Tahoe Critical Care Conference

Pacific NW Regional Pacific NW Regional Respiratory Care Respiratory Care

ConferenceConference

Clinical Uses of the Open Lung Clinical Uses of the Open Lung Tool in Tool in

Lung RecruitmentLung Recruitment

Mark A. MartinezMark A. Martinez

Cardiopulmonary EducatorCardiopulmonary Educator

Sutter Roseville Medical CenterSutter Roseville Medical Center

What is a Recruitment Maneuver?What is a Recruitment Maneuver?

A Recruitment Maneuver is a A Recruitment Maneuver is a procedure where a sustained positive procedure where a sustained positive

pressure is applied, to an injured pressure is applied, to an injured lung, over an increment of time, to lung, over an increment of time, to recruit, open and keep open closed recruit, open and keep open closed

alveoli. alveoli.

Why is Recruitment done?Why is Recruitment done?

Recruitment maneuvers are performed to Recruitment maneuvers are performed to help improve oxygenation, help improve help improve oxygenation, help improve distribution of ventilation, and improve distribution of ventilation, and improve shunts.shunts.

To try and determine the “Optimal PEEP” To try and determine the “Optimal PEEP” to keep the lung from dynamic collapse to keep the lung from dynamic collapse and alveolar de-recruitment.and alveolar de-recruitment.

*It is also done to re-recruit the lungs once *It is also done to re-recruit the lungs once there has been a break in the ventilation there has been a break in the ventilation circuit.*circuit.*

Patient SelectionPatient Selection

Primarily on patients with ARDS/ALIPrimarily on patients with ARDS/ALI• ARDS - (PaO2/FIO2 <200) w/ bilateral infiltrates ARDS - (PaO2/FIO2 <200) w/ bilateral infiltrates

on x-ray.on x-ray.• ALI – (PaO2/FIO2 <300)ALI – (PaO2/FIO2 <300)

Patients in Patients in early phaseearly phase ARDS, before the ARDS, before the onset of fibro-proliferation.onset of fibro-proliferation.

Ventilator Induced Lung Injury patients.Ventilator Induced Lung Injury patients. Patients that are having trouble Patients that are having trouble

oxygenating due to the shunting caused oxygenating due to the shunting caused by the injured lung.by the injured lung.

Patient SelectionPatient Selection

Also in non-ARDS patients.Also in non-ARDS patients.• *Patients with Alveolar Collapse.*Patients with Alveolar Collapse.• *Patients with Overnight turn lung *Patients with Overnight turn lung

status.status.• Patients with consistent Atelectasis.Patients with consistent Atelectasis.

Types of ARDSTypes of ARDS Direct (Pulmonary/Primary)-HardDirect (Pulmonary/Primary)-Hard

• Effects lung parenchymaEffects lung parenchyma PneumoniaPneumonia AspirationAspiration Lungs are primarily consolidatedLungs are primarily consolidated Inhalation InjuryInhalation Injury Lung ContusionLung Contusion Near DrownNear Drown

Indirect (Extra-Pulmonary/Secondary)Indirect (Extra-Pulmonary/Secondary)• Due to Acute Systemic Inflammatory ResponseDue to Acute Systemic Inflammatory Response

SepsisSepsis TraumaTrauma Acute PancreatitisAcute Pancreatitis Alveolar collapseAlveolar collapse Drug OverdoseDrug Overdose

Three Compartments of ARDSThree Compartments of ARDS

1.1. Aerated normal lung susceptible to Aerated normal lung susceptible to barotrauma induced by inappropriate barotrauma induced by inappropriate ventilation. Usually located in the ventilation. Usually located in the nondependent regions.nondependent regions.

2.2. Areas that are collapsed due to Areas that are collapsed due to interstitial infiltration and are potentially interstitial infiltration and are potentially recruitable.recruitable.

3.3. Airspaces that are filled with Airspaces that are filled with exudates and not recruitable lung. Usually exudates and not recruitable lung. Usually in the dependant lung regions.in the dependant lung regions.

Adult ARDSAdult ARDSAdult ARDSAdult ARDS

Lung Protective Strategy PatientsLung Protective Strategy Patients ARDSNet StudyARDSNet Study

• 6 ml/Kg IBW6 ml/Kg IBW• RR up to 35 to maintain a pH > 7.30, then HCO3 if <7.15RR up to 35 to maintain a pH > 7.30, then HCO3 if <7.15• Plateau Pressure < 30 cm H2OPlateau Pressure < 30 cm H2O• Oxygenation Saturation 88 – 95%Oxygenation Saturation 88 – 95%• PEEP/FIO2 AlgorithmPEEP/FIO2 Algorithm

FIO2FIO2 .3-.4.3-.4 .4-.5.4-.5 .5-.7.5-.7 .7-.8.7-.8 .9.91.01.0

PEEPPEEP 5 5 8-10 8-10 10-1210-12 12-1412-14 16-1816-1820-2420-24

Reduces lung inflammation, improves oxygenation and Reduces lung inflammation, improves oxygenation and gas distribution, prevents destruction of lung with gas distribution, prevents destruction of lung with repetitive opening and closing of the alveoli.repetitive opening and closing of the alveoli.

