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Estrategia de pulmón abierto Estrategia de pulmón abierto Presentation Transcript

  • Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares
    Edgar Jiménez, MD, FCCM
    Director – UCI y Co-Chairman Medicina Crítica
    Orlando Regional Medical Center
    Profesor Asociado de Medicina
    University of Florida, Florida StateUniversity & University of Central Florida
    Presidente
    Federación Mundial de Sociedades de Medicina Crítica
    2º Seminario de Ventilación Mecánica - VAFO
    Asociación Panameña de Medicina Crítica y Terapia Intensiva
    Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011
  • Estrategia de “Pulmón Abierto” UtilizandoPresionesTranspulmonares
    Edgar Jiménez, MD, FCCM
    Director – UCI y Co-Chairman Medicina Crítica
    Orlando Regional Medical Center
    Profesor Asociado de Medicina
    University of Florida, Florida StateUniversity & University of Central Florida
    Presidente
    Federación Mundial de Sociedades de Medicina Crítica
    2º Seminario de Ventilación Mecánica - VAFO
    Asociación Panameña de Medicina Crítica y Terapia Intensiva
    Hospital Santo Tomás, Ciudad de Panamá, Julio de 2011
  • View slide
  • View slide
  • Disclosures
    Research:
    NASA
    CareFusion®
    CCCTG & CIHR
  • Objectives
    Using in vivovideomicroscopy will demonstrate the anatomical, physiological and pathophysiological findings of:
    Normal lungs
    Acutely injured lungs
    Lung recruitment using Ptp
    Intra-abdominal hypertension
  • Fantastic Voyage
    1966
    “Oscar” for Special Effects
    Isaac Azimov
    Richard Fleischer
    Raquel Welch
  • Raquel Welch
  • Real-life“Fantastic Voyager”
    Gary Nieman, BA
    Director:
    Critical Care Translational Research Laboratory
    ORMC, Orlando, FL
    Cardiopulmonary and Critical Care Laboratory
    SUNY, Syracuse, NY
  • Labs in Syracuse, NYand Orlando, FL
  • How come?
    In vivovideomicroscopy
    Concept of RACE:
    Repetitive alveolar closing and expansion
  • Mechanisms of VILI
    Barotrauma
    Volutrauma
    Biotrauma
    Atelectrauma
  • Mechanisms of VILI
    Barotrauma
    Volutrauma
    Biotrauma
    Atelectrauma
  • To understand:abnormal alveolar mechanics
    We must first understand:
    normal alveolar mechanics
  • “The end”of the Bronchial Tree
  • F. Possmayer, PhD. U. of Western Ontario
  • Alveolar Duct
    F. Possmayer, PhD. U. of Western Ontario
  • F. Possmayer, PhD. U. of Western Ontario
  • How do we breathe?
  • Alveolar Duct
    Expiration
    Alveolar Duct
    Inspiration
    Weibel et al Respir Physiol 1985
  • Normal alveolar dynamics
    G Nieman, SUNY
  • G Nieman, SUNY
  • G Nieman, SUNY
  • G Nieman, SUNY
  • Alveoli:Not Just a Bunch of Grapes
    Prange H: Adv Physiol Educ 2003
  • Mead: JAP 1970
    Alveolar Independence
    Structural Support
    Honeycomb-like structural support
  • Hiroko & Nieman, SUNY 2005
  • Hiroko & Nieman, SUNY 2005
  • Hiroko & Nieman, SUNY 2005
  • Stressed alveolar sac
    G Nieman, SUNY
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • Strain
    G r a v i t y
    Stress
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Courtesy of Dr. Marcelo Amato
  • G r a v i t y
    Pendeluft
    Courtesy of Dr. Marcelo Amato
  • Stresses on the Epithelium during Fluid Displacement
    Bilek AM et al. J Appl Physiol 2003;94:770-783
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Rigid airway
    Courtesy of Dr. Marcelo Amato
  • Stresses on Epithelium during Airway Opening
    Bilek AM et al. J Appl Physiol 2003;94:770-783
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Flexible airway
    Courtesy of Dr. Marcelo Amato
  • Steinberg J.et al. Am J RespCrit Care Med2004
  • Steinberg et al. AJRCCM.2004;169:57-63
    Heterogeneous Lung Injury
    Injured lung:
    In vivo Microscopy
    Histology + IHC
    Normal lung: In vivo Microscopy
    Histology + IHC
  • Unstable Alveoli
    Stable Alveoli
    Low PEEP Group
    (3)
    Steinberg et al. AJRCCM.2004;169:57-63
  • Alveoli Stabilized
    With PEEP
    Stable Alveoli
    High PEEP Group
    (15)
    Steinberg et al. AJRCCM.2004;169:57-63
  • PEEP = improves oxygenation
  • PEEP = improves oxygenation
    It’s more than that!
