CLINICAL ALGORITHM FOR THE MANAGEMENT OF INTUBATED PATIENTS PRESENTING WITH CHANGES VISSIBLE ON CxR

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CLINICAL ALGORITHM FOR THE MANAGEMENT OF
INTUBATED PATIENTS PRESENTING WITH CHANGES
VISSIBLE ON CxR
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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) RECOMMEN
DATION 1 (ATELECTASIS)
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ET tube placement is correct (Stiller 96)
YES
NO
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Notify Consultant
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• 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)

YES
NO
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• 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)

YES
NO
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• Position pt for 15 minutes in gravity assisted
  drainage position with affected lung uppermost
  (Berney et al 2004 Ntoumenopolous 02 Berney
  2002)

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• Position pt for 15 minutes in modified PD
  position with affected lung uppermost (Stiller
  96 Unoki et al 2005 Hodgson 2000 Paratz 2002)

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Is it safe to use a recruitment maneuver?

• Check the cardiovascular stability Berney 02
  Paratz 06
• MAP gt 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

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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

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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

YES
NO
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• Develop a patient specific mobility plan (refer
  to mobility algorithm)
• Suction of patient based on best practice suction

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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)
• RECOMMENDATION 3 (MHI)

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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
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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
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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
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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)

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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

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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).

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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

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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)

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Suction Procedure

• Refer to Best Practice suction
• RECOMMENDATION 2 (VAP)
• RECOMMENDATION 2 (AIRWAY CLEARANCE)

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