Shenandoah University acute Respiratory Distress Syndrome Protocol Capstone Dear,I need help writing a full formal protocol for ARDS patients, I have this

Shenandoah University acute Respiratory Distress Syndrome Protocol Capstone Dear,I need help writing a full formal protocol for ARDS patients, I have this updated study to use as guidelines. I need it for my hospital as a protocol.I am a respiratory therapist PART I: VENTILATOR SETUP AND ADJUSTMENT
1. Calculate predicted body weight (PBW)
Males = 50 + 2.3 [height (inches) – 60]
Females = 45.5 + 2.3 [height (inches) -60]
2. Select any ventilator mode
3. Set ventilator settings to achieve initial VT = 8 ml/kg PBW
4. Reduce VT by 1 ml/kg at intervals ? 2 hours until VT = 6ml/kg PBW.
5. Set initial rate to approximate baseline minute ventilation (not > 35
bpm).
6. Adjust VT and RR to achieve pH and plateau pressure goals below.
INCLUSION CRITERIA: Acute onset of
1. PaO2/FiO2 ? 300 (corrected for altitude)
2. Bilateral (patchy, diffuse, or homogeneous) infiltrates consistent with
pulmonary edema
3. No clinical evidence of left atrial hypertension
NIH NHLBI ARDS Clinical Network
Mechanical Ventilation Protocol Summary
ARDSne t
0.5
18
0.5-0.8
20
0.8
22
0.9
22
0.3
14
0.9
18
0.5
10
1.0
22
0.4
14
1.0
18-24
0.6
10
1.0
24
0.4
16
0.7
10
0.5
16
0.7
12
__________________________________________________________
PLATEAU PRESSURE GOAL: ? 30 cm H2O
Check Pplat (0.5 second inspiratory pause), at least q 4h and after each
change in PEEP or VT.
If Pplat > 30 cm H2O: decrease VT by 1ml/kg steps (minimum = 4
ml/kg).
If Pplat < 25 cm H2O and VT< 6 ml/kg, increase VT by 1 ml/kg until Pplat > 25 cm H2O or VT = 6 ml/kg.
If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O. FiO2 PEEP 0.3 12 Higher PEEP/lower FiO2 FiO2 0.3 0.3 0.3 PEEP 5 8 10 0.8 14 0.9 16 0.7 14 0.5 8 0.9 14 FiO2 PEEP Lower PEEP/higher FiO2 FiO2 0.3 0.4 0.4 PEEP 5 5 8 OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations such as shown below (not required) to achieve goal. PART II: WEANING A. Conduct a SPONTANEOUS BREATHING TRIAL daily when: 1. FiO2 ? 0.40 and PEEP ? 8 OR FiO2 < 0.50 and PEEP < 5. 2. PEEP and FiO2 ? values of previous day. 3. Patient has acceptable spontaneous breathing efforts. (May decrease vent rate by 50% for 5 minutes to detect effort.) 4. Systolic BP ? 90 mmHg without vasopressor support. 5. No neuromuscular blocking agents or blockade. _____________________________________________________________ pH GOAL: 7.30-7.45 Acidosis Management: (pH < 7.30) If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR = 35). . If pH < 7.15: Increase RR to 35. If pH remains < 7.15, VT may be increased in 1 ml/kg steps until pH >
7.15 (Pplat target of 30 may be exceeded).
May give NaHCO3
Alkalosis Management: (pH > 7.45) Decrease vent rate if possible.
______________________________________________________
I: E RATIO GOAL: Recommend that duration of inspiration be < duration of expiration. 2. 3. 4. 1. Extubated with face mask, nasal prong oxygen, or room air, OR T-tube breathing, OR Tracheostomy mask breathing, OR CPAP less than or equal to 5 cm H20 without pressure support or IMV assistance. Definition of UNASSISTED BREATHING (Different from the spontaneous breathing criteria as PS is not allowed) B. SPONTANEOUS BREATHING TRIAL (SBT): If all above criteria are met and subject has been in the study for at least 12 hours, initiate a trial of UP TO 120 minutes of spontaneous breathing with FiO2 < 0.5 and PEEP < 5: 1. Place on T-piece, trach collar, or CPAP ? 5 cm H2O with PS < 5 2. Assess for tolerance as below for up to two hours. a. SpO2 ? 90: and/or PaO2 ? 60 mmHg b. Spontaneous VT ? 4 ml/kg PBW c. RR ? 35/min d. pH ? 7.3 e. No respiratory distress (distress= 2 or more) HR > 120% of baseline