  • PEEP = stabilizes alveoli
  • PEEP = decreases RACE
  • PEEP = decreases VILI
  • ARDSNet (NHLBI)
    NEJM, May – 2000
    10 University Centers
    Criteria:
    Bilateral infiltrates
    Intubation and mechanical ventilation
    PaO2/FiO2 <300
  • 28 Day Survival
    6 ml/kg
    12 ml/kg
    ARDSNetNEJM, 2000
  • Respiratory Cycle
    Ppeak
    Pplat
    Trigger
    PEEP
  • Initial table for FiO2 & PEEP
    ARDSNetNEJM, 2000
  • ARDSNet demonstrated:An outcome changeprimarily associated to achange in ventilatory strategy(LV)
  • A big question:
    Is the ARDS Net Protocol enough?
  • Not really
    We may not know the true transpulmonary pressure (Ptp)
    Timid and arbitrary PEEP scale
  • Meta-Analysis Based on
    ALVEOLI
    LOVS
    EXPRESS
    Briel, M. et al. JAMA 2010;303:865-873.
  • Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline
    Non-ARDS
    ARDS
    All Pts
    Briel, M. et al. JAMA 2010;303:865-873.
  • Clinical Outcomes in Patients Stratified by Presence of ARDS at Baseline
    Non-ARDS
    ARDS
    All Pts
    Briel, M. et al. JAMA 2010;303:865-873.
  • Optimized Lung Volume “Safe Window”
    Overdistension
    Edema fluid accumulation
    Surfactant degradation
    High oxygen exposure
    Mechanical disruption
    Derecruitment
    Atelectasis
    Inflammatory response
    Surfactant inhibition
    Local hypoxemia
    Compensatory overexpansion
    Zone of
    Overdistention
    Injury
    “Safe”
    Window
    Zone of
    Derecruitment
    and Atelectasis
    Volume
    Injury
    Pressure
    Froese: Crit Care Med 1997
  • CT 2
    CT 1
    CT 3
    Froese: Crit Care Med 1997
  • How do We Open the Lung and Keep it Open?
  • How do We Open the Lung and Keep it Open?
    Open:
    Recruitment maneuver
  • How do We Open the Lung and Keep it Open?
    Open:
    Recruitment maneuver
    Keep it open:
    PEEP or HFOV
  • Ware and MatthayNEJM 342 (18): 1334
  • Current Ventilation Practices
    Volume Ventilation, Low VT, PEEP
    Pressure Control Ventilation
     PEEP, Inverse I:E Ratio
    VCV or PCV with PEEP adjusted by Ptp
    Non-Conventional Ventilation
    APRV/Bi-Level
    HFOV
    Pronation, iNO
    ECMO
  • How do we know we have achieved OL-PEEP?
  • How do we do it?
    ARDS Net
    ALVEOLI, LOVS, EXPRESS
    Decremental PEEP Trial
    Pes and Ptp
    Volumetric Capnography
    Auscultation
    Ultrasound
    Respiratory Impedance Pletysmography
    Electrical Impedance Tomography
    HFOV - TOOLS
  • How do we do it?
    ARDS Net
    ALVEOLI, LOVS, EXPRESS
    Decremental PEEP Trial
    Pes and Ptp
    Volumetric Capnography
    Auscultation
    Ultrasound
    Respiratory Impedance Pletysmography
    Electrical Impedance Tomography
    HFOV - TOOLS
  • How do we do it?
    ARDS Net
    ALVEOLI, LOVS, EXPRESS
    Decremental PEEP Trial
    Pes and Ptp
    Volumetric Capnography
    Auscultation
    Ultrasound
    Respiratory Impedance Pletysmography
    Electrical Impedance Tomography
    HFOV - TOOLS
  • Can we do better?
  • Let’s talk about pressure…
  • Let’s talk about pressure…
    and the trumpet player
  • How much airway pressure can a trumpet player generate?
  • Trumpet player
    Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
  • Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
  • Bouhuys A: Physiology and musical instruments. Nature. 1969. 221:1199-1204
  • Cook. J Applied Phys. 1964. 1016
  • Cook. J Applied Phys. 1964. 1016
  • Answer: 100-120 cm H2O
    Cook. J Applied Phys. 1964. 1016
  • So…
    Why don’t we see more ALI and ARDS in these players?
  • Answer:
    Because they keep the Ptp within tolerable limits
  • Answer:
    Because they keep the Ptp within tolerable limits
    with
    the use of their respiratory muscles
  • Let’s go to extremes ofairway pressure
  • Paw at sea level:
  • Paw at sea level: 1034 cm H2O
  • Paw at a 33 ft dive:
  • Paw at a 33 ft dive: 2068 cm H2O
  • Paw at a 33 ft dive: 2068 cm H2O
    Add 1034 cm H2O for every 33 ft.
