Ventilatory Strategy for Patients with the Acute Respiratory Distress Syndrome (ARDS) as Proposed by the ARDS Network

Ventilatory Strategy for Patients with the Acute Respiratory Distress Syndrome (ARDS) as Proposed by the ARDS Network - Flowchart Acute Respiratory Distress Syndrome Acute Respiratory Distress Syndrome

«Flowchart»

Ventilatory Strategy for Patients With ARDS^*

Ventilatory Strategy for Patients With ARDS^* ^* ^*

Goal 1: Low Vt /P_plat

Initiation:

Calculate PBW

Male: 50 + 2. 3 (height [inches] – 60)
Female: 45.5 + 2.3 (height [inches] – 60)

Initiate volume assist control

start with 8 mL/kg, and to 6 mL/kg over a few hours

Goal 1: Low Vt /P_plat

Goal 1: Low Vt /P_plat _plat

Initiation:

Calculate PBW

Male: 50 + 2. 3 (height [inches] – 60)
Female: 45.5 + 2.3 (height [inches] – 60)

Initiate volume assist control

start with 8 mL/kg, and to 6 mL/kg over a few hours

Calculate PBW

Male: 50 + 2. 3 (height [inches] – 60)
Female: 45.5 + 2.3 (height [inches] – 60)

Male: 50 + 2. 3 (height [inches] – 60)
Female: 45.5 + 2.3 (height [inches] – 60)
Initiate volume assist control

start with 8 mL/kg, and to 6 mL/kg over a few hours

start with 8 mL/kg, and to 6 mL/kg over a few hours Goal 1

Goal 2: Adequate Oxygenation

Specific goal:

PaO₂ 55-80 mm Hg
or
SpO₂ 88-95%
Use only FIO₂ /PEEP combinations shown below to achieve this target

if oxygenation is low, choose FIO₂ /PEEP combination (from FIO₂ /PEEP table) to the right
if oxygenation is high, choose FIO₂ /PEEP combination to the left

Goal 2: Adequate Oxygenation

Specific goal:

PaO₂ 55-80 mm Hg
or
SpO₂ 88-95%
Use only FIO₂ /PEEP combinations shown below to achieve this target

if oxygenation is low, choose FIO₂ /PEEP combination (from FIO₂ /PEEP table) to the right
if oxygenation is high, choose FIO₂ /PEEP combination to the left

PaO₂ 55-80 mm Hg
or ₂

SpO₂ 88-95% ₂
Use only FIO₂ /PEEP combinations shown below to achieve this target IO₂ ₂

if oxygenation is low, choose FIO₂ /PEEP combination (from FIO₂ /PEEP table) to the right
if oxygenation is high, choose FIO₂ /PEEP combination to the left

if oxygenation is low, choose FIO₂ /PEEP combination (from FIO₂ /PEEP table) to the right IO₂ ₂ IO₂ ₂
if oxygenation is high, choose FIO₂ /PEEP combination to the left IO₂ ₂ Goal 2

Goal 3: Arterial pH

Goal:

pH: 7.30–7.45

Acidosis algorithm

If pH 7.15–7.30

set rate until pH >7.30 or PaCO2 < 25 mm Hg (max RR = 35)
if RR = 35 & pH < 7.30 NaHCO3 may be given

If pH <7.15

set RR to 35
if set RR = 35 & pH <7.15, Vt may be in 1 mL/kg steps until pH >7.15 (P_plat target may be exceeded)

Alkalosis algorithm

If pH >7.45

set RR until patient RR > set RR (minimum set RR = 6/min)

Goal 3: Arterial pH

Goal:

Goal

pH: 7.30–7.45

Acidosis algorithm

If pH 7.15–7.30

set rate until pH >7.30 or PaCO2 < 25 mm Hg (max RR = 35)
if RR = 35 & pH < 7.30 NaHCO3 may be given

If pH <7.15

set RR to 35
if set RR = 35 & pH <7.15, Vt may be in 1 mL/kg steps until pH >7.15 (P_plat target may be exceeded)

Alkalosis algorithm

If pH >7.45

set RR until patient RR > set RR (minimum set RR = 6/min)

pH: 7.30–7.45

Acidosis algorithm

If pH 7.15–7.30

set rate until pH >7.30 or PaCO2 < 25 mm Hg (max RR = 35)
if RR = 35 & pH < 7.30 NaHCO3 may be given

