This document provides guidance on the diagnosis and management of Acute Respiratory Distress Syndrome (ARDS) including ventilator adjustments. It outlines the Berlin Definition of ARDS and goals of mechanical ventilation in ARDS. It provides recommendations on initial ventilator settings, PEEP titration, recruitment maneuvers, prone positioning, neuromuscular blockade, inhaled vasodilators, and extracorporeal membrane oxygenation for refractory hypoxemia. Tables are included with PEEP and FiO2 combinations to achieve oxygenation goals based on severity.
This document provides guidance on the diagnosis and management of Acute Respiratory Distress Syndrome (ARDS) including ventilator adjustments. It outlines the Berlin Definition of ARDS and goals of mechanical ventilation in ARDS. It provides recommendations on initial ventilator settings, PEEP titration, recruitment maneuvers, prone positioning, neuromuscular blockade, inhaled vasodilators, and extracorporeal membrane oxygenation for refractory hypoxemia. Tables are included with PEEP and FiO2 combinations to achieve oxygenation goals based on severity.
This document provides guidance on the diagnosis and management of Acute Respiratory Distress Syndrome (ARDS) including ventilator adjustments. It outlines the Berlin Definition of ARDS and goals of mechanical ventilation in ARDS. It provides recommendations on initial ventilator settings, PEEP titration, recruitment maneuvers, prone positioning, neuromuscular blockade, inhaled vasodilators, and extracorporeal membrane oxygenation for refractory hypoxemia. Tables are included with PEEP and FiO2 combinations to achieve oxygenation goals based on severity.
This document provides guidance on the diagnosis and management of Acute Respiratory Distress Syndrome (ARDS) including ventilator adjustments. It outlines the Berlin Definition of ARDS and goals of mechanical ventilation in ARDS. It provides recommendations on initial ventilator settings, PEEP titration, recruitment maneuvers, prone positioning, neuromuscular blockade, inhaled vasodilators, and extracorporeal membrane oxygenation for refractory hypoxemia. Tables are included with PEEP and FiO2 combinations to achieve oxygenation goals based on severity.
Diagnosis and Management Tip Sheet for Providers PB 840 PB 980 Maquet Hamilton C1 OR Vent
Berlin Definition of ARDS Ventilator Adjustments in ARDS Refractory Hypoxemia
Timing Within 1 week of insult Imaging Bilateral opacities PRONE POSITIONING Origin of Edema Not due to heart failure Step 1: Ensure you are meeting your oxygenation goals (PaO2 55-80, or SpO2 88-96%) Mortality Benefit for Moderate-Severe ARDS (PaO2:FiO2< 150) Severity Mild PaO2:FiO2 200-300 • Assess sedation requirements Caution if… HD instability; facial/pelvic fractures; arrhythmias *on ≥ 5 PEEP Moderate PaO2:FiO2 100-200 Ensure Vent Synchrony • Goal RASS -2 to -3 initially 1) Pre-proning huddle: establish roles*, don airborne PPE Severe PaO2:FiO2 < 100 • Use ARDSNet table or driving pressure to set optimal PEEP 2) Prone for at least 16 hours PEEP Titration 3) Turn supine for 4-8 hours, then reassess candidacy for proning Goals of Mechanical Ventilation in ARDS • Monitor for hypotension as PEEP increases 4) Repeat steps 2-3 if PaO2:FiO2 remains < 150 after 4 hours supine ARDSNet PEEP TABLES Driving Pressure Titration for PEEP * Monitor lines, ET tube, vent connections, hemodynamics Maintain oxygenation PaO2 goal 55-80 mmHg Tidal Volume (Vt) goal 6 cc/kg Consider incremental FiO2/PEEP combinations as Driving pressure = Pplat – PEEP Minimize volutrauma shown below to achieve PaO2 or SpO2 goal (goal is to find PEEP that minimizes Driving Pressure) ECMO (Extracorporeal Membrane Oxygenation) *Ideal body weight (IBW) Low PEEP/FiO2 Table Step 1: measure Pplat with inspiratory pause • Call ECMO team if PaO2 < 80 on FIO2 100% despite