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CLINICAL ALGORITHM FOR CLINICAL ALGORITHM FOR THE MANAGEMENT OF THE MANAGEMENT OF INTUBATED PATIENTS INTUBATED PATIENTS

PRESENTING WITH PRESENTING WITH CHANGES VISSIBLE CHANGES VISSIBLE

ON CxRON CxR

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Assessment of patientAssessment of patient Changes visible on CxRChanges visible on CxR::

Increased infiltrates Increased infiltrates (Suh-Hwa Maa 05; Hodgson 00; (Suh-Hwa Maa 05; Hodgson 00;

Ntoumenopolous 02)Ntoumenopolous 02) or or Volume loss: Radiographic density: fissure Volume loss: Radiographic density: fissure

displacement; mediastinal shift; diaphragmatic displacement; mediastinal shift; diaphragmatic elevation; compensatory hyperinflationelevation; compensatory hyperinflation (Stiller 96; (Stiller 96; Raoof 99; Krause 2000; Crowe 2006)Raoof 99; Krause 2000; Crowe 2006)

Evidence of excessive amounts of Evidence of excessive amounts of secretions eg added breath sounds secretions eg added breath sounds (Unoki et al (Unoki et al 2005)2005)

Decreased oxygenation Decreased oxygenation ((Hodgson 00)Hodgson 00)

RECOMMENDATION 3 (VAP)RECOMMENDATION 1 (MHI)

RECOMMENDATION 1 (AIRWAY CLEARANCE)RECOMMENDATION 1 (ATELECTASIS)


ET tube placement is correctET tube placement is correct (Stiller (Stiller 96)96)

YESNO

Notify ConsultantNotify Consultant

Back to algorithm

Is Pt able to tolerate side lying?Is Pt able to tolerate side lying?

(Stiller 96; Berney et al 2004 )(Stiller 96; Berney et al 2004 ) RECOMMENDATION 3 (VAP)RECOMMENDATION 3 (VAP)

RECOMMENDATION 1 (MHI)RECOMMENDATION 1 (MHI)

RECOMMENDATION 1 (AIRWAY CLEARANCE)RECOMMENDATION 1 (AIRWAY CLEARANCE)

RECOMMENDATION 1 (ATELECTASES)RECOMMENDATION 1 (ATELECTASES)

YESNO

Can pt be positioned in head down Can pt be positioned in head down position? position?

Berney et al 2004Berney et al 2004

RECOMMENDATION 3 (VAP)RECOMMENDATION 3 (VAP)


RECOMMENDATION 1 (AIRWAY CLEARANCE)RECOMMENDATION 1 (AIRWAY CLEARANCE)


YESNO

Position pt for 15 minutes in gravity Position pt for 15 minutes in gravity assisted drainage position with assisted drainage position with affected lung uppermost affected lung uppermost ((Berney et al 2004; Berney et al 2004; Ntoumenopolous 02; Berney 2002)Ntoumenopolous 02; Berney 2002)

Next step in the algorithmPrevious step in algorithm

Position pt for 15 minutes in modified Position pt for 15 minutes in modified PD position with affected lung PD position with affected lung uppermost uppermost ((Stiller 96; Unoki et al 2005; Hodgson 2000; Stiller 96; Unoki et al 2005; Hodgson 2000; Paratz 2002);Paratz 2002);


Is it safe to use a Is it safe to use a recruitment maneuver?recruitment maneuver?

Check the cardiovascular stability Check the cardiovascular stability Berney 02; Berney 02; Paratz 06Paratz 06

MAP > 75 mmHg and does not fluctuate more MAP > 75 mmHg and does not fluctuate more than 15 mmHg with position changethan 15 mmHg with position change

Heart rate is less than 130.Heart rate is less than 130. Arterial oxygen saturation SaO2 is not less than Arterial oxygen saturation SaO2 is not less than

9090 No Cardiac arythmias presentNo Cardiac arythmias present Pt is hemodynamically stable as discussed with Pt is hemodynamically stable as discussed with

intensivistintensivist



None of the following pathologies are None of the following pathologies are presentpresent:: Hodgson 00; Hodgson 07Hodgson 00; Hodgson 07

ARDS; Acute pulmonary edema; Acute ARDS; Acute pulmonary edema; Acute head injury; Acute bronchospasm; head injury; Acute bronchospasm;

Subcutaneous emphysema; presence of Subcutaneous emphysema; presence of inetrcostal catheter with a visible air leak inetrcostal catheter with a visible air leak



Check the state of the pulmonary systemCheck the state of the pulmonary system Hodgson 2000; Hodgson 2007; Savian 2006Hodgson 2000; Hodgson 2007; Savian 2006

The peak inspiratory airway pressure is The peak inspiratory airway pressure is less than 40cmH20;less than 40cmH20;

The patient is not ventilated with PEEP of The patient is not ventilated with PEEP of more than 10cm H2O more than 10cm H2O

YESNO

Develop a patient specific mobility plan Develop a patient specific mobility plan (refer to mobility algorithm)(refer to mobility algorithm)

Suction of patient based on best practice Suction of patient based on best practice suctionsuction

Back to algorithm

Which Equipment to use?Which Equipment to use?