But…But…mostmost don’t follow the whole protocol! don’t follow the whole protocol!

We have observed that Low Tidal Volume Ventilation…We have observed that Low Tidal Volume Ventilation…without sufficient amounts of PEEP….can cause alveolar without sufficient amounts of PEEP….can cause alveolar de-recruitment.de-recruitment.

Different Ways to Recruit the LungDifferent Ways to Recruit the Lung

Use of high CPAP for short periods of Use of high CPAP for short periods of time. 40/40 ruletime. 40/40 rule

Increased levels of PEEP - arbitraryIncreased levels of PEEP - arbitrary Sustained inflation maneuversSustained inflation maneuvers Sigh breaths Sigh breaths Optimal PEEP studyOptimal PEEP study

Pressure Control with PEEPPressure Control with PEEP Am J Respir Crit Care Med Vol 167. pp 1620-1626, Am J Respir Crit Care Med Vol 167. pp 1620-1626,

2003. Neiman. (pigs)2003. Neiman. (pigs) Peak pressure of 45 cm H2O with a PEEP of 35 cm Peak pressure of 45 cm H2O with a PEEP of 35 cm

H2O for 1 minute.H2O for 1 minute. After the Recruitment, he applied either 5 cmH2O After the Recruitment, he applied either 5 cmH2O

or 10 cmH2O to see which PEEP level created or 10 cmH2O to see which PEEP level created more stability for the previously collapsed alveoli.more stability for the previously collapsed alveoli.

5 cmH2O of PEEP showed significant instability 5 cmH2O of PEEP showed significant instability and the 10 cmH2O of PEEP were stable.and the 10 cmH2O of PEEP were stable.

Concluded that after Recruitment maneuvers, Concluded that after Recruitment maneuvers, inadequate amounts of PEEP permits unstable inadequate amounts of PEEP permits unstable alveoli and may result in ventilator-induced lung alveoli and may result in ventilator-induced lung injury despite improved oxygenation. injury despite improved oxygenation.

Injured Alveoli w/ Insufficient Injured Alveoli w/ Insufficient Amounts of PEEPAmounts of PEEP

Injured Alveoli w/ Sufficient Injured Alveoli w/ Sufficient Amounts of PEEPAmounts of PEEP

PEEP UsagePEEP Usage

Study by A. Estaban. AJRCCM 2000;161: Study by A. Estaban. AJRCCM 2000;161: 1450-14581450-1458

• PEEP usage in ICUsPEEP usage in ICUs 31% of patients were on ZERO PEEP.31% of patients were on ZERO PEEP. 47% were on 1-5 cmH2O47% were on 1-5 cmH2O 18% were on 6-10 cmH2O18% were on 6-10 cmH2O 3% were on 11-15 cmH2O3% were on 11-15 cmH2O 0.2% were on greater than 15 cmH2O0.2% were on greater than 15 cmH2O

How do you know it worked?How do you know it worked? Improvements in oxygenation.Improvements in oxygenation.

• A 20% change or greater in PaO2/FIO2A 20% change or greater in PaO2/FIO2 Improvements in intrapulmonary Improvements in intrapulmonary

shunting.shunting. Improvements in lung mechanics.Improvements in lung mechanics. Greater Tidal Volume for same Greater Tidal Volume for same

pressure in (PC).pressure in (PC). Same Tidal Volume at less pressure Same Tidal Volume at less pressure

in (VC).in (VC).

How do you know it worked?How do you know it worked?

Lower Plateau Pressure for the same Lower Plateau Pressure for the same Vt after a RM has been applied.Vt after a RM has been applied.

*Best after disconnection from *Best after disconnection from ventilator or post suctioning.ventilator or post suctioning.

*Rapidly counters the prolonged drop *Rapidly counters the prolonged drop in PaO2 post suction. in PaO2 post suction.

Potential ProblemsPotential Problems Hemodynamic instabilityHemodynamic instability

• Increased Pleural pressures may adversely effect Increased Pleural pressures may adversely effect pulmonary vascular resistance and cardiac filling or pulmonary vascular resistance and cardiac filling or performance.performance.

• Cardiac Output decreases more profoundly in patients Cardiac Output decreases more profoundly in patients with pneumonia. with pneumonia.

Caution should be used. Caution should be used. Decrease in OxygenationDecrease in Oxygenation

Cardiac arrhythmiasCardiac arrhythmias PneumothoraxPneumothorax Regional Alveolar OverdistentionRegional Alveolar Overdistention Ideal patient is deeply sedated or paralyzed.Ideal patient is deeply sedated or paralyzed. Not indicated for awake patients.Not indicated for awake patients.

Oxygenation


230 bed, Level 2 Trauma Hospital.230 bed, Level 2 Trauma Hospital. 75 “Awesome” ICU trained therapists!75 “Awesome” ICU trained therapists! 4 ICUs (2 Trauma, Cardiac and Medical).4 ICUs (2 Trauma, Cardiac and Medical). All Staff trained in the use of the Open All Staff trained in the use of the Open

Lung Tool.Lung Tool. Policy and Procedure in place for Physician Policy and Procedure in place for Physician

to order “Open Lung Tool (freq)”.to order “Open Lung Tool (freq)”. When OLT ordered, *automatic When OLT ordered, *automatic

abbreviated maneuver performed when abbreviated maneuver performed when Circuit/PEEP is broken.Circuit/PEEP is broken.

