ARDS Management Algorithm yy Confirm ARDS, Diagnose and Treat Cause ARDS Ditterentit: * Assess whether 1% or 2% ARDS (see Box3) Pulmonary vasculitis, PCP pneumonia * Set TV 4-6mi/kkg IBW, Pplat 24-28 (see Box 1) LV failure Lymphangitis « Set PEEP according to ARDSNET (see Box 2) TRALI Interstitial pneumonitis * Permissive Hypercapnoea to pH > 7.25 Inhalational injury Anaphylaxis « Prone positioning for 16hr sessions « NMB infusion first 24hrs if P/F < 130 « Use Bi-level Ventilation mode if possible « Aim for Neutral Fluid Balance once CVS stable or 48hrs after ITU admission, whichever earlier High Airway EXCLUDE: Pressure: Distant Sepsis Mucous Plug Vit infection — Hv, cay HN PERSISTENT Bronchial intubation neumothorax -_— al Pleural Collection HYPOXAEMIA Pneumothorax Pulmonary Embolus RV Dysfunction Undiagnosed Intra-Abdominal Hypertension extubation Sickle Trait (see Box 4) * Optimise haemodynamics, target ScvO2 > 65% * Consider early ECMO referral if < 7days ventilated * Trial bolus NMB HiPEEP post RM if Pt Recruitable (see Box 2) * Echo => iNO if RV distension, ? t / | PEEP. « If unable to prone, consider High Frequency Oscillator (see Box 5) * Consider Aggressive Diuresis +/- CVVHF * Reduce Targets: 02 Sats >88%, pH > 7.2 * Optimise Hb (target >10) and Albumin (Target >18) * Consider ECCO;R if pH < 7.15, pCO2 > 10 + RV failure‘Box 1 — Setting Tidal Volu Box 5 - HFOV Protocol Set TV at 46mg Idea! Body Weight Use made that pes spontaneous venation 69 BiLovel {nial Settings deal Body Weight Calelaton (height inches) imPaw + cmH for lates = 50+ 2.3 (Ht ~60) thors 10 for Females = 501.7 (it~ 60) 1 Frequency 8H er Pplat < 30 (ideally < 28) inerrant neue Ppl < 30 (seal < 1 Blas Fow 20min For Patients on Pressure Control / BiLevel modes, Pplat = Ppeak when end-inspiratory flow = zero Ree Flew Zoli For Patents on Volume Contol modes, use Isprtary hold manoeue to moasue Pat, overs ovoniaiasion and For Patents with Prmary ARDS (lacaized changes on CT) consider Ppt 28 foconan Sonne ‘Alow Permissive Hypercapnoea, aiming for pH > 7.26, pCO2« 11kPa Containdeavons «HCP, COPD Ansotite Conta:ndleaton ~Traumate Brainy ygenatlon (Lung Reerutme Relave Conte ination ~Pumonay Hypertension oer Tw GET ‘ mPaw by 2 cmH4O and do ABG ater 20 mins Keep 1 mPau'by 2cm0 every 20 Box = Setng PE ‘ins unl 0; age achieved or Paw = 40 omH:0 enn tuo | paren ‘Sot PEEP inaly according to ARDSNET 2000 PEEP Protocal 20] 20 | 90 | 00] x00) roo Better High {and iow Cycle volume possale sf se fe [oofof of eff] ef se] ef 20] aa] an i ‘1Gyete volume by 10 ml every 20, ‘mins unl max ora given f £ fby 1 Hz every 20 mins unt S He or pH > 7.25 If pH sil < 7.25 Inoduce cu leak = il naed to? bas low For Pts with increasing FiO: / Pressure requirements ONLY AFTER APPROVAL BY ICU CONSULTANT [Assess liked for lung cruitment (Primary ve Secondary ARDS) > ace mn net aint Fad 0 cases ania Trg 20:2 3 era tooumunttarenans raat tase uaa 60 Monsing Fama P20. 8402 ‘© 405mH,0 CPAP (or 40-50 mPaw ifn HFOV) for 40 seconds x2 oF 4 hours unl mPaw = 20 em HO © ALTV omg IBW, gradually increase PEEP from 15 025, Ppeak Up to : amen «+ Next 1 F10; by 0.1 every 4 hours ‘+ Reduce PEEP to 1ScmH.0 and recheck PaO, pCO:, Compliance pices i {1213 values have improved by > 10%, Ptmay benef fm Higher PEEP + Mow mPav by 20m HO every Seling High PEEP —2 methods: «+ Transton to Conventional Vent *Titale PEEP until at -6mikg IBW TV. Plat = 20emH20 + SIM PC is suggestes + AflerRM, reduce PEEP gracualy unl point of infection on deflation slope of P-V curve 4 PEEP + 10/12 cm H.O reached (= level of PEEP al max ung compliance) then rerecrut and set PEEP + Adjust PC to give same mPaw as Zemi.0 above this level onHFov ‘Box 3 — Primary vs Secondary ARDS ‘Theres some evidence that ARDS caused by atiologles that dectytraumatize the lung (e9 pneumonia, aspiration ~ Primary ARDS) may respond ciferent to ARDS caused by aetiologies distant from the lung (eg Trauma, nr-lung sepsis, Pancreails ~ Secondary ARDS) {As well as different actologes, CT scans may aso ad differentiation a the 2( Primary ARDS = patchy changes, Secondary ARDS = moe confluent, homogeneous changes on CT) In terms of Mi ‘+ Primary AROS ~ more vunerable to volutrauma hence it Plat. Less likely to recruit hence int PEEP. Primary ARDS du to CAP ‘may benef rom 7éay course of Low dose stereds from Day 1 ‘+ Secondary ARDS - more key to recruit with High PEEP and higher Pplat. Howover, associated morality also higher than Primary ARDS, most ikely due to primary aetiology ie in ARDS + Distant sepsis, partculatly CVC retate infection and Sinusitis + Lung sepsis ~ as well as VAP, consider val pneumonia and check NPA +(- Tracheal aspirate for HSV, CMV, HIN + Early CT scan ~ as wel as 1° vs 2” ARDS, may help direct BAL and exclude pneumothorax, PE, Empyemaabscess,Itesiial [pneumonitis (as diferntial of ARDS) Irmo pathogen isolated, consider early BAL (esp. fImmunosupressed - POP, TB, Aspergilus, CMV, HSV) Consider Lung Biopsy if diagnosis stil unclear (can change Min upto 50% cases ) AH common =i present, Ppat may ignieanty overestimate ranspulmonary pressure RV dysfunction ~ present in aprox 10%, dlagnase on ECHO, Rx ~ Reduce Pplat/ pCO? I possible, INO, optimize lung recrutment Prone posiion (bes). Consider Sidenafi