1. Ventilator Management in Different Disease Entities

20. Clinical Trials of Traditional Versus Lower Tidal Volume Ventilation Strategies in Acute Lung Injury and Acute Respiratory Distress Syndrome Number of Tidal Volumes Tidal Volumes Mortality Patients as Reported per kg PBW (%) Randomized T L T L T L Stewart et al 120 10.8+ 7.2+ 12.2 8.1 47 50 Brochard et al 116 10.3 7.1 11.3 7.8 38 47 Brower et al 52 10.2 7.3 10.2 7.3 46 50 ARDS Network 861 11.8 6.2 11.8 6.2 40 31

22. Summary of Alternative Ventilator Strategies for ALI/ARDS Ventilatory No. of Strategy Year How Studies Patients Comments Study Low tidal 1999 Phase III 861 Mortality was reduced by ARDS volume 22% with a 6 ml/kg Network predicted body weight tidal volume. This is the first large randomized multicenter controlled trial to show a mortality benefit from a specific therapy in ALI/ARDS Low tidal 2002 Phase III 549 There was no mortality ARDS volume with benefit to increase levels Network high PEEP of PEEP compared with the standard ARDS Network low tidal volume strategy

23. Higher versus Lower Positive End-Expiratory Pressures in Patients with the Acute Respiratory Distress Syndrome ARDS Network NEJM 2002

31. Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.

35. Algorithm for ventilator management of ARDS using the ARDSnet protocol Calculate predicted body weight CMV (A/C). VCV. Set initial volume to 8 mL/kg, then 7 mL/kg after 1 hr, then 6 mL/kg after next hr. increase respiratory rate to maintain minute ventilation. I:E ratio 1:2. PEEP and FiO2 per FiO2/PEEP table Pplat < 30 cm H2O Adjust FiO2 or PEEP per FiO2/PEEP table ↑ rate ↑ V T by 1 mL/kg ↑ V T to 7-8 mL/kg ↓ V T to 4 mL/kg ↓ rate ↑ rate Consider HCO3 ↑ V T Evaluate for weaning V T 4 mL/kg Pplat < 25 cm H2O V T < 6 mL/kg Severe dyspnea PaO2 55-80 SpO2 88-95 FiO2≦0.4 PEEP=8 pH pH< 7.15 START no no no no no no no no yes yes yes yes yes yes yes yes 7.30-7.45 >7.45 <7.30 ARDS Network N Engl J Med 2000; 342:1301

38. Algorithm for the ventilator management of the patient with COPD (A/C), PCV or VCV, V T 8-10 mL/kg, Pplat < 30 cm H2O, rate 10/min, Ti 0.6-1.2 s, PEEP 5 cm H2O, FiO2 for SpO2 90-95% Clear secretions Administer bronchodilators ↑ PEEP if missed trigger efforts ↓ V T or rate ↓ FiO2 ↑ FiO2 ↑ rate ↑ V T NPPV Continue NPPV Candidate For NPPV Patient tolerates Clinically improved PaO2 mmHg pH Pplat < 25 cm H2O Pplat > 30 cm H2O ↓ rate ↓ V T Auto-PEEP Auto-PEEP START yes yes yes yes yes yes no no yes no yes no >75 55-75 mmHg <55 7.30-7.45 <7.30 >7.45 intubate intubate intubate Fumeaux T et al Intensive Care Med 2001;27:1868 Gladwin MT et al Intensive Care Med 1998;24:898 Nava S et al Ann Intern Med 1998; 128:721

41. Algorithm for Mechanical Ventilation of the Patient with Chest Trauma START Calhoon JH et al Chest Surg Clin N Am 1997;7:199 Ferguson M et al 1996 2:449 Gentilello LM et al Am J Respir Crit Care Med 2001 163:604 CMV (A/C), V T 6 to 10 mL/kg, FiO2 1.0. rate 15/min, Ti 1 s, VCV or PCV, PEEP 5 cm H2O Titrate FiO2 to SpO2 92-95% Good lung down ↑ PEEP ↓ V T and ↑ rate ↑ FiO2 Maintain Current settings ↓ rate ↑ rate ↑ V T or ↑ rate FiO2 <0.6 Broncho- Pleural fistula ICP >20 Unilateral disease Pplat> 30 cm H2O Pplat pH no no no no yes yes yes yes yes Unilateral disease no >25 ≦ 25 >7.45 7.30-7,45 <7.30