SRMC ProtocolSRMC Protocol PURPOSE: PURPOSE: To provide safety and effectiveness guidelines for the use of the Open Lung Tool, to To provide safety and effectiveness guidelines for the use of the Open Lung Tool, to

optimize ventilation by recruiting alveoli with lung recruitment maneuvers, to establish an optimize ventilation by recruiting alveoli with lung recruitment maneuvers, to establish an alveolar closing pressure, to re-open the lung, and to keep the lung open. The Open Lung alveolar closing pressure, to re-open the lung, and to keep the lung open. The Open Lung Tool protocol is a lung recruitment and best PEEP protocol.Tool protocol is a lung recruitment and best PEEP protocol.

SUPPORTIVE DATA:SUPPORTIVE DATA: Studies show that Lung Recruitment maneuvers, with a sustained increase in airway Studies show that Lung Recruitment maneuvers, with a sustained increase in airway

pressure, can open collapsed alveoli. Combined with the addition of sufficient PEEP, to pressure, can open collapsed alveoli. Combined with the addition of sufficient PEEP, to keep and maintain the alveoli open, the Lung Recruitment maneuvers may improve keep and maintain the alveoli open, the Lung Recruitment maneuvers may improve outcomes in patients with ARDS. The Open Lung Tool, combined with Lung Protective outcomes in patients with ARDS. The Open Lung Tool, combined with Lung Protective Ventilation Strategies, prevents destruction of the lung due to repetitive opening and Ventilation Strategies, prevents destruction of the lung due to repetitive opening and closing of alveoli, reduces lung inflammation, and improves gas distribution and closing of alveoli, reduces lung inflammation, and improves gas distribution and oxygenation.oxygenation.

POLICY:POLICY: The Open Lung Tool will be utilized by trained Respiratory Care Practitioners who have The Open Lung Tool will be utilized by trained Respiratory Care Practitioners who have

demonstrated competency. Upon physician order, the Respiratory Care Practitioners will demonstrated competency. Upon physician order, the Respiratory Care Practitioners will strictly follow the procedure listed below.strictly follow the procedure listed below.

PROCEDURE:PROCEDURE: Verify all orders for therapy on the physician order sheet of the patient’s medical record.Verify all orders for therapy on the physician order sheet of the patient’s medical record. Check the patient's identification bracelet.Check the patient's identification bracelet. A chest tube tray should be available.A chest tube tray should be available. Obtain baseline ABG, if there has not been an ABG in the last 8 hours, note pre-therapy Obtain baseline ABG, if there has not been an ABG in the last 8 hours, note pre-therapy

hemodynamic values, verify with nursing staff that patient has stable values before hemodynamic values, verify with nursing staff that patient has stable values before performing this procedure, and address any ICP issues at this time.performing this procedure, and address any ICP issues at this time.

SRMC ProtocolSRMC Protocol Calculate patient Ideal Body Weight using the following formulas:Calculate patient Ideal Body Weight using the following formulas: Male=50 + 2.3 [height (inches)-60] or 50 + 0.91 [height (cm) -152.4]Male=50 + 2.3 [height (inches)-60] or 50 + 0.91 [height (cm) -152.4] Female=45.5 + 2.3 [height (inches)-60] or 45.5 + 0.91 [height (cm) -Female=45.5 + 2.3 [height (inches)-60] or 45.5 + 0.91 [height (cm) -

152.4]152.4] Calculate tidal volume for 6cc, 7cc and 8cc of Ideal Body Weight.Calculate tidal volume for 6cc, 7cc and 8cc of Ideal Body Weight. Note PIP, Vt, Plateau pressure, EtCO2, Compliance, PEEP level and SpO2.Note PIP, Vt, Plateau pressure, EtCO2, Compliance, PEEP level and SpO2. Change the ventilation mode to Pressure Control. Avoid any other Change the ventilation mode to Pressure Control. Avoid any other

changes to the ventilator settings i.e. FiO2 unless absolutely necessary.changes to the ventilator settings i.e. FiO2 unless absolutely necessary. Go to Open Lung Tool Screen, adjust the “Breath” count scale at the Go to Open Lung Tool Screen, adjust the “Breath” count scale at the

bottom right of the screen by pressing the (+) zoom key until the scale bottom right of the screen by pressing the (+) zoom key until the scale is 62 or 129 breaths.is 62 or 129 breaths.

Simultaneously raise the PEEP, above closing pressure, by increasing Simultaneously raise the PEEP, above closing pressure, by increasing PEEP gradually to 15 – 25 cm H2O, while decreasing the PC level at the PEEP gradually to 15 – 25 cm H2O, while decreasing the PC level at the same increments. same increments. Note:Note: Use PEEP levels 15-20 cm H2O for patients > 40 Use PEEP levels 15-20 cm H2O for patients > 40 years of age that have preexisting lung conditions. Use PEEP levels 20-years of age that have preexisting lung conditions. Use PEEP levels 20-25 cmH2O for patients < 40 years of age with no preexisting lung 25 cmH2O for patients < 40 years of age with no preexisting lung conditions.conditions.