proning, Minimize barotrauma Plateau pressure (Pplat) ≤ 30 FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 Step 2: Increase PEEP by 2-4 hemodynamic instability X 12 hours PEEP 5 5-8 8-10 10 10-12 12-14 18 18-24 Step 3: After 20 sec remeasure Pplat • Exclusions: BMI > 45, Age > 65, > 30 pack year smoking history Permissive hypercapnia pH ≥ 7.2 Step 4: If decrease in driving pressure, High PEEP/FiO2 Table repeat 1-3. if increased or hypotension, NEUROMUSCULAR BLOCKADE FiO2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 1.0 PEEP 5-14 14-16 16-18 18-20 18-20 20-22 22 22-24 return to prior PEEP Initial Ventilator Settings in ARDS - Ensure adequate sedation (RASS <-4) before staring paralytic - Discuss medication shortages / alternatives with pharmacy Step 2: Perform an inspiratory pause to check the plateau pressure Pplat (goal < 30) - Cisatracium – dosing 0.1-0.2 mg/kg bolus, 2-10 mcg/kg/min gtt Mode: Assist Control-Volume Control (AC-VC) - Can use either bolus dosing or bolus followed by infusion Please see dedicated ventilator cards for specific guidance using different ventilator models, - Trend TOF (train of four) to assess adequacy of paralysis Tidal Volume (VT) 6 cc/kg (IBW) including how to check inspiratory hold maneuvers to assess Pplat (QR codes in RUQ of card) - Note: Paralysis is NOT necessary for proning Respiratory Rate (RR) Match pre-intubation RR FiO2 100% Is Pplat at goal < 30 mm Hg? INHALED VASODILATORS PEEP 10 cm H2O (5 if hypotensive) Inhaled Nitric Oxide Ideal Body Weight (IBW) Table for VT 6cc/kg YES NO • Initial dosing 40 ppm. Titration up to 80ppm Height (in) 5'0" 5'1" 5'2" 5'3" 5'4" 5'5" 5'6" 5'7" • Avoid epoprostenol (iFlolan) in COVID/PUI, clogs viral filter Male 300 310 330 340 360 370 380 400 Female 270 290 300 310 330 340 360 370 Continue • Assess sedation requirements RECRUITMENT MANEUVERS 1. Ensure Vent Synchrony Height (in) 5'8" 5'9" 5'10" 5'11" 6'0" 6'1" 6'2" 6'3" current • Goal RASS -2 to -3 initially Male 410 420 440 450 470 480 490 510 settings, 2. Lower VT below 6 cc/kg • Decrease by 0.5-1 cc/kg (minimum 4 cc/kg IBW) - Set PEEP to 30 for 30 seconds (“30 for 30”) or “40 for 40” Female 380 400 410 420 440 450 470 480 proceed - Caution: Potential ↑ mortality, risk of ↓BPs and barotrauma • If Pplat remains > 30, repeat steps 1-3 to Step 3 3. Repeat inspiratory pause Sedation and Analgesia • If Pplat > 30 despite Vt at 4 cc/kg, call for help Additional Considerations for ARDS Step 3: Check Blood Gas 15 to 20 minutes after changes to assess adequacy of ventilation • Ensure sedation plan includes both analgesic + sedation • Can wean to analgesia alone if not paralyzed Increase RR, monitor for auto-PEEP • Plan for line placement on same side for safer proning If pH < 7.2 • Steroids not recommended for ARDS management unless • Target RASS -2 to -3 initially; target 0-1 once improving Consider increasing VT by 0.5 - 1 cc/kg, call for help • Discuss medication shortages / alternatives with pharmacy concomitant refractory septic shock If pH 7.2 – 7.40 No changes, permissive hypercapnia OK to allow for low VT • Conservative fluid strategy and/or diuresis for negative 24- Medication Class Dosing Notable SEs hour fluid balance, even if requiring low dose vasopressors Bolus 25-50 mcg Caution in renal/liver If pH > 7.40 Reduce set RR, assess for analgesia/sedation needs Fentanyl Analgesic Gtt 50-200 mcg failure Caution in renal/liver Visit the Penn Check out the Start with 0.5-4mg COVID-19 Mechanical Midazolam Sedative Gtt 2-8 mg/hr failure; accumulates in Step 4: Reassess to ensure achieving ARDS ventilation goals adipose, ↑ delirium • PaO2 60-80 mm Hg, SpO2 (90-94%), Vt (6 cc/kg), Pplat (<30), and pH (> 7.2) Learning Ventilation ↓BPs, ↓HRs, ↑TGs; Center Site Tip Sheet Propofol Sedative 5-80 mg/hr PRIS • Titrate down FiO2 for PaO2 60-80 mm Hg, SpO2 (90-94%)