If pH <7.15

set RR to 35
if set RR = 35 & pH <7.15, Vt may be in 1 mL/kg steps until pH >7.15 (P_plat target may be exceeded)

Alkalosis algorithm

If pH >7.45

set RR until patient RR > set RR (minimum set RR = 6/min)

Acidosis algorithm

If pH 7.15–7.30

set rate until pH >7.30 or PaCO2 < 25 mm Hg (max RR = 35)
if RR = 35 & pH < 7.30 NaHCO3 may be given

If pH <7.15

set RR to 35
if set RR = 35 & pH <7.15, Vt may be in 1 mL/kg steps until pH >7.15 (P_plat target may be exceeded)

If pH 7.15–7.30

set rate until pH >7.30 or PaCO2 < 25 mm Hg (max RR = 35)
if RR = 35 & pH < 7.30 NaHCO3 may be given

set rate until pH >7.30 or PaCO2 < 25 mm Hg (max RR = 35)
if RR = 35 & pH < 7.30 NaHCO3 may be given
If pH <7.15

set RR to 35
if set RR = 35 & pH <7.15, Vt may be in 1 mL/kg steps until pH >7.15 (P_plat target may be exceeded)

set RR to 35
if set RR = 35 & pH <7.15, Vt may be in 1 mL/kg steps until pH >7.15 (P_plat target may be exceeded) P_plat target may be exceeded _plat
Alkalosis algorithm

If pH >7.45

set RR until patient RR > set RR (minimum set RR = 6/min)

If pH >7.45

set RR until patient RR > set RR (minimum set RR = 6/min)

set RR until patient RR > set RR (minimum set RR = 6/min) minimum set RR = 6/min Goal 3

End

Keep P_plat (based on 0.5-sec pause) <35 cm H₂O

If P_plat >30 cm H₂O, Vt by 1 mL/kg to 5 or 4 mL/kg
If P_plat <25 AND Vt <6 mL/kg, Vt by 1 mL/kg until P_plat >25 cm H₂O OR Vt = 6 mL/kg
If patient severely distressed and/or breath stacking, consider Vt to 7 or 8 mL/kg, as long as P_plat 30 cm H₂O^†

Keep P_plat (based on 0.5-sec pause) <35 cm H₂O

_plat ₂

If P_plat >30 cm H₂O, Vt by 1 mL/kg to 5 or 4 mL/kg _plat ₂
If P_plat <25 AND Vt <6 mL/kg, Vt by 1 mL/kg until P_plat >25 cm H₂O OR Vt = 6 mL/kg _plat _plat ₂
If patient severely distressed and/or breath stacking, consider Vt to 7 or 8 mL/kg, as long as P_plat 30 cm H₂O^† _plat ₂ ^† ^†

^*Based on ARDS Network Algorithm

^†If compliance of the chest wall is markedly decreased (e.g., massive ascites), it may be reasonable or necessary (if the patient is very hypoxemic) to allow a P_plat >30 cm H₂O.

^† _plat ₂

FIO₂/PEEP Table

FIO₂	0.3	0.4	0.4	0.5	0.5	0.6	0.7	0.7	0.7	0.8	0.9	0.9	0.9	1.0
PEEP	5	5	8	8	10	10	10	12	14	14	14	16	18	18–24

FIO₂/PEEP Table

FIO₂	0.3	0.4	0.4	0.5	0.5	0.6	0.7	0.7	0.7	0.8	0.9	0.9	0.9	1.0
PEEP	5	5	8	8	10	10	10	12	14	14	14	16	18	18–24

FIO₂/PEEP Table

FIO₂/PEEP Table IO ₂

FIO₂	0.3	0.4	0.4	0.5	0.5	0.6	0.7	0.7	0.7	0.8	0.9	0.9	0.9	1.0
PEEP	5	5	8	8	10	10	10	12	14	14	14	16	18	18–24

FIO₂0.30.40.40.50.50.60.70.70.70.80.90.90.91.0 FIO₂ IO ₂ 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0 PEEP558810101012141414161818–24 PEEP 5 5 8 8 10 10 10 12 14 14 14 16 18 18–24