Raise the Pressure Control Level by increments of 5 cm H2O until a PIP Raise the Pressure Control Level by increments of 5 cm H2O until a PIP of 40 cm H2O is reached. Hold that PIP for 2 minutes to recruit the lung. of 40 cm H2O is reached. Hold that PIP for 2 minutes to recruit the lung. Note:Note: At the lowest PEEP level of 15 cm H2O, the PIP may need to be At the lowest PEEP level of 15 cm H2O, the PIP may need to be greater than 40 cm H2O if a minimum Vt of 6cc per kg is not achieved, if greater than 40 cm H2O if a minimum Vt of 6cc per kg is not achieved, if Vt is not above 8cc/Kg, or if patient’s Plateau pressures are high. Vt is not above 8cc/Kg, or if patient’s Plateau pressures are high. Never go above PIP of 60 cm.Never go above PIP of 60 cm.

Maneuver should be stopped if patient becomes Maneuver should be stopped if patient becomes hemodynamicallyhemodynamically unstable . unstable .

SRMC ProtocolSRMC Protocol Decrease PC level until a calculated tidal volume of 6 – 8 cc/kg is achieved. Wait 3 to 4 Decrease PC level until a calculated tidal volume of 6 – 8 cc/kg is achieved. Wait 3 to 4

breaths per change until the calculated tidal volume is achieved.breaths per change until the calculated tidal volume is achieved. Decrease PEEP by 1 – 2 cm H2O, waiting 3 – 4 breaths per change, until alveolar collapse is Decrease PEEP by 1 – 2 cm H2O, waiting 3 – 4 breaths per change, until alveolar collapse is

noted. Alveolar collapse is recognized as a large decrease in tidal volume with a small noted. Alveolar collapse is recognized as a large decrease in tidal volume with a small decrease in pressure level, a large decrease in dynamic characteristic on the C dyn wave decrease in pressure level, a large decrease in dynamic characteristic on the C dyn wave form, or a downward spike in VtCO2. Use the cursor to note the PEEP level before collapse.form, or a downward spike in VtCO2. Use the cursor to note the PEEP level before collapse.

Increase the PEEP to pre-lung collapse level, plus 2 – 4 cm H2O.Increase the PEEP to pre-lung collapse level, plus 2 – 4 cm H2O. Increase PC level by increments of 5 until a PIP of 40 cm H2O is achieved and hold for 2 Increase PC level by increments of 5 until a PIP of 40 cm H2O is achieved and hold for 2

minutes to re-recruit the lung.minutes to re-recruit the lung. Slowly decrease the PC level, waiting 3-4 breaths per change, until a calculated tidal volume Slowly decrease the PC level, waiting 3-4 breaths per change, until a calculated tidal volume

of 6–8 cc/kg is achieved.of 6–8 cc/kg is achieved. At this point, you should see the same, or slightly higher, tidal volume at a lower ventilating At this point, you should see the same, or slightly higher, tidal volume at a lower ventilating

pressure, and an improved lung compliance.pressure, and an improved lung compliance. Monitor the patient’s vital signs and ventilator function. Monitor the patient’s vital signs and ventilator function. Document on the Continuous Ventilation Record. Documentation should include pre and Document on the Continuous Ventilation Record. Documentation should include pre and

post PIP, PEEP, Plateau pressure, VtCo2, compliance, vital signs, SpO2 and any other post PIP, PEEP, Plateau pressure, VtCo2, compliance, vital signs, SpO2 and any other pertinent hemodynamic values necessary.pertinent hemodynamic values necessary.

Switch patient back to original mode of ventilation and notify physician of the new PEEP Switch patient back to original mode of ventilation and notify physician of the new PEEP level.level.

Monitor patient ABG’s as needed.Monitor patient ABG’s as needed. This procedure may need to be repeated anytime there is a loss of PEEP or a ventilator This procedure may need to be repeated anytime there is a loss of PEEP or a ventilator

disconnection.disconnection. Care should be taken to clamp the ET tube to prevent lung collapse. If the patient has a Care should be taken to clamp the ET tube to prevent lung collapse. If the patient has a

tracheostomy tube, a flex tube adapter will be added and clamped.tracheostomy tube, a flex tube adapter will be added and clamped. A post procedure Chest X-ray, if indicated, A post procedure Chest X-ray, if indicated, maymay be obtained after the first Open Lung be obtained after the first Open Lung

maneuver to verify that no pneumothorax has been caused.maneuver to verify that no pneumothorax has been caused.

8 step open lung picture8 step open lung picture


SRMCSRMC

RESPIRATORY RESPIRATORY THERAPISTSTHERAPISTS

ROCK!!!ROCK!!!

So does Adam Morrison!So does Adam Morrison!

John Doe Case StudyJohn Doe Case StudyDay OneDay One

36 year old male involved in a Auto 36 year old male involved in a Auto vs. Tree accident….The Tree won.vs. Tree accident….The Tree won.