Marked accessory muscle use
Abdominal paradox
Diaphoresis
Marked dyspnea
3. If tolerated for at least 30 minutes, consider extubation.
4. If not tolerated resume pre-weaning settings.
(2019) 9:69
Papazian et al. Ann. Intensive Care
https://doi.org/10.1186/s13613-019-0540-9
Open Access
REVIEW
Formal guidelines: management of acute
respiratory distress syndrome
Laurent Papazian1*, Cécile Aubron2, Laurent Brochard3, Jean-Daniel Chiche4, Alain Combes5, Didier Dreyfuss6,
Jean-Marie Forel1, Claude Guérin7, Samir Jaber8, Armand Mekontso-Dessap9, Alain Mercat10,
Jean-Christophe Richard11, Damien Roux6, Antoine Vieillard-Baron12 and Henri Faure13
Abstract
Fifteen recommendations and a therapeutic algorithm regarding the management of acute respiratory distress
syndrome (ARDS) at the early phase in adults are proposed. The Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology has been followed. Four recommendations (low tidal volume, plateau
pressure limitation, no oscillatory ventilation, and prone position) had a high level of proof (GRADE 1 + or 1 ?); four
(high positive end-expiratory pressure [PEEP] in moderate and severe ARDS, muscle relaxants, recruitment maneuvers, and venovenous extracorporeal membrane oxygenation [ECMO]) a low level of proof (GRADE 2 + or 2 ?); seven
(surveillance, tidal volume for non ARDS mechanically ventilated patients, tidal volume limitation in the presence of
low plateau pressure, PEEP > 5 cmH2O, high PEEP in the absence of deleterious e?ect, pressure mode allowing spontaneous ventilation after the acute phase, and nitric oxide) corresponded to a level of proof that did not allow use of
the GRADE classification and were expert opinions. Lastly, for three aspects of ARDS management (driving pressure,
early spontaneous ventilation, and extracorporeal carbon dioxide removal), the experts concluded that no sound
recommendation was possible given current knowledge. The recommendations and the therapeutic algorithm were
approved by the experts with strong agreement.
Introduction
Acute respiratory distress syndrome (ARDS) is an inflammatory process in the lungs that induces non-hydrostatic
protein-rich pulmonary oedema. The immediate consequences are profound hypoxemia, decreased lung compliance, and increased intrapulmonary shunt and dead
space. The clinicopathological aspects include severe
inflammatory injury to the alveolar-capillary barrier, surfactant depletion, and loss of aerated lung tissue.
The most recent definition of ARDS, the Berlin definition, was proposed by a working group under the
aegis of the European Society of Intensive Care Medicine [1]. It defines ARDS by the presence within 7 days
of a known clinical insult or new or worsening respiratory symptoms of a combination of acute hypoxemia
*Correspondence: Laurent.PAPAZIAN@ap-hm.fr
1
Service de Médecine Intensive – Réanimation, Hôpital Nord, Chemin des
Bourrely, 13015 Marseille, France
Full list of author information is available at the end of the article
(PaO2/FiO2 ? 300 mmHg), in a ventilated patient with
a positive end-expiratory pressure (PEEP) of at least
5 cmH2O, and bilateral opacities not fully explained
by heart failure or volume overload. The Berlin definition uses the PaO2/FiO2 ratio to distinguish mild
ARDS (200 < PaO2/FiO2 ? 300 mmHg), moderate ARDS (100 < PaO2/FiO2 ? 200 mmHg), and severe ARDS (PaO2/ FiO2 ? 100 mmHg). Much information on the epidemiology of ARDS has accrued from LUNG SAFE, an international, multicenter, prospective study conducted in over 29,000 patients in 50 countries [2]. During this study, ARDS accounted for 10% of admissions to intensive care unit (ICU) and 23% of ventilated patients. Hospital mortality, which increased with the severity of ARDS [2], was about 40%, and reached 45% in patients presenting with severe ARDS [2–4]. Significant physical, psychological, and cognitive sequelae, with a marked impact on quality of life, have been reported up to 5 years after ARDS [5]. © The Author(s) 2019. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. Papazian et al. Ann. Intensive Care (2019) 9:69 One of the most important results of the LUNG SAFE study was that ARDS was not identified as such by the primary care clinician in almost 40% of cases [2]. This was particularly so for mild ARDS, in which only 51% of cases were identified [2]. When all ARDS criteria were met, only 34% of ARDS patients were identified, suggesting that there was a delay in adapting the treatment, in particular mechanical ventilation [2]. This is the main reason why these formal guidelines are not limited to patients presenting with severe ARDS, but are intended for application to all mechanically ventilated intensive care patients. Results from the LUNG SAFE study suggest that the ventilator settings used did not fully respect the principles of protective mechanical ventilation [2]. Plateau pressure was measured in only 40% of ARDS patients [2]. And only two-thirds of patients for whom plateau pressure was reported were receiving protective mechanical ventilation (tidal volume ? 8 mL/kg predicted body weight [PBW] and plateau pressure ? 