Pacific NW RegionalPacific NW Regional
Respiratory CareRespiratory Care
ConferenceConference
Clinical Uses of the Open Lun...
What is a Recruitment Maneuver?What is a Recruitment Maneuver?
A Recruitment Maneuver is aA Recruitment Maneuver is a
proc...
Why is Recruitment done?Why is Recruitment done?
 Recruitment maneuvers are performed toRecruitment maneuvers are perform...
Patient SelectionPatient Selection
 Primarily on patients with ARDS/ALIPrimarily on patients with ARDS/ALI
• ARDS - (PaO2...
Patient SelectionPatient Selection
 Also in non-ARDS patients.Also in non-ARDS patients.
• *Patients with Alveolar Collap...
Types of ARDSTypes of ARDS
 Direct (Pulmonary/Primary)-HardDirect (Pulmonary/Primary)-Hard
• Effects lung parenchymaEffec...
Three Compartments of ARDSThree Compartments of ARDS
 1.1. Aerated normal lung susceptible toAerated normal lung suscepti...
Adult ARDSAdult ARDS
Lung Protective Strategy PatientsLung Protective Strategy Patients
 ARDSNet StudyARDSNet Study
• 6 ml/Kg IBW6 ml/Kg IBW
•...
Different Ways to Recruit the LungDifferent Ways to Recruit the Lung
 Use of high CPAP for short periods ofUse of high CP...
Pressure Control with PEEPPressure Control with PEEP
 Am J Respir Crit Care Med Vol 167. pp 1620-Am J Respir Crit Care Me...
Injured Alveoli w/ InsufficientInjured Alveoli w/ Insufficient
Amounts of PEEPAmounts of PEEP
Injured Alveoli w/ SufficientInjured Alveoli w/ Sufficient
Amounts of PEEPAmounts of PEEP
PEEP UsagePEEP Usage
 Study by A. Estaban. AJRCCM 2000;161:Study by A. Estaban. AJRCCM 2000;161:
1450-14581450-1458
• PEE...
How do you know it worked?How do you know it worked?
 Improvements in oxygenation.Improvements in oxygenation.
• A 20% ch...
How do you know it worked?How do you know it worked?
 Lower Plateau Pressure for the sameLower Plateau Pressure for the s...
Potential ProblemsPotential Problems
 Hemodynamic instabilityHemodynamic instability
• Increased Pleural pressures may ad...
Oxygenation
Sutter Roseville Medical CenterSutter Roseville Medical Center
 230 bed, Level 2 Trauma Hospital.230 bed, Level 2 Trauma ...
SRMC ProtocolSRMC Protocol
 PURPOSE:PURPOSE:
 To provide safety and effectiveness guidelines for the use of the Open Lun...
SRMC ProtocolSRMC Protocol
 Calculate patient Ideal Body Weight using the following formulas:Calculate patient Ideal Body...
SRMC ProtocolSRMC Protocol
 Decrease PC level until a calculated tidal volume of 6 – 8 cc/kg is achieved. Wait 3 to 4Decr...
8 step open lung picture8 step open lung picture
Sutter Roseville Medical CenterSutter Roseville Medical Center
SRMCSRMC
RESPIRATORYRESPIRATORY
THERAPISTSTHERAPISTS
ROCK!!...
John Doe Case StudyJohn Doe Case Study
Day OneDay One
 36 year old male involved in a Auto36 year old male involved in a ...
John Doe Case StudyJohn Doe Case Study
Day OneDay One
 X-ray obtained and showed a Right Main StemX-ray obtained and show...
John Doe Case StudyJohn Doe Case Study
Day OneDay One
 JD was being treated for HemorrhagicJD was being treated for Hemor...
John Doe Case StudyJohn Doe Case Study
Day OneDay One
 JD was admitted to the Trauma ICU.JD was admitted to the Trauma IC...
John Doe Case StudyJohn Doe Case Study
Day ThreeDay Three
Oh yea, we are dealing withOh yea, we are dealing with
Trauma Do...
John Doe Case StudyJohn Doe Case Study
Day ThreeDay Three
 JD was stable for two days then the picture turned toward aJD ...
John Doe Case StudyJohn Doe Case Study
Day ThreeDay Three
 RTs & OLT to the Rescue!RTs & OLT to the Rescue!
 The respira...
John Doe Case StudyJohn Doe Case Study
Day ThreeDay Three
 Remember your “Categorizations of ARDS”. ThisRemember your “Ca...
Open Lung Tool On JDOpen Lung Tool On JD
 Here we go!Here we go!
 RTs checked the orders, identified the patient,RTs che...
Open Lung Tool On JDOpen Lung Tool On JD
 We started at a PEEP of 18 cmH2O and a PC of 22We started at a PEEP of 18 cmH2O...
Open Lung Tool On JDOpen Lung Tool On JD
 Since we just collapsed his lungs, weSince we just collapsed his lungs, we
imme...
Open Lung Tool On JDOpen Lung Tool On JD
 The Post-Open Lung Tool X-ray readingThe Post-Open Lung Tool X-ray reading
was ...
Recruitment ManeuverRecruitment Maneuver
8 step open lung picture8 step open lung picture
Case Study #1Case Study #1
 53 year old female that came to53 year old female that came to
Sutter Roseville Medical Cente...