43. Algorithm for Mechanical Ventilation of the Patient with Head Injury Unilateral lung disease CMV (A/C), PCV or VCV, V T 4 t0 8 mL/kg.FiO2 1.0, rate 20/min, Ti 1 s, PEEP 5 cm H2O CMV (A/C), PCV or VCV, V T 8 t0 12 mL/kg.FiO2 1.0, rate 20/min, Ti 1 s, PEEP 5 cm H2O Titrate FiO2 for SpO2 ≧92% PaCO2 Pplat ＞ 30 PaO2 FiO2 >0.6 ICP ICP ICP< 20 FiO2 >0.6 Maintain ventilator settings More aggressive Medical therapy Slowly ↓rate to initial setting ↑ rate ↓ rate ↓ V T ↑ rate ↓ FiO2 ↑ FiO2 ↑ PEEP START yes yes no no no yes <35 >45 35 - 45 >100 70 - 100 <70 no no yes >20 <20 >20 <20 no Berrouschot J et al Crit Care Med 2000 28:2956 yes

46. Algorithm for Mechanical Ventilation of the Post-operative Patient Ventilate consistent with underlying disease Ventilate consistent with negative lung pathology Consider extubation Spontaneous breathing trial Titrate FiO2 For SpO2> 92% CMV (A/C), VCV or PCV, VT 10 – 12 mL/kg, rate 12/min , I;E:1:3 PEEP 5 cm H2O, FiO2:1.0 Adjust rate and tidal volume for normal acid-base ↑ PEEP Prior lung disease Single lung transplant Tolerated Spontaneous Breathing efforts. Hemodunamically Stable, FiO2≦0.5 PEEP≦5 FiO2 START yes yes no no yes no yes no ≧ 0.6 <0.6

47. Initial Ventilator Settings for Postoperative Patients with no Prior Disease Setting Recommendation Mode A/C (CMV) Rate 10 - 16/min Volume/pressure control Pressure or volume Tidal volume 10-12 mL/kg IBW and plateau pressure <30 cm H2O Inspiratory time 1 s PEEP ≤ 5 cm H2O FiO2 Sufficient to maintain PaO2 > 80 mm Hg Flow waveform Descending ramp

48. Initial Ventilator Settings for Postoperative Patients with Prior Obstructive Lung Disease Setting Recommendation Mode A/C (CMV) Rate 8 – 12 /min Volume/pressure control Pressure or volume Tidal volume 8-10 mL/kg IBW and plateau pressure <30 cm H2O Inspiratory time 0.6 – 1.2 s PEEP 5 cm H2O; counterbalance auto-PEEP FiO2 Sufficient to maintain PaO2 > 60 mm Hg Flow waveform Descending ramp

49. Initial Ventilator Settings for Postoperative Patients with Prior Restrictive Lung Disease Setting Recommendation Mode A/C (CMV) Rate 15 –25 /min Volume/pressure control Pressure or volume Tidal volume < 8 mL/kg IBW and plateau pressure <30 cm H2O Inspiratory time 1 s PEEP 5 cm H2O FiO2 Sufficient to maintain PaO2 > 60 mm Hg Flow waveform Descending ramp

52. Algorithm for Mechanical Ventilation of the Patient with Neuromuscular Disease without Lung Disease CMV (A/C), VCV, V T 15 mL/kg, FiO2 0.40 Rate 10/min, Ti 1 s, PEEP 0 cm H2O ↓ FiO2 ↑ FiO2 ↑ PEEP In-Exsufflattor ↑ V T ↑ V T ↑ rate ↑ rate In-Exsufflattor Maintain therapy ↓ rate or ↓V T Consider mechanical dead space Secretions or atelectasis dyspnea dyspnea secretions pH Pplat SpO2 <95% SpO2 START yes yes yes no no yes no no no yes >7.45 7.35-7.45 <7.35 >25 ≦ 25 >95% <92% 92-95%

57. Algorithm for Mechanical ventilation of the Patient with Cardiac Failure Bersten AD et al New Engl J Med 1991 325:1825 Poppas A et al Am J Respir Crit Care Med 2002 165:4 Awake and cooperative Patient tolerates PaCO2> 45 mm Hg PaCO2. 45 mm Hg Acute MI Pplat pH Hemodynamic stability SpO2<92%; Pulmonary edema CMV (A/C), VCV or PCV, V T 8-10 mL/kg, Pplat < 30 cm H2O, I;E:1:2 PEEP 5 cm H2O, FiO2 1.0 Mask CPAP, 5-10 cm H2O, FiO2 1.0 Continue therapy, Definitive medical therapy Titrate FiO2 For SpO2>92% ↑ PEEP NPPV Manipulate PEEP and FiO2 ↑ rate ↓ V T ↓ rate START yes yes yes yes yes no no yes no no no no intubate intubate <30 ≧ 30 <7.35 7.35-7.45 >7.45 no yes