30 cmH2O) [2]. Analysis of the LUNG SAFE results also shows a lack of relation between PEEP and the PaO2/FIO2 ratio [2]. In contrast, there was an inverse relation between FIO2 and SpO2, suggesting that the clinicians used FIO2 to treat hypoxemia. Lastly, prone positioning was used in just 8% of patients presenting with ARDS, essentially as salvage treatment [2]. The reduction in mortality associated with ARDS over the last 20 years seems to be explained largely by a decrease in ventilator-induced lung injury (VILI). VILI is essentially related to volutrauma closely associated with “strain” and “stress”. Lung stress corresponds to transpulmonary pressure (alveolar pressure–pleural pressure), and lung strain refers to the change in lung volume indexed to functional residual capacity of the ARDS lung at zero PEEP. So, volutrauma corresponds to generalized excess stress and strain on the injured lung [6–8]. High-quality CT scan studies and physiological studies have revealed that lung lesions are unequally distributed, the injury or atelectasis coexisting with aerated alveoli of close-to-normal structure [9]. ARDS is not a disease; it is a syndrome defined by a numerous clinical and physiological criteria. It is therefore not surprising that lung-protective ventilatory strategies that are based on underlying physiological principles have been shown to be e?ective in improving outcome. Minimizing VILI thus generally aims reducing volutrauma (reduction in global stress and strain). Lowering airway pressures has the theoretical dual benefit of minimizing overdistension of the aerated areas and mitigating negative hemodynamic consequences. The current SRLF guidelines are more than 20 years old and so there was a pressing need to update them. The main aim with these formal guidelines was voluntarily to limit the topics to the best studied fields, so as to Page 2 of 18 provide practitioners with solid guidelines with a high level of agreement between experts. Certain very important aspects of ARDS management were deliberately not addressed because there is insu?cient assessment of their e?ects on prognosis (respiratory rate, mechanical power, target oxygenation, pH, PaCO2…). We also limited these guidelines to adult patients, to early phase of ARDS (first few days), and to invasive mechanical ventilation. Methods These guidelines have been formulated by an expert working group selected by the SRLF. The organizing committee first defined the questions to be addressed and then designated the experts in charge of each question. The questions were formulated according to a Patient Intervention Comparison Outcome (PICO) format after a first meeting of the expert group. The literature was analyzed using Grade of Recommendation Assessment, Development and Evaluation (GRADE) methodology. A level of proof was defined for each bibliographic reference cited as a function of the type of study and its methodological quality. An overall level of proof was determined for each endpoint. The experts then formulated guidelines according to the GRADE methodology (Table 1). A high overall level of proof enabled formulation of a “strong” recommendation (should be done… GRADE 1 +, should not be done… GRADE 1 ?). A moderate, low, or very low overall level of proof led to the drawing up of an “optional” recommendation (should probably be done… GRADE 2 +, should probably not be done… GRADE 2 ?). When the literature was inexistent or insu?cient, the question could be the subject of a recommendation in the form of an expert opinion (the experts suggest…). The proposed recommendations were presented and discussed at a second meeting of the expert group. Each expert then reviewed and rated each recommendation using a scale of 1 (complete disagreement) to 9 (complete agreement). The collective rating was done using a GRADE grid methodology. To approve a recommendation regarding a criterion, at least 50% of the experts had to agree and less than 20% had to disagree. For a strong agreement, at least 70% of the experts had to agree. In the absence of strong agreement, the recommendations were reformulated and rated again, with a view to reaching a consensus (Table 2). Area 1: Evaluation of ARDS management R1.1 - The experts suggest that the e?cacy and safety of all ventilation parameters and therapeutics associated with ARDS management should be evaluated at least every 24 h. EXPERT OPINION Papazian et al. Ann. Intensive Care (2019) 9:69 Page 3 of 18 Table 1 Recommendations according to the GRADE methodology Recommendations according to the GRADE methodology High level of proof Strong recommendation “…should be done…” Grade 1 + Moderate level of proof Optional recommendation “… should probably be done…” Grade 2 + Insu?cient level of proof Recommendation in the form of an expert opinion “The experts suggest…” Expert opinion Moderate level of proof Optional recommendation “… should probably not be done…” Grade 2 ? High level of proof Strong recommendation “…should not be done…” Grade 1 ? Insu?cient level of proof Rationale: Evaluation of the e?cacy and safety of mechanical ventilation settings and treatments is a cornerstone of the early phase of the management of ARDS patients. As shown in these formal guidelines, the settings of ventilation parameters, such as PEEP, are based on their e?cacy and tolerance. Moreover, the indication for some treatments depends on the severity of ARDS and these treatments