Acute Lung Injury Ventilation Strategy

For patients suspected of being in Adult Respiratory Distress Syndrome (ARDS), you will want to implement the Acute Lung Injury Strategy.

What patients should be included in the ALI Strategy?

• PaO2/ FiO2 > 300
• Bilateral, patchy, difuse infiltratees on x-ray
• Non cardiogenic pulmonary edema
• No evidence of left atrial hypertension

Ventilator set-up:

• Tital Volume: 6-10cc/kg ideal body weight
• Select any mode

Static (Plateau) pressure goal:

• Check after each change in PEEP or Static Pressure
• If greater than 30 decrease Vt by one until Static Pressure less than 30
• If less than 25 and Vt less than 6 ml/kg idw, increase Vt by 1 until static pressure is 25 or Vt is at least 6 ml/kg ibw
• If less than 30 and breath stacking, increase Vt in increments of 1 until Static is greater than 25 or Vt greater than 6ml/kg ibw.

pH Goal: Goal 7.30 to 7.45

A. Acidosis Management: pH 7.15-7.30

• pH less than 7.30 = increase rate until pH greater than 7.30 or pCO2 less than 25
• Maximum set rate is 35

B. Acidosis Management: pH less than 7.15 = increase rate to 35

• If pH remains less than 7.15, Vt may be increased in 1 ml/kg steps until pH greater than 7.15.
• Static Pressure limit of 30 may be exceeded

C. Alkalosis Management: pH greater than 7.45 = decrease rate if possible

Oxygenation Strategy: Goal PO2 55-80 and SpO2 88-95%

A. Lower PEEP higher FiO2 Strategy:

• FiO2 30% = PEEP 5
• FiO2 40% = PEEP 5-8
• FiO2 50% = PEEP 8-10
• FiO2 60% = PEEP 10
• FiO2 70% = PEEP 10-14
• FiO2 80% = PEEP 14
• FiO2 90% = PEEP 14-18
• FiO2 100% = PEEP 18-24

B. Higher PEEP lower FiO2 strategy:

• FiO2 30% = PEEP 5-14
• FiO2 40% = PEEP 14-16
• FiO2 50% = PEEP 16-18
• FiO2 60-80% = PEEP 20-22
• FiO2 90% = PEEP 22
• FiO2 100% = PEEP 22-24

Follow the daily extubation protocol, however add the following adjustments:

A patient meets weening criteria when:

• FiO2 less than 40 and PEEP less than 8
• PEEP and FiO2 are lower than the previous day
• Acceptable spontaneous breathing efforts
• Systolic Blood Pressure greater than 90
• No neuromuscular blocking agents on board

The above information was obtained from ardsnet.org