JD was awake at the scene, JD was awake at the scene, developed decreased mental status, developed decreased mental status, was intubated in the field, and was intubated in the field, and airlifted to SRMC.airlifted to SRMC.

JD arrived at SRMC Hypotensive JD arrived at SRMC Hypotensive 90/38mmHg, HR 127, difficult to 90/38mmHg, HR 127, difficult to obtained Pulse Ox, and Decreased BS obtained Pulse Ox, and Decreased BS in the Left Lung Fields. in the Left Lung Fields.


X-ray obtained and showed a Right Main Stem X-ray obtained and showed a Right Main Stem Intubation, Left Atelectasis and lung volumes very Intubation, Left Atelectasis and lung volumes very low.low.

ABG pH 7.008, pCOABG pH 7.008, pCO2 2 43, HCO43, HCO33 10.3, sO 10.3, sO2 2 78.9%, 78.9%, Base deficit of -19.6, Hb 8.6, Lactate level 8.6.Base deficit of -19.6, Hb 8.6, Lactate level 8.6.

ETT pulled back 3 cm.ETT pulled back 3 cm. Ultrasound revealed free fluid in the abdomen.Ultrasound revealed free fluid in the abdomen. JD was transfused with packed cells, platelets.JD was transfused with packed cells, platelets. JD was 250lbs. (114 Kg), moderately obese. JD was 250lbs. (114 Kg), moderately obese.


JD was being treated for Hemorrhagic Shock, JD was being treated for Hemorrhagic Shock, an Avulsion Fracture with Effusion, Blunt Head an Avulsion Fracture with Effusion, Blunt Head Injury, Abdominal Trauma, Acute Respiratory Injury, Abdominal Trauma, Acute Respiratory Distress, Orbital and Maxillary/Mandible Distress, Orbital and Maxillary/Mandible fractures.fractures.

JD went to surgery for a Transverse Colon JD went to surgery for a Transverse Colon resection, right Hemi-colonectomy, Ortho-resection, right Hemi-colonectomy, Ortho-surgery on his knee, an ICP monitor, and they surgery on his knee, an ICP monitor, and they delayed closing the granulating abdomen delayed closing the granulating abdomen wound (packed open).wound (packed open).

Oh yea, they brought him out 15 liters positive!Oh yea, they brought him out 15 liters positive! History revealed Opiate drug dependency…History revealed Opiate drug dependency…

why the tree won. why the tree won.


JD was admitted to the Trauma ICU.JD was admitted to the Trauma ICU. Initial vent setting on the Servo Initial vent setting on the Servo i i were: PRVC, RR- were: PRVC, RR-

20, Vt-850, PEEP-7 and FiO20, Vt-850, PEEP-7 and FiO22 100%. 100%. ABG: 7.39/25.2/142/15.2/98% on FiOABG: 7.39/25.2/142/15.2/98% on FiO22 100% 100% HCO3 was given.HCO3 was given. Ventilator changed to RR-14, Vt-700, PEEP-5.Ventilator changed to RR-14, Vt-700, PEEP-5. We then settled in for the night trying to keep JD We then settled in for the night trying to keep JD

stable.stable. The ICU RTs tried to be proactive and suggest The ICU RTs tried to be proactive and suggest

vent changes based on the ABGs.vent changes based on the ABGs.

John Doe Case StudyJohn Doe Case StudyDay ThreeDay Three

Oh yea, we are dealing with Oh yea, we are dealing with Trauma Doctors! Let me explain Trauma Doctors! Let me explain

the obvious.the obvious.


JD was stable for two days then the picture turned toward a JD was stable for two days then the picture turned toward a ARDS type patient. ARDS type patient.

Trouble started around 0300. RT noticed that JD’s SpOTrouble started around 0300. RT noticed that JD’s SpO22 dropped from 99% to 96%, the Compliance had dropped and dropped from 99% to 96%, the Compliance had dropped and PIP had gone up to 37 - 40 cmHPIP had gone up to 37 - 40 cmH22O. ABG revealed that JD’s pOO. ABG revealed that JD’s pO

2 2 went from 196 mmHg to 90 mmHg on the same FiOwent from 196 mmHg to 90 mmHg on the same FiO22 of 60 %. of 60 %. The PEEP was raised to 7 cmHThe PEEP was raised to 7 cmH22O. O. Later in the morning, an X-ray was ordered and showed Later in the morning, an X-ray was ordered and showed

“diminished lung volumes with increased densities in the “diminished lung volumes with increased densities in the Lingular area obscuring the Left Heart margin as well as in the Lingular area obscuring the Left Heart margin as well as in the Right Middle Lobe consistent with Atelectasis / PNA”.Right Middle Lobe consistent with Atelectasis / PNA”.

JD’s abdomen was also enlarging and his ICPs were going up. JD’s abdomen was also enlarging and his ICPs were going up. The abdomen was decompressed but did not change the The abdomen was decompressed but did not change the ventilation status. JD’s ICPs remained high. ventilation status. JD’s ICPs remained high.