60. Algorithm for Mechanical Ventilation of Patient with Asthma START Decrease minute ventilation CMV (A/C), PCV or VCV, V T 4-8 mL/kg, Pplat≦ 30 cm H2O rate 8-20/min, Ti 1 s, PEEP 5 cm H2O, FiO2 1.0 SpO2 Auto-PEEP Auto-PEEP Pplat< 25 cm H2O pH Pplat> 30 cm H2O Administer bronchodilators ↑ V T ↑ rate ↑ FiO2 ↓ FiO2 ↓ V T ↓ rate yes yes yes yes no no no 92-95% >95% <92% >7.45 <7.30 7.30-7.45 Afzal M et al Clin Rev Allergy Immunol 2001 20:385 Mansel JK et al Am J Med 1990 89:42 Koh Y Int Aneshesiol Clin 2001 39:63 no

62. Algorithm for Mechanical Ventilation of Patient with Burn and Inhalation Injury Fitzpatrick JC et al Respir Care Clin N Am 1997 3:21 CMV (A/C), PCV or VCV, V T 6 to 12 mL/kg, FiO2 1.0, rate 15/min, Ti 1 s Consider: Bronchodilators Diuretics Secretion clearance PEEP Recruitment maneuver Prone Inhaled nitric oxide Treat with: Bronchodilators, diuretics Titrate FiO2 for SpO2≧92% Maintain ventilator settings ↑ rate ↑ V T ↑ FiO2 ↓ V T ↓ rate Consider V T ↑ ↓ FiO2 ↓ Chest wall compliance Pplat>30 pH PaO2 FiO2< 0.6 FiO2< 0.6 ABG results Pplat>30 Cm H2O yes yes yes yes yes no no no no no no <7.30 >7.45 7.30-7.45 >100 <70 70-100 Continue 100% O2 CO poisoning yes START

64. Algorithm for Mechanical Ventilation of Patient with Bronchopleural Fistula CMV (A/C), VCV or PCV, rate 6-20/min V T 4 – 8 mL/kg, Ti ≤ 1 s PEEP 3 cm H2O, FiO2:1.0 Exhaled V T >75% Inhaled V T Systemicaly evaluate changes in: Tidal volume Respiratory Rate PEEP Inspiratory time Pressure control vs. volume control Titrate FiO2 for SpO2 92-95% pH rate rate Start yes no 7.25-7.45 >7.45 <7.25

66. Algorithm for Mechanical Ventilation of Patient with Drug Overdose CMV (A/C), VCV or PCV,,rate 10/min VT 8 to 12 mL/kg, Ti 1 s, PEEP 5 cm H2O, FiO2 1.0 Spontaneous Breathing trial Consider extubation ↑ PEEP Titrate FiO2 for SpO2 > 92% Adjust rate and tidal volume for normal acid-base FiO2 tolerated Spontaneous breathing efforts hemodynamically stable, FiO2≦0.5 PEEP≦5 START yes yes no no <0.60 ≧ 0.60

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69. Algorithm for ventilator management of ARDS using the open lung approach Consider prone position Consider accepting lower level of oxygenation Consider inhaled nitric oxide CMV (A/C). PCV to achieve V T of 4-8 mL/kg, Ti to Avoid auto-PEEP. Rate 20/min. FiO2 1.0. PEEP 10 cm H2O Recruitment maneuver PEEP 20 cm H2O FiO2 to maintain SpO2 90-95% Decrease PEEP to maintain SpO2 90-95% ↑ pressure control if Pplat < 30 cm H2O ↑ rate (avoid auto-PEEP) Consider accepting lower pH Recruitment maneuver ↑ increase PEEP ↑ increase FiO2 Maintain ventilator settings ↓ FiO2 ↓ PEEP if FiO2 < 0.05 ↓ pressure control ↓ rate SpO2 SpO2 pH <90% ≧ 90% 90-95% >95% <90% 7.25-7.45 < 7.25 >7.45 START Amato MBP et al. N Engl J Med 1998 338:347

74. Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.