiO2< <70 >100
↑ FiO2 PaO2 yes
0.6
Exhaled VT
yes
>75%
Inhaled VT
no
Systemicaly evaluate changes in:
Tidal volume
Respiratory Rate Titrate FiO2 for
PEEP SpO2 92-95%
Inspiratory time
Pressure control vs. volume control
<7.25 >7.45
rate pH rate
7.25-7.45
Indications for Mechanical Ventilation in
Patients with Drug Overdose
Apnea
Titrate FiO2
for SpO2 > 92%
≧0.60
FiO2 ↑PEEP
<0.60
Adjust rate and tidal volume for
normal acid-base
Consider extubation
yes
Spontaneous
no breathing efforts yes Spontaneous
hemodynamically no
Breathing tolerated
stable, FiO2≦0.5 trial
PEEP≦5
謝謝 !
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Ventilator Setting for ALI or ARDS
Open Lung Approach
Maintaining a low plateau
pressure
Monitoring tidal volume
Using recruitment maneuvers and
high levels of PEEP to maximize
alveolar recruiment
Algorithm for ventilator management of ARDS using the open
CMVlung approach
(A/C). PCV to achieve VT of 4-8 mL/kg,
START Ti to Avoid auto-PEEP. Rate 20/min. FiO2 1.0.
PEEP 10 cm H2O
Recruitment maneuver
PEEP 20 cm H2O
FiO2 to maintain SpO2 90-95%
Decrease PEEP to maintain SpO2 90-95%
90-95%
≧90%
SpO2 Maintain ventilator settings
<90%
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