RTs & OLT to the Rescue!RTs & OLT to the Rescue! The respiratory staff saw this as a great The respiratory staff saw this as a great

chance to use the Open Lung Tool to show chance to use the Open Lung Tool to show remarkable results!remarkable results!

The patient needed lower pressures to The patient needed lower pressures to protect his lungs, needed to keep his lungs protect his lungs, needed to keep his lungs open from collapse to avoid atelectasis, open from collapse to avoid atelectasis, needed to find the “optimal PEEP” to help needed to find the “optimal PEEP” to help Oxygenation and needed instant results Oxygenation and needed instant results you could see.you could see.


Remember your “Categorizations of ARDS”. This Remember your “Categorizations of ARDS”. This falls into the “Indirect (Secondary or Extra-falls into the “Indirect (Secondary or Extra-Pulmonary)” category because of Trauma, Pulmonary)” category because of Trauma, Alveolar Collapse, a Pancreatitis type “belly Alveolar Collapse, a Pancreatitis type “belly swell”, and the patient had transfusions.swell”, and the patient had transfusions.

We knew, therefore, that he would be easier to We knew, therefore, that he would be easier to control.control.

““Indirects” are easier to see results on the Indirects” are easier to see results on the ventilator graphics.ventilator graphics.

JD made for a perfect training candidate!JD made for a perfect training candidate! We must have had 15 people in the room to We must have had 15 people in the room to

watch the maneuver! watch the maneuver!

Open Lung Tool On JDOpen Lung Tool On JD

Here we go!Here we go! RTs checked the orders, identified the patient, RTs checked the orders, identified the patient,

ensured a chest tube tray was available and got a ensured a chest tube tray was available and got a baseline ABG.baseline ABG.

As a practice, I have my RTs calculate the IBW for As a practice, I have my RTs calculate the IBW for 6 ml/Kg, 7 ml/Kg, 8 ml/Kg.6 ml/Kg, 7 ml/Kg, 8 ml/Kg.

Do notDo not use the “room board weight”. use the “room board weight”. IBW:IBW: Males:Males: 50 + [ 2.3 X (height in inches-60) ] 50 + [ 2.3 X (height in inches-60) ] Females:Females: 45.4 + [ 2.3 X (height in inches-60) ] 45.4 + [ 2.3 X (height in inches-60) ] RTs noted the RTs noted the PRE-PRE-PIP, Vt, Plateau pressure, PIP, Vt, Plateau pressure,

VtCO2, Compliance, PEEP and SpO2 level.VtCO2, Compliance, PEEP and SpO2 level.

Open Lung Tool On JDOpen Lung Tool On JD We started at a PEEP of 18 cmH2O and a PC of 22 We started at a PEEP of 18 cmH2O and a PC of 22

mmHg (need to get above 8 ml/Kg)mmHg (need to get above 8 ml/Kg) We watched the Compliance graphic.We watched the Compliance graphic. Our protocol is never to go above 60 cmHOur protocol is never to go above 60 cmH22O!O! We held this for Two Minutes!We held this for Two Minutes! We then decreased the PC until we achieved a We then decreased the PC until we achieved a

Tidal Volume of 6 ml/Kg.Tidal Volume of 6 ml/Kg. We then decreased the PEEP by increments of 1-We then decreased the PEEP by increments of 1-

2 cmH2 cmH22O until we saw alveolar collapse.O until we saw alveolar collapse. JD’s collapse happened at 10 cmHJD’s collapse happened at 10 cmH22O.O. We saw a decrease in Compliance, in VtCOWe saw a decrease in Compliance, in VtCO22 and and

in Volume.in Volume.

Open Lung Tool On JDOpen Lung Tool On JD Since we just collapsed his lungs, we Since we just collapsed his lungs, we

immediately put JD’s PEEP to 12 cmHimmediately put JD’s PEEP to 12 cmH22O O and took the PC up to 28 mmHg to get a and took the PC up to 28 mmHg to get a PIP of 40 cmHPIP of 40 cmH22O and held for 2 minutes.O and held for 2 minutes.

We then decreased the PC until we We then decreased the PC until we achieved 6 ml/Kg. We switched JD back to achieved 6 ml/Kg. We switched JD back to PRVC and everyone went “WOW”. PRVC and everyone went “WOW”.

JD’s Oxygenation status went from a pOJD’s Oxygenation status went from a pO22 of 90 mmHg to 239 mmHg.of 90 mmHg to 239 mmHg.

JD’s PIP went from 37 cmHJD’s PIP went from 37 cmH22O to 28 cmHO to 28 cmH22O.O. JD’s Compliance went from 36 ml/cmHJD’s Compliance went from 36 ml/cmH22O O

to 46 ml/cmHto 46 ml/cmH22O.O.

Open Lung Tool On JD Open Lung Tool On JD The Post-Open Lung Tool X-ray reading The Post-Open Lung Tool X-ray reading

was “improved aeration in both lung fields was “improved aeration in both lung fields compared to prior study” and the Trauma compared to prior study” and the Trauma doctor’s note stated “there was dramatic doctor’s note stated “there was dramatic improvement”. improvement”.

