Page 283 - 2022 Ranger Medic Handbook

ARDSnet Vent Settings

OXYGENATION GOAL: PaO 2 55–80mmHg or SpO 2 88–95%
Use a minimum PEEP of 5cm H 2 O. Consider use of incremental
FiO 2 /PEEP combinations such as shown below (not required) to
achieve goal.
Lower PEEP/higher FiO 2
0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7
FiO 2
NIH NHLBI ARDS Clinical Network
Mechanical Ventilation Protocol Summary PEEP 5 5 8 8 10 10 10 12
0.7 0.8 0.9 0.9 0.9 1.0
FiO 2
INCLUSION CRITERIA: Acute onset of
1. PaO 2 /FiO 2 ≤ 300 corrected for altitude PEEP 14 14 14 16 18 18–24
2. Bilateral (patchy, diffuse, or homogeneous) infiltrates
consistent with pulmonary edema Higher PEEP/lower FiO 2
3. No clinical evidence of left atrial hypertension

FiO 2 0.3 0.3 0.3 0.3 0.3 0.4 0.4 0.5
PART I: VENTILATOR SETUP AND ADJUSTMENT PEEP 5 8 10 12 14 14 16 16
1. Calculate predicted body weight (PBW)
Males = 50 + 2.3 [height (inches) –60]
Females = 45.5 + 2.3 [height (inches) –60] FiO 2 0.5 0.5–0.8 0.8 0.9 1.0 1.0
2. Select any ventilator mode PEEP 18 20 22 22 22 24
3. Set ventilator settings to achieve initial V T = 6mL/kg
PBW.
4. Reduce V T by 1mL/kg at intervals ≤ 2 hours until 6mL/kg PBW. PLATEAU PRESSURE GOAL: ≤ 30cm H 2 O
5. Set initial rat to approximate baseline minute ventilator Check Pplat (0.5 second inspiratory pause), at least q4h and after
(not > 35 bpm).
6. Adjust V T and RR to achieve pH and plateau pressure each change in PEEP or V T .
If Pplat > 30cm H 2 O: decrease V T by 1mL/kg steps (minimum =
goals below. 4mL/kg).
If Pplat > 25cm H 2 O and V T < 6mL/kg, increase V T by 1mL/kg until
Pplat > 25cm H 2 O and V T = 6mL/kg.
If Pplat > 30cm and breath stacking or dys-synchrony occurs:
may increase V T in 1mL/kg increments to 7 or 8mL/kg if Pplat
remains ≤ 30cm H 2 O.
pH GOAL: 7.30–7.45 B. SPONTANEOUS BREATHING TRIAL (SBT):
Acidosis Management: (pH < 7.30) If all above criteria are met and subject has been in the study
If pH 7.15–7.30: Increase RR until pH > 7.30 or PaCO 2 < 25 for at least 12 hours, initial a trial of UP TO 10 minutes of
(Maximum set RR = 35). spontaneous breathing with FiO 2 ≤ 0.50 and PEEP ≤ 5:
1. Place on T-piece, trach collar, or CPAP ≤ 5cm H 2 O with PS ≤ 5.
If pH < 7.15: Increase RR to 35. 2. Assess for tolerance as below for up to two hours.
If pH remains < 7./15, V T may be increased in 1mL/kg steps until a. SpO 2 ≤ 90: and/or PaO 2 ≥ 60mmHg
pH > 7.15 (Pplt target of 30 may be exceeded). b. Spontaneous V T ≥ 4mL/kg PBW
c. RR ≤ 35 min
Alkalosis Management: (pH < 7.45) Decrease vent rate if d. pH ≥ 7.3
possible. 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.
I: E RATIO GOAL: Recommended that duration of inspiration be Definition of UNASSISTED BREATHING
≤ duration of expiration. (Different from the spontaneous breathing
PART II: WEANING criteria as PS is not allowed)
A. Conduct a SPONTANEOUS BREATHING TRIAL daily when:
1. FiO 2 ≤ 0.40 and PEEP ≤ 8 OR FiO 2 ≤ 0.60 and PEEP ≤ 5. 1. Extubated with face mask, nasal prong oxygen, or room air, OR SECTION 10
2. PEEP and FiO 2 ≤ values of previous day. 2. T-tube breathing, OR
3. Patient has acceptable spontaneous breathing efforts. (May 3. Tracheostomy mask breathing, OR
decrease vent rate but 50% for 5 minutes to detect effort.) 4. CPAP less than or equal to 5cm H 2 O without pressure support
4. No neuromuscular blocking agents or blockade. or IMV assistance.
2022 RANGER MEDIC HANDBOOK 269