  • Paw at a 100 ft dive:
    Add 1034 cm H2O for every 33 ft.
  • Paw at a 100 ft dive: 4140 cm H2O
    Add 1034 cm H2O for every 33 ft.
  • So…
    Why don’t we see more ALI and ARDS in these divers?
  • Answer:
    Because they keep the Ptp within tolerable limits
  • Answer:
    Because they keep the Ptp within tolerable limits
    with
    a similar increase in the external environmental pressure
  • It’s all relative!
  • <0.5 MPH
  • 17,000 MPH
    <0.5 MPH
    17,000 MPH
  • 17,000 MPH
    Success!
  • What is the Paw at 10,000 ft?
  • What is the Paw at 10,000 ft?
    795 cm H2O
  • What is the Paw at 10,000 ft?
    795 cm H2O
    30% less
    than MSL
  • What is the Paw atMt. Everest’s summit?
  • What is the Paw atMt. Everest’s summit?
    285 cm H2O
  • What is the Paw atMt. Everest’s summit?
    285 cm H2O
    72% less
    than MSL
  • They can get in LOTS of trouble!
  • They can get in LOTS of trouble!
  • Management of ALI and ARDS using Transpulmonary Pressures
  • Management of ALI and ARDS usingTranspulmonarypressures
    Factorsthatmay alter currentrecomendationsbasedon↓Ccw:
    Obesity
    Edema/anasarca
    Intra-abdominal pressure
    Pregnancy
    Chestwalldeformities
    Scars
  • The problem???
    With Pplat, we are measuring only one side of the equation!!!!!
    What happens with patients with compromised compliances?
  • The problem???
    With Pplat, we are measuring only one side of the equation!!!!!
    What happens with patients with compromised compliances?
    We DON’T KNOW!
  • Intrathoracic pressures
    PROX. AIRWAY PRESSURE (Paw)
    TRACHEAL PRESSURE (Ptr)
    PLEURAL
    PRESSURE
    (Ppl)
    (Pes)
    ALVEOLAR PRESSURE
    (Palv)
  • Pplat
    PROX. AIRWAY PRESSURE (Paw)
    TRACHEAL PRESSURE (Ptr)
    PLEURAL
    PRESSURE
    (Ppl)
    (Pes)
    ALVEOLAR PRESSURE
    (Palv)
  • Ptp
    PROX. AIRWAY PRESSURE (Paw)
    TRACHEAL PRESSURE (Ptr)
    PLEURAL
    PRESSURE
    (Ppl)
    (Pes)
    ALVEOLAR PRESSURE
    (Palv)
  • Ptp
    PROX. AIRWAY PRESSURE (Paw)
    Pes
    TRACHEAL PRESSURE (Ptr)
    PLEURAL
    PRESSURE
    (Ppl)
    (Pes)
    ALVEOLAR PRESSURE
    (Palv)
  • Position of Esophagus and Pleura
  • Position of Esophagus and Pleura
  • Pplat and Ptp
    Kubiak, Jimenez, Silva, Nieman
    Marked variability among patients in abdominaland pleural pressures
    For a given PEEP, Ptp may vary unpredictably from patient to patient.
    Malbrain ML et al. Incidence and prognosis of intraabdominal hypertension in a mixed population of critically ill patients: a multiple-center epidemiological study.
    Crit Care Med 2005;33:315-322.
    Talmor D et al. Esophageal and transpulmonary pressures in acute respiratory failure. Crit Care Med 2006;34:1389-1394
  • Relationship Ptp - Tv
    Ptp
    (cm H2O)
    Tv(mL/kg)
    Talmor et al. Crit Care Med, 2006
  • Figure 1
    Increasing IAP
    Vt
    PEEP
    30
    25
    20
    15
    10
    5
    0
    0
    0
    Stage One
    Stage Two
    Kubiak, Jimenez, Nieman, J Surg Trials, 2010
  • Kubiak, Jimenez, Nieman, J Surg Trials, 2010
  • Kubiak, Jimenez, Nieman, J Surg Trials, 2010
  • Kubiak, Jimenez, Nieman, J Surg Trials, 2010
  • Jimenez, Nieman ORMC, 2008
  • Transpulmonary Pressure, Plateau (Ptp-plat)
    Increased Ptp :
    ↓ compliance
    ↑ negative Ppl
    Decreased Ptp :
    normal compliance
    not assisting on the ventilator
  • Intrathoracic pressures
    Tracheal pressures are measured at distal end of ET Tube
  • Ptr (Paw)
  • Esophageal Pressure Measurements
  • Connections
  • Connections
  • Connections
    Ptp
  • Esophageal Balloon
    • Placed in lower 1/3 of esophagus, above diaphragm
    • Measured pressures reflect pleural pressures
  • The Baydur Maneuver
    20
    10
    0
    -10
    -20
    20
    10
    0
    -10
    -20
    Paw
    cm H2O
    Pes
    Breath Initiation
  • Hypothesis
    Patients with↑ Pplwith conventional settings:
    Underinflation -> causeshypoxemia
    Raising PEEP to maintain a positive Ptp improves aeration and oxygenationwithout overdistention.