JD had a second Open Lung Tool done JD had a second Open Lung Tool done seven hours later that day and the RTs seven hours later that day and the RTs were able to keep him progressing and were able to keep him progressing and decreasing his ventilator settings.decreasing his ventilator settings.

By the next day his ventilator setting were By the next day his ventilator setting were all back downall back down

Due to his injuries he went for a Due to his injuries he went for a Tracheotomy.Tracheotomy.

He stayed in the hospital for a total of 11 He stayed in the hospital for a total of 11 days and then went to Trauma Rehab.days and then went to Trauma Rehab.

Recruitment ManeuverRecruitment Maneuver


Case Study #1Case Study #1

53 year old female that came to 53 year old female that came to Sutter Roseville Medical Center after Sutter Roseville Medical Center after a motor vehicle rollover. At the a motor vehicle rollover. At the scene, she was conscious, anxious, scene, she was conscious, anxious, and complaining of left sided chest and complaining of left sided chest pain. She went into a panic attack, pain. She went into a panic attack, her respiratory status continued to her respiratory status continued to deteriorate, her blood pressure deteriorate, her blood pressure bottomed out, she went unconscious, bottomed out, she went unconscious, and was intubated. and was intubated.


Her X-ray revealed focal densities on Her X-ray revealed focal densities on the right side and focal densities left the right side and focal densities left lower lobes. Aeration of the right lower lobes. Aeration of the right lower lobe appeared slightly worse. lower lobe appeared slightly worse. Left sided rib fractures were present. Left sided rib fractures were present. No Pneumothorax was noted. Diffuse No Pneumothorax was noted. Diffuse air space disease, consistent with air space disease, consistent with either edema, infection or contusion. either edema, infection or contusion. Small right pleural effusion. Small right pleural effusion.

X-ray from ER admitX-ray from ER admit

Case Study #1Case Study #1 The Patient was on a FiO2 of 65% with a PaO2 of The Patient was on a FiO2 of 65% with a PaO2 of

200mmHg. Ventilator settings were with in Low 200mmHg. Ventilator settings were with in Low Volume Ventilation strategy ranges…but..Peep Volume Ventilation strategy ranges…but..Peep was at 5cmH2O.was at 5cmH2O.

Over night, the patient’s oxygenation status Over night, the patient’s oxygenation status deteriorated to a PaO2 of 48.1mmHg, on 100% deteriorated to a PaO2 of 48.1mmHg, on 100% FiO2, with a oxygen saturation of 84%. FiO2, with a oxygen saturation of 84%.

RT’s to the rescue. The SRMC staff knew that if RT’s to the rescue. The SRMC staff knew that if we were able to get the Open Lung Protocol we were able to get the Open Lung Protocol ordered that we could turn the patient.ordered that we could turn the patient.

The protocol was ordered, the RTs used a base The protocol was ordered, the RTs used a base PEEP of 20 and PC of 20 cmH2O. The patient’s PEEP of 20 and PC of 20 cmH2O. The patient’s collapse point was found to be 9 cmH2O and the collapse point was found to be 9 cmH2O and the PEEP was raised to 11 cmH2O. PEEP was raised to 11 cmH2O.

X-Ray after first ManeuverX-Ray after first Maneuver


The patient’s PaO2 went up to 239mmHg The patient’s PaO2 went up to 239mmHg after the maneuver. after the maneuver.

The patient was easier to ventilate at a The patient was easier to ventilate at a lower pressure.lower pressure.

Along with a few more Open Lung Along with a few more Open Lung Maneuvers, the patient’s contusion and Maneuvers, the patient’s contusion and left pleural effusion was resolving. left pleural effusion was resolving.

The patient’s progress was dramatic and The patient’s progress was dramatic and the patient was quickly weaned and the patient was quickly weaned and extubated. extubated.


OPEN LUNG TOOL SCREENOPEN LUNG TOOL SCREEN


SRMCSRMCRESPIRATORY THERAPISTSRESPIRATORY THERAPISTS

ROCK!!!ROCK!!!No….No….

Gonzaga Rocks!!Gonzaga Rocks!!


19 year old female in a head on collision. 19 year old female in a head on collision. She had lung contusions, a lacerated liver, She had lung contusions, a lacerated liver, lower extremity damage.lower extremity damage.

Her PaO2 on her blood gas was 85mmHg Her PaO2 on her blood gas was 85mmHg on a FiO2 of 70% then dropped to on a FiO2 of 70% then dropped to 36.4mmHg on a FiO2 of 95%.36.4mmHg on a FiO2 of 95%.

This is what her initial X-Ray looked like.This is what her initial X-Ray looked like.



Patient needed to go through surgery Patient needed to go through surgery first, so a low tidal volume strategy first, so a low tidal volume strategy was used. Her PEEP was at 8cmH2O was used. Her PEEP was at 8cmH2O and two chest tubes were inserted to and two chest tubes were inserted to drain fluid. After her first round of drain fluid. After her first round of surgeries, the RTs asked for the surgeries, the RTs asked for the Open Lung Protocol. Through daily Open Lung Protocol. Through daily OLT maneuvers the RTs were able to OLT maneuvers the RTs were able to get her lung to this position.get her lung to this position.