First Choice:First Choice: Ventilator Ventilator (Berney 2004; Savian 2006; (Berney 2004; Savian 2006; Hodgson 2007)Hodgson 2007)


If not possible:If not possible: use a reservoir bag use a reservoir bag attached to spring loaded valve (eg Mapleson attached to spring loaded valve (eg Mapleson C, Mapleson F, Magill) C, Mapleson F, Magill) ((Hodgson 2007; Brazier 2003)Hodgson 2007; Brazier 2003)

RECOMMENDATION 3 (MHIRECOMMENDATION 3 (MHI))

another option:another option: Silicone bag eg Laerdal, Air Silicone bag eg Laerdal, Air Viva Viva ((Hodgson 2007; Barker 2000)Hodgson 2007; Barker 2000)



VENTILATOR HYPERINFLATIONVENTILATOR HYPERINFLATION

Optimal volume / pressuresOptimal volume / pressures In volume control increase the VT in In volume control increase the VT in

increments of 200ml (aiming at 130% increments of 200ml (aiming at 130% increase in VT) until a peak pressure of increase in VT) until a peak pressure of 40cmH2O is reached. 40cmH2O is reached.

Maintain baseline PEEP values.Maintain baseline PEEP values.


EXPERT OPINION: CRITERIA USED BY Berney 2002; Savian 2006

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Ventilator SettingsVentilator Settings Breath rate of at least 6 breaths / minBreath rate of at least 6 breaths / min inspiratory flow of 20 l/mininspiratory flow of 20 l/min Choose a square wave form Choose a square wave form 2-s end inspiratory pause2-s end inspiratory pause Use FiO2 that pt is ventilated on Use FiO2 that pt is ventilated on ((Hodgson 2007; Hodgson 2007;

Hodgson 2000; Rothen 1995)Hodgson 2000; Rothen 1995)





TechniqueTechnique Once the Peak pressure is reached, six Once the Peak pressure is reached, six

mechanical breaths will be delivered to the mechanical breaths will be delivered to the patient. patient.

After this, the ventilator is reset to pre-After this, the ventilator is reset to pre-treatment variables and the patient is treatment variables and the patient is rested for 30 s. rested for 30 s.

Repeat the sequence for a total duration of Repeat the sequence for a total duration of 20 minutes20 minutes




MANUAL HYPERINFLATIONMANUAL HYPERINFLATION

Optimal volume / pressuresOptimal volume / pressures Manually hyperinflate to a PIP of AT LEAST Manually hyperinflate to a PIP of AT LEAST

35 cmH2O 35 cmH2O (Paratz 2006; Paratz 2002; Hodgson 2000)(Paratz 2006; Paratz 2002; Hodgson 2000)

but NOT MORE than 40cmH2O but NOT MORE than 40cmH2O ((Hodgson 2007; Hodgson 2007; Denehy 2004; Savian 2006)Denehy 2004; Savian 2006)


MANUAL HYPERINFLATIONMANUAL HYPERINFLATIONEquipmentEquipment

Bag must have volume of 2 litresBag must have volume of 2 litres Attach an in line Manometer Attach an in line Manometer (Suh-Hwa 2005)(Suh-Hwa 2005)

Use FiO2 that pt is ventilated on – insert blender in Use FiO2 that pt is ventilated on – insert blender in circuit circuit (Hodgson 2007; Hodgson 2000; Rothen 95)(Hodgson 2007; Hodgson 2000; Rothen 95)

15 liters / min fresh gas flow 15 liters / min fresh gas flow (Savian 2006;(Savian 2006; Suh-Hwa 2005)Suh-Hwa 2005)

PEEP valve attached to circuit and set at the same PEEP valve attached to circuit and set at the same level of PEEP currently dialed on the mechanical level of PEEP currently dialed on the mechanical ventilator ventilator (Savian 2006)(Savian 2006)

expiratory valve – adjust from fully open position expiratory valve – adjust from fully open position but manually closed during inspirationbut manually closed during inspiration



TechniqueTechnique two-handed techniquetwo-handed technique slow inspiration (2 – 3 sec) slow inspiration (2 – 3 sec) inflate until peak pressure of at least 35 cmH2O inflate until peak pressure of at least 35 cmH2O

((Paratz 2006; Paratz 2002; Hodgson 2000)Paratz 2006; Paratz 2002; Hodgson 2000) NOT MORE than NOT MORE than 40cmH2O as measured by in-line manometer is 40cmH2O as measured by in-line manometer is reached.reached.

at least 2 sec hold (can hold for as long as 5 sec) at least 2 sec hold (can hold for as long as 5 sec) Suh-Hwa 2005Suh-Hwa 2005

expiration passive (1sec duration) with fast release expiration passive (1sec duration) with fast release of the valve to ensure a short expiration while of the valve to ensure a short expiration while maintaining bag pressure maintaining bag pressure ((Paratz 2006)Paratz 2006)..



DurationDuration At least six sets of six hyperinflation At least six sets of six hyperinflation

breaths breaths (Berney 2002; Berney 2004; Hodgson 2000)(Berney 2002; Berney 2004; Hodgson 2000)

Follow these hyperinflated breath sets up Follow these hyperinflated breath sets up with six breaths to a peak airway pressure with six breaths to a peak airway pressure of 20 cmH2O of 20 cmH2O (Berney 2002; Berney 2004; Hodgson 2000)(Berney 2002; Berney 2004; Hodgson 2000)

Total duration 20 minutesTotal duration 20 minutes


Frequency of Frequency of interventionintervention

Volume loss on CxR: hourly for 6 Volume loss on CxR: hourly for 6 hours hours (Stiller et al 1996)(Stiller et al 1996)


Infiltrates on CxR: twice daily Infiltrates on CxR: twice daily (Ntoumenopolous et al 2002)(Ntoumenopolous et al 2002)

RECOMMENDATION 3 (VAP)RECOMMENDATION 3 (VAP)


Suction ProcedureSuction Procedure

Refer to Best Practice suctionRefer to Best Practice suction RECOMMENDATION 2 (VAP)RECOMMENDATION 2 (VAP) RECOMMENDATION 2 (AIRWAY CLEARANCE)RECOMMENDATION 2 (AIRWAY CLEARANCE)


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