ARDSnet

OXYGENATION GOAL: PaO2 55-80 mmHg or SpO2 88-95% Use a minimum PEEP of 5 cm H2O. Consider use of incremental FiO2/PEEP combinations such as shown below (not required) to achieve goal. Lower PEEP/higher FiO2 FiO2 0.3 0.4 0.4 PEEP 5 5 8 0.5 8 0.9 16 0.5 10 0.9 18 0.6 10 1.0 18-24 0.7 10 0.7 12

NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary

FiO2 PEEP

0.7 14

0.8 14

0.9 14

INCLUSION CRITERIA: Acute onset of 1. PaO2/FiO2 ≤ 300 (corrected for altitude) 2. Bilateral (patchy, diffuse, or homogeneous) infiltrates consistent with pulmonary edema 3. No clinical evidence of left atrial hypertension PART I: VENTILATOR SETUP AND ADJUSTMENT 1. Calculate predicted body weight (PBW) Males = 50 + 2.3 [height (inches) - 60] Females = 45.5 + 2.3 [height (inches) -60] 2. Select any ventilator mode 3. Set ventilator settings to achieve initial VT = 8 ml/kg PBW 4. Reduce VT by 1 ml/kg at intervals ≤ 2 hours until VT = 6ml/kg PBW. 5. Set initial rate to approximate baseline minute ventilation (not > 35 bpm). 6. Adjust VT and RR to achieve pH and plateau pressure goals below.

Higher PEEP/lower FiO2 FiO2 0.3 0.3 0.3 PEEP 5 8 10 FiO2 PEEP 0.5 18 0.5-0.8 20

0.3 12 0.8 22

0.3 14 0.9 22

0.4 14 1.0 22

0.4 16 1.0 24

0.5 16

__________________________________________________________ PLATEAU PRESSURE GOAL: ≤ 30 cm H2O Check Pplat (0.5 second inspiratory pause), at least q 4h and after each change in PEEP or VT. If Pplat > 30 cm H2O: decrease VT by 1ml/kg steps (minimum = 4 ml/kg). If Pplat < 25 cm H2O and VT< 6 ml/kg, increase VT by 1 ml/kg until Pplat > 25 cm H2O or VT = 6 ml/kg. If Pplat < 30 and breath stacking or dys-synchrony occurs: may increase VT in 1ml/kg increments to 7 or 8 ml/kg if Pplat remains < 30 cm H2O.

_____________________________________________________________ pH GOAL: 7.30-7.45 Acidosis Management: (pH < 7.30) If pH 7.15-7.30: Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR = 35). . If pH < 7.15: Increase RR to 35. If pH remains < 7.15, VT may be increased in 1 ml/kg steps until pH > 7.15 (Pplat target of 30 may be exceeded). May give NaHCO3 Alkalosis Management: (pH > 7.45) Decrease vent rate if possible. ______________________________________________________ I: E RATIO GOAL: Recommend that duration of inspiration be < duration of expiration. PART II: WEANING A. Conduct a SPONTANEOUS BREATHING TRIAL daily when: 1. FiO2 ≤ 0.40 and PEEP ≤ 8 OR FiO2 < 0.50 and PEEP < 5. 2. PEEP and FiO2 ≤ values of previous day. 3. Patient has acceptable spontaneous breathing efforts. (May decrease vent rate by 50% for 5 minutes to detect effort.) 4. Systolic BP ≥ 90 mmHg without vasopressor support. 5. No neuromuscular blocking agents or blockade.

B. SPONTANEOUS BREATHING TRIAL (SBT): If all above criteria are met and subject has been in the study for at least 12 hours, initiate a trial of UP TO 120 minutes of spontaneous breathing with FiO2 < 0.5 and PEEP < 5: 1. Place on T-piece, trach collar, or CPAP ≤ 5 cm H2O with PS < 5 2. Assess for tolerance as below for up to two hours. a. SpO2 ≥ 90: and/or PaO2 ≥ 60 mmHg b. Spontaneous VT ≥ 4 ml/kg PBW c. RR ≤ 35/min d. pH ≥ 7.3 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.

Definition of UNASSISTED BREATHING (Different from the spontaneous breathing criteria as PS is not allowed)
1. 2. 3. 4. Extubated with face mask, nasal prong oxygen, or room air, OR T-tube breathing, OR Tracheostomy mask breathing, OR CPAP less than or equal to 5 cm H20 without pressure support or IMV assistance.