The patient was The patient was taken back to do taken back to do her last surgery her last surgery and this is what and this is what she came back she came back like.like.

Fluid over loaded Fluid over loaded with Atelectasis with Atelectasis complements of complements of Anesthesia.Anesthesia.


The RTs knew that The RTs knew that the Open Lung the Open Lung could reverse the could reverse the patient and get her patient and get her back in shape and back in shape and after 3 maneuvers after 3 maneuvers her was her X-Ray.her was her X-Ray.


The RTs were very happy to see her The RTs were very happy to see her turn and their confidence grew. They turn and their confidence grew. They were now using the Protocol in the were now using the Protocol in the right patients at the right times and right patients at the right times and the breath to breath analysis the breath to breath analysis recognition was allowing the RTs to recognition was allowing the RTs to do the procedure in a rapid and safe do the procedure in a rapid and safe way. way.



ROCK!!!ROCK!!!Adam Morrison for Adam Morrison for

President!President!


43 year old male 43 year old male that came in for that came in for fever and fever and Pneumonia. Here Pneumonia. Here was his initial X-was his initial X-Ray.Ray.


The patient was The patient was admitted to our admitted to our floor for care and floor for care and then went into then went into respiratory respiratory distress. The next distress. The next day, his x-ray day, his x-ray looked like this.looked like this.

Case Study #3 Case Study #3

The patient The patient continued down continued down the slippery slope the slippery slope and now looked and now looked like this.like this.

He got intubated He got intubated and had high and had high ventilating and ventilating and plateau pressures.plateau pressures.


The patient’s PaO2 was 47.9mmHg when The patient’s PaO2 was 47.9mmHg when the RTs finally got the OK to do the Open the RTs finally got the OK to do the Open Lung Protocol. The Rt’s had been asking Lung Protocol. The Rt’s had been asking for a day and a half.for a day and a half.

The patient’s PaO2 went from 47.9mmHg The patient’s PaO2 went from 47.9mmHg to 148.0 mmHg with the first maneuver. to 148.0 mmHg with the first maneuver. The RTs identified the new PEEP setting The RTs identified the new PEEP setting and kept the patients lung open to and kept the patients lung open to improve oxygenation and to lower the improve oxygenation and to lower the ventilating pressures.ventilating pressures.


Here is the X-Ray Here is the X-Ray after the after the Maneuver.Maneuver.

This was followed This was followed by maneuvers by maneuvers every shift for 24 every shift for 24 hours.hours.




ROCK!!!ROCK!!!

Go ZAGS!Go ZAGS!

What have we learned doing all our What have we learned doing all our Open Lung Tool maneuvers?Open Lung Tool maneuvers?

We have learned to get as many people involved We have learned to get as many people involved with every OLT maneuver you do.with every OLT maneuver you do.

We needed to review how long the maneuver was We needed to review how long the maneuver was taking. Before 24 hours.taking. Before 24 hours.

If you have a really high Plateau Pressure you If you have a really high Plateau Pressure you will will notnot see the big “compliance change”. Look for see the big “compliance change”. Look for the VT & VtCOthe VT & VtCO22..

If you have a high Plateau pressure you might If you have a high Plateau pressure you might have to go to 60 cmHhave to go to 60 cmH22O to get about 8 ml/Kg!O to get about 8 ml/Kg!

If you don’t have the OLT screen down to 62- 129 If you don’t have the OLT screen down to 62- 129 breaths the RTs might go too high trying to see breaths the RTs might go too high trying to see the change.the change.


Train the RTs to watch the Ventilator, the Train the RTs to watch the Ventilator, the Patient and the Monitor! NO “deer in the Patient and the Monitor! NO “deer in the head lights!”head lights!”

Teach your RTs that when you go too high Teach your RTs that when you go too high on the PC, the Compliance graphic will go on the PC, the Compliance graphic will go down not up. Do not keep going up on the down not up. Do not keep going up on the PC to try to turn it the other way. In this PC to try to turn it the other way. In this case, you are so distended that there is no case, you are so distended that there is no room for the lungs to expand which room for the lungs to expand which decreases compliance.decreases compliance.

This happens if you use the “room board This happens if you use the “room board weight” to calculate the IBW.weight” to calculate the IBW.


In our Policy and Procedure, there is a note In our Policy and Procedure, there is a note about where to start the PEEP levels: Use about where to start the PEEP levels: Use PEEP gradually to 15-20 cmH2O for PEEP gradually to 15-20 cmH2O for patients>40 years of age that have patients>40 years of age that have preexisting lung conditions. Use PEEP preexisting lung conditions. Use PEEP levels 20-25 cmH2O for patients<40 years levels 20-25 cmH2O for patients<40 years of age with no preexisting lung conditions.of age with no preexisting lung conditions.

We now use this in all ICUs, and on ARDS We now use this in all ICUs, and on ARDS and Non-ARDS patients.and Non-ARDS patients.

If doctors make changes in the middle, If doctors make changes in the middle, end the protocol and protect your RTs.end the protocol and protect your RTs.

Pick a Protocol and stick to it!Pick a Protocol and stick to it!

Recruitment ManeuverRecruitment Maneuver



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