will only be implemented when there is insufficient response to first-line treatments. No recommendation Figure 1 shows the treatments implemented to patients with ARDS based on the severity of respiratory distress. The decision to initiate some treatments is taken after a “stabilization” phase [10] that includes optimization of mechanical ventilation as the first step of management. Early evaluation of e?cacy based on the PaO2/FiO2 ratio is necessary in order to discuss the relevance of neuromuscular blocking agents and of prone positioning (Fig. 1). The safety of drug therapies and procedures must also be regularly evaluated. These guidelines also address the Fig. 1 Therapeutic algorithm regarding early ARDS management (EXPERT OPINION) Papazian et al. Ann. Intensive Care (2019) 9:69 main safety problems of the treatments. Literature support for such practices is lacking, and they are guided by good clinical sense. Indeed, data are scarce on the benefits of regular assessment of ventilation settings and/or disease severity in ARDS patients. A single-center observational study has shown the value of systematic evaluation of respiratory mechanics during ARDS in the initial phase (mostly in the first 48 h) [11]. In this study, evaluation of the passive mechanics of the lung and thoracic cage, of the response to PEEP, and of alveolar recruitment prompted changes in ventilation parameters in most patients (41 of 61 analyzed). These changes were associated with improvements in plateau pressure (? 2 cmH2O on average), driving pressure (? 3 cmH2O on average), and oxygenation index [11]. It is di?cult to define how often to assess ventilation parameters and treatments in ARDS. It seems that a frequency at least similar to that proposed for the evaluation of criteria for weaning from the ventilator (i.e. daily) is reasonable [12]. Nonetheless, more frequent assessment might be necessary and benefit in some cases. Area 2: Tidal volume management Tidal volume adjustment R2.1.1 – A tidal volume around 6 mL/kg of predicted body weight (PBW) should be used as a first approach in patients with recognized ARDS, in the absence of severe metabolic acidosis, including those with mild ARDS, to reduce mortality. GRADE 1 +, STRONG AGREEMENT R2.1.2 – The experts suggest a similar approach for all patients on invasive mechanical ventilation and under sedation in ICU, given the high rate of failure to recognize ARDS and the importance of rapidly implementing pulmonary protection. EXPERT OPINION Rationale: To control potentially deleterious increases in PaCO2 (which raise pulmonary arterial pressure), a relatively high respiratory rate of between 25 and 30 cycles/min should be adopted first. Too high a rate, however, engenders a risk of dynamic hyperinflation and also increases each minute cumulative exposure to potentially risky insu?ation. A PaCO2 below 50 mmHg is generally acceptable. A reduction in instrumental dead space is also appropriate, and a heated humidifier should be used in first intention. Page 4 of 18 The PBW should be calculated for each patient upon admission as a function of height and sex. The tidal volume delivered will induce a pressure increase from the PEEP, thus necessitating monitoring of plateau pressure, which should be kept below 30 cmH2O. Clinicians need to be aware of the potential risks of low tidal volume, such as dyssynchrony and double triggering. Guidelines on pressure and volume reduction issued in the late 1980s were based on experimental and clinical data [13–16]. Several randomized clinical trials with rather few subjects in the 1990s found no survival advantage of low tidal volume [17, 18]. A lack of power may, of course, explain these negative results. Note also that these trials were not intended to achieve control of PaCO2, which may have contributed to the deleterious e?ects of hypercapnic acidosis in the study arms using reduced tidal volume. Although the clinical evidence is not easy to demonstrate, hypercapnia has unquestionable side e?ects [19], like increased pulmonary vascular resistance, which can worsen prognosis. In 2000, the ARMA study run by the NHLBI ARDS Network in the USA yielded key data comparing a pulmonary protection strategy using “low” tidal volume, on average 6 mL/kg PBW, a plateau pressure limited to 30 cmH2O, and a respiratory rate up to 35 breaths/min, with a non-protection strategy using a tidal volume of 12 mL/kg PBW [20]. The use of PBW calculated as a function of sex and height was an important innovation in adapting tidal volume to the expected lung volume. In this study, increased respiratory rate leading to low-volume ventilation was associated with only a minimal increase in PaCO2, a result that may have contributed to the benefits of this treatment arm. A 25% reduction in the relative risk of mortality was observed, i.e., a 30–40% decrease in overall mortality. This study had an enormous impact on clinical practice. It was not the first to use low volumes successfully, that accolade falls to the two-center study by Amato et al., but low tidal volume was combined with higher PEEP, the idea being to reduce driving pressure [21]. Other studies using the same approach as Amato et al. found a similar reduct... Purchase answer to see full attachment