  • Hypothesis
    Patients with↓ Pplwith conventional settings:
    Maintaining low PEEP would keep low Ptp
    Prevents overdistention
    Minimizing adversehemodynamic effects of high PEEP
    Beyer J et al: The influence of PEEP ventilation on organ blood flow and peripheral oxygen delivery. Intensive Care Med 1982;8:75-80. 
  • Goal
    To provide sufficientPtp (Paw - Ppl)to:
    Maintain acceptable PaO2
    Minimize repeated alveolar collapse
    Minimize overdistention
    Ptp = Ptr – Pes
    Slutsky AS. Lung injury caused by mechanical ventilation. Chest 1999;116:Suppl:9S-15S. 
  • Methods
    Supine
    HOB 30º
    Esophageal balloon catheter passed to 60 cmfrom incisors
    Gentle compression of abdomen
    Thenwithdrawn to 40 cm
    Cardiac artifact
    1/3 couldn’t be passed into stomach
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Methods
    Recruitment maneuver
    40 cm H2O X 40 sec.
    Max Ptp-plat < 25 cm H2O
    VT: 6 mL/kg PBW
    PBW:
    ♂: 50 + 0.91 X (cm – 152.4)
    ♀: 45.5 + 0.91 X (cm – 152.4)
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Strategy
    PaO2: 55-120 mm Hg
    Or SpO2: 88-98 %
    pH: 7.30-7.45
    pCO2: 40-60 mm Hg
    VT: Adjusted to keep Ptp-plat < 25 cm H2O
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Stress-strain curve of healthy pigs
    Specific Lung
    Elastance
    5.8 cmH2O
    Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]
  • Protti A. et al. Am J RespirCrit Care Med. 2011 Feb 4. [Epub ahead of print]
  • Strategy
    PCV or VCV
    I:E : 1:1 to 1:3
    RR: < 35
    RM: PRN for suction/disconnection
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Table
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Table
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Study
    Stopped after 61 pts as criteria were met in interim analysis
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • PaO2/FiO2
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Respiratory System Compliance(mL/cm H2O)
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • VD/VT
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • PEEP
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Ptp - EE
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Ptp - PEEP
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Pplat
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Ptp – PLAT
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • Ptp – EI
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • K-M Survival
    Talmor D et al. Mechanical ventilation guided by esophageal pressure in acute lung injury. NEJM 2008; 359: 2095-2014
  • ARDSNetLung(ARMA)
    Jimenez E, Nieman G, ORMC 2011
  • Ptp Lung
    Jimenez E, Nieman G, ORMC 2011
  • Talmor presents:An improvement in oxygenation and compliance withPtp significantly lower thanoverestimated Pplat
  • Talmor presents:A persistent negative Ptp-PEEP when using the ARDS Net scale
  • A big question:
    Is this enough?
  • Not really
    Arbitrary PEEP scale
    We need to know how to adjust it better
    We need to find morbidity/mortality data
  • What else can we use?
  • Volumetric Capnography
  • Terminology
    End-Tidal CO2 (ETCO2)
    Peak concentration of CO2at end exhalation.
    Time-Based Capnography
    Concentration of CO2 plotted as a scale
    Volumetric Capnography
    Concentration of CO2 integrated with flow.
  • Zero baseline (A-B)
    End tidal value (D)
    Rapid, sharp rise (B-C)
    Rapid, sharp downstroke (D-E)
    Alveolar plateau (C-D)
  • Capnography Volumetric CO2
    EtCO2
    Capnogram
    RR
    CO2 Elimination
    Deadspace
    Alveolar Ventilation
    Cardiac Output / Perfusion
    Physiologic Vd/Vt
  • PEEP & VCO2
  • VCO2is
    CO2elimination from CO2production… …in a steady state!!!
  • Important questions for us:
    Is the pt OK with LVHP (ARDS Net)?
    Is the FiO2 > 0.60?
    Is your Pplat > 30 cm H2O?
    Is your Paw > 20 cm H2O?
    Is your Ptp plat> 20 cm H2O?
    PEEP > 15 cm H2O?
    OI > 15?
  • Important questions for us:
    Is the pt OK with LVHP (ARDS Net)?
    Is the FiO2 > 0.60?
    Is your Pplat > 30 cm H2O?
    Is your Paw > 20 cm H2O?
    Is your Ptp plat> 20 cm H2O?
    PEEP > 15 cm H2O?
    OI > 15?
  • What’s Next ????