Lung recruitment maneuver
Revision as of 08:03, 13 April 2016 by Kxl328 (talk | contribs) (→ProcedureMedical College of Georgia. Open Lung Tool Procedure Protocol. Updated 2014.)
Background
- Controversial in terms of safety and efficacy
- No mortality/morbidity outcome benefits
- May be of more benefit to extra-pulmonary ARDS than to pulmonary ARDS
- Multiple methods reported
- Below is only one method
- Refer to your RT for hospital protocol
- Severe ARDS in which PaO2 recalcitrant to maximal ventilator settings, APRV, PCV
- Biotrauma and cytokine release occur due to:
- Dependent areas of airway are collapsed throughout TVs
- Cyclic collapse causes shear injury atelectrauma with each breath
- Least dependent areas inflated throughout TVs are also easily hyperinflated causing volutrauma and barotrauma, especially in:
- TVs > 6 cc/kg
- Pplat > 30-35 cmH2O
- Derecruitment of alveoli occurs due to[1]:
- Standard low TV ventilation in ARDS
- Insufficient PEEP
- High FiO2 absorptive atelectasis
- Goals to recruit alveoli and maintain with PEEP to prevent cyclic collapse
- Improving hypoxemia
- Decrease ventilator-induced lung injury
Risks
- May only be temporary benefit
- Hemodynamic instability with drop off in preload
- CO2 retention
- May worsen oxygenation by shunting blood to poorly aerated lung (opposing physiological hypoxic pulmonary vasoconstriction)
- May worsen ventilator-induced lung injury with volutrauma/barotrauma
- Pneumothorax
- Contraindications
- Unstable BP
- Ptx or high risk of ptx (blebs, necrotising pna)
- ARDS > 1 wk (relative contraindication)
Procedure[2]
- Goal is to find the derecruitment point
Failure
- Before attempting, know when the maneuver should be stopped
- Stop and return to baseline PCV settings if:
- HR < 60 bpm
- HR > 140 bpm
- New dysrhythmia on monitor (may indicate significant respiratory acid-base shift)
- SBP < 80 mmHg
- Sustained SaO2 < 85%
- Drop in dynamic compliance (pneumothorax)
Preparation
- May require increased sedation or paralysis
- Optimize preload (maneuver decreases preload)
- Maintain a very reliable, good waveform SaO2 (that matches ABGs)
- Pressure control ventilation using current rate, PEEP, FiO2
- I:E to 1:1
- Adjust FiO2 to SaO2 90-92%
- Record baseline VSs and vent settings
- Take note of dynamic compliance levels
- Maintain appropriate minute ventilations
- 14 ga needles x2 in case of pneumothorax
Increasing PEEP
- Adjust PC level (Pi) above PEEP to maintain TV at 6 cc/kg
- Adjust RR to maintain appropriate MV, not any > 35 bpm
- Increase PEEP to 15 cmH2O
- Go on with protocol if < 20% SBP drop
- If unstable BP or SBP drop > 20%, halt procedure
- Increase PIP (peak insp pressure) to 40 cmH2O
- Set PC level to 15 cmH2O above PEEP
- Maintain this difference between PEEP and PC level (Pi)
- Increase q2 minutes PEEP to 20 --> 30 --> 40 cmH2O
- Pi will reach 55 cmH2O
- Note maximum SaO2 obtained
- Treat SBP drops as necessary, but halt procedure if > 20% SBP drop despite pressors/fluids
- Increase PIP as necessary
- Maintain minute ventilation
- Reduce RR before PIP increase since TV will increase
Reducing PEEP
- Reduce q3 minutes PEEP to 25 --> 22.5 --> 20 --> 17.5 cmH2O
- Remember that SpO2 monitor disaplys results up to 1.5 min after clinical change
- Until:
- Decrease in SaO2 of 1% from maximum SaO2 observed, which is the derecruitment point
- OR minimum of 15 cmH2O PEEP reached
Re-recruitment
- Increase PEEP step-wise q2 minutes to 40 cmH2O again
- Maintain PEEP at 40 cmH2O for 2 minutes
- Return to PEEP level 2-4 cmH2O above decruitment point
- Adjust TV 4-6 cc/kg and plateau pressures < 30 cmH2O
- Tolerate permissive hypercapnea if pH > 7.15
- May increase RR up to maximum of 38 bpm
Adjuncts
- Inhaled nitric oxide (iNO)
- Prostacyclins, epoprostenol (Flolan)
- ECMO
- Oscillation ventilation, High frequency oscillation ventilation (HFOV)
See Also
References
- ↑ Nickson C. Lung Recruitment Maneuvers. 21 Sept 2014. http://lifeinthefastlane.com/ccc/recruitment-manoeuvres-in-ards/
- ↑ Medical College of Georgia. Open Lung Tool Procedure Protocol. Updated 2014.