CLINICAL ALGORITHM FOR THE MANAGEMENT OF INTUBATED PATIENTS PRESENTING WITH CHANGES VISSIBLE ON CxR Next step in the algorithm

Assessment of patient Changes visible on CxR: Increased infiltrates (Suh-Hwa Maa 05; Hodgson 00; Ntoumenopolous 02) or Volume loss: Radiographic density: fissure displacement; mediastinal shift; diaphragmatic elevation; compensatory hyperinflation (Stiller 96; Raoof 99; Krause 2000; Crowe 2006) Evidence of excessive amounts of secretions eg added breath sounds (Unoki et al 2005) Decreased oxygenation (Hodgson 00) RECOMMENDATION 3 (VAP) RECOMMENDATION 1 (MHI) RECOMMENDATION 1 (AIRWAY CLEARANCE) RECOMMENDATION 1 (ATELECTASIS) Next step in the algorithm

ET tube placement is correct (Stiller 96) NO YES

Notify Consultant Back to algorithm

Is Pt able to tolerate side lying? (Stiller 96; Berney et al 2004 ) RECOMMENDATION 3 (VAP) RECOMMENDATION 1 (MHI) RECOMMENDATION 1 (AIRWAY CLEARANCE) RECOMMENDATION 1 (ATELECTASES) NO YES

Can pt be positioned in head down position? Berney et al 2004 RECOMMENDATION 3 (VAP) RECOMMENDATION 1 (MHI) RECOMMENDATION 1 (AIRWAY CLEARANCE) RECOMMENDATION 1 (ATELECTASES) NO YES

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

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

Is it safe to use a recruitment maneuver? Check the cardiovascular stability Berney 02; Paratz 06 MAP > 75 mmHg and does not fluctuate more than 15 mmHg with position change Heart rate is less than 130. Arterial oxygen saturation SaO2 is not less than 90 No Cardiac arythmias present Pt is hemodynamically stable as discussed with intensivist Previous step in algorithm Next step in the algorithm

Is it safe to use a recruitment maneuver? None of the following pathologies are present: Hodgson 00; Hodgson 07 ARDS; Acute pulmonary edema; Acute head injury; Acute bronchospasm; Subcutaneous emphysema; presence of inetrcostal catheter with a visible air leak Previous step in algorithm Next step in the algorithm

Is it safe to use a recruitment maneuver? Check the state of the pulmonary system Hodgson 2000; Hodgson 2007; Savian 2006 The peak inspiratory airway pressure is less than 40cmH20; The patient is not ventilated with PEEP of more than 10cm H2O NO YES

Develop a patient specific mobility plan (refer to mobility algorithm) Suction of patient based on best practice suction Back to algorithm

Which Equipment to use? First Choice: Ventilator (Berney 2004; Savian 2006; Hodgson 2007) RECOMMENDATION 2 (MHI) If not possible: use a reservoir bag attached to spring loaded valve (eg Mapleson C, Mapleson F, Magill) (Hodgson 2007; Brazier 2003) RECOMMENDATION 3 (MHI) another option: Silicone bag eg Laerdal, Air Viva (Hodgson 2007; Barker 2000) Previous step in algorithm Next step in the algorithm

VENTILATOR HYPERINFLATION Optimal volume / pressures In volume control increase the VT in increments of 200ml (aiming at 130% increase in VT) until a peak pressure of 40cmH2O is reached. Maintain baseline PEEP values. EXPERT OPINION: CRITERIA USED BY Berney 2002; Savian 2006 Next step in the algorithm Previous step in algorithm

VENTILATOR HYPERINFLATION Ventilator Settings Breath rate of at least 6 breaths / min inspiratory flow of 20 l/min Choose a square wave form 2-s end inspiratory pause Use FiO2 that pt is ventilated on (Hodgson 2007; Hodgson 2000; Rothen 1995) EXPERT OPINION: CRITERIA USED BY Berney 2002; Savian 2006 Previous step in algorithm Next step in the algorithm

VENTILATOR HYPERINFLATION Technique Once the Peak pressure is reached, six mechanical breaths will be delivered to the patient. After this, the ventilator is reset to pre-treatment variables and the patient is rested for 30 s. Repeat the sequence for a total duration of 20 minutes EXPERT OPINION: CRITERIA USED BY Berney 2002; Savian 2006 Previous step in algorithm Next step in the algorithm

MANUAL HYPERINFLATION Optimal volume / pressures Manually hyperinflate to a PIP of AT LEAST 35 cmH2O (Paratz 2006; Paratz 2002; Hodgson 2000) but NOT MORE than 40cmH2O (Hodgson 2007; Denehy 2004; Savian 2006) Previous step in algorithm Next step in the algorithm

MANUAL HYPERINFLATION Equipment Bag must have volume of 2 litres Attach an in line Manometer (Suh-Hwa 2005) Use FiO2 that pt is ventilated on – insert blender in circuit (Hodgson 2007; Hodgson 2000; Rothen 95) 15 liters / min fresh gas flow (Savian 2006; Suh-Hwa 2005) PEEP valve attached to circuit and set at the same level of PEEP currently dialed on the mechanical ventilator (Savian 2006) expiratory valve – adjust from fully open position but manually closed during inspiration Next step in the algorithm Previous step in algorithm

MANUAL HYPERINFLATION Technique two-handed technique slow inspiration (2 – 3 sec) inflate until peak pressure of at least 35 cmH2O (Paratz 2006; Paratz 2002; Hodgson 2000) NOT MORE than 40cmH2O as measured by in-line manometer is reached. at least 2 sec hold (can hold for as long as 5 sec) Suh-Hwa 2005 expiration passive (1sec duration) with fast release of the valve to ensure a short expiration while maintaining bag pressure (Paratz 2006). Next step in the algorithm Previous step in algorithm

MANUAL HYPERINFLATION Duration At least six sets of six hyperinflation breaths (Berney 2002; Berney 2004; Hodgson 2000) Follow these hyperinflated breath sets up with six breaths to a peak airway pressure of 20 cmH2O (Berney 2002; Berney 2004; Hodgson 2000) Total duration 20 minutes Previous step in algorithm Next step in the algorithm

Frequency of intervention Volume loss on CxR: hourly for 6 hours (Stiller et al 1996) RECOMMENDATION 1 (ATELECTASES) Infiltrates on CxR: twice daily (Ntoumenopolous et al 2002) RECOMMENDATION 3 (VAP) Previous step in algorithm Next step in the algorithm

Suction Procedure Refer to Best Practice suction RECOMMENDATION 2 (VAP) RECOMMENDATION 2 (AIRWAY CLEARANCE) Previous step in algorithm