Case Study #1Case Study #1
 Her X-ray revealed focal densities onHer X-ray revealed focal densities on
the right side and...
X-ray from ER admitX-ray from ER admit
Case Study #1Case Study #1
 The Patient was on a FiO2 of 65% with a PaO2 ofThe Patient was on a FiO2 of 65% with a PaO2 o...
X-Ray after first ManeuverX-Ray after first Maneuver
Case Study #1Case Study #1
 The patient’s PaO2 went up to 239mmHgThe patient’s PaO2 went up to 239mmHg
after the maneuver...
Case Study #1Case Study #1
OPEN LUNG TOOL SCREENOPEN LUNG TOOL SCREEN
Sutter Roseville Medical CenterSutter Roseville Medical Center
SRMCSRMC
RESPIRATORY THERAPISTSRESPIRATORY THERAPISTS
ROCK!...
Case Study #2Case Study #2
 19 year old female in a head on collision.19 year old female in a head on collision.
She had ...
Case Study #2Case Study #2
Case Study #2Case Study #2
 Patient needed to go through surgeryPatient needed to go through surgery
first, so a low tida...
Case Study #2Case Study #2
Case Study #2Case Study #2
 The patient wasThe patient was
taken back to dotaken back to do
her last surgeryher last surg...
Case Study #2Case Study #2
 The RTs knew thatThe RTs knew that
the Open Lungthe Open Lung
could reverse thecould reverse ...
Case Study #2Case Study #2
 The RTs were very happy to see herThe RTs were very happy to see her
turn and their confidenc...
Sutter Roseville Medical CenterSutter Roseville Medical Center
SRMCSRMC
RESPIRATORY THERAPISTSRESPIRATORY THERAPISTS
ROCK!...
Case Study #3Case Study #3
 43 year old male43 year old male
that came in forthat came in for
fever andfever and
Pneumoni...
Case Study #3Case Study #3
 The patient wasThe patient was
admitted to ouradmitted to our
floor for care andfloor for car...
Case Study #3Case Study #3
 The patientThe patient
continued downcontinued down
the slippery slopethe slippery slope
and ...
Case Study #3Case Study #3
 The patient’s PaO2 was 47.9mmHg whenThe patient’s PaO2 was 47.9mmHg when
the RTs finally got ...
Case Study #3Case Study #3
 Here is the X-RayHere is the X-Ray
after theafter the
Maneuver.Maneuver.
 This was followedT...
Case Study #3Case Study #3
Sutter Roseville Medical CenterSutter Roseville Medical Center
SRMCSRMC
RESPIRATORY THERAPISTSRESPIRATORY THERAPISTS
ROCK!...
What have we learned doing all ourWhat have we learned doing all our
Open Lung Tool maneuvers?Open Lung Tool maneuvers?
 ...
What have we learned doing all ourWhat have we learned doing all our
Open Lung Tool maneuvers?Open Lung Tool maneuvers?
 ...
What have we learned doing all ourWhat have we learned doing all our
Open Lung Tool maneuvers?Open Lung Tool maneuvers?
 ...
Recruitment ManeuverRecruitment Maneuver
8 step open lung picture8 step open lung picture
Sutter Roseville Medical CenterSutter Roseville Medical Center
SRMCSRMC
RESPIRATORYRESPIRATORY
THERAPISTSTHERAPISTS
ROCK!!...
Tahoe Critical Care Conference
Tahoe Critical Care Conference
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Tahoe Critical Care Conference

  1. 1. Pacific NW RegionalPacific NW Regional Respiratory CareRespiratory Care ConferenceConference Clinical Uses of the Open LungClinical Uses of the Open Lung Tool inTool in Lung RecruitmentLung Recruitment Mark A. MartinezMark A. Martinez Cardiopulmonary EducatorCardiopulmonary Educator Sutter Roseville Medical CenterSutter Roseville Medical Center
  2. 2. What is a Recruitment Maneuver?What is a Recruitment Maneuver? A Recruitment Maneuver is aA Recruitment Maneuver is a procedure where a sustained positiveprocedure where a sustained positive pressure is applied, to an injuredpressure is applied, to an injured lung, over an increment of time, tolung, over an increment of time, to recruit, open and keep open closedrecruit, open and keep open closed alveoli.alveoli.
  3. 3. Why is Recruitment done?Why is Recruitment done?  Recruitment maneuvers are performed toRecruitment maneuvers are performed to help improve oxygenation, help improvehelp improve oxygenation, help improve distribution of ventilation, and improvedistribution of ventilation, and improve shunts.shunts.  To try and determine the “Optimal PEEP”To try and determine the “Optimal PEEP” to keep the lung from dynamic collapseto keep the lung from dynamic collapse and alveolar de-recruitment.and alveolar de-recruitment.  *It is also done to re-recruit the lungs*It is also done to re-recruit the lungs once there has been a break in theonce there has been a break in the ventilation circuit.*ventilation circuit.*
  4. 4. Patient SelectionPatient Selection  Primarily on patients with ARDS/ALIPrimarily on patients with ARDS/ALI • ARDS - (PaO2/FIO2 <200) w/ bilateralARDS - (PaO2/FIO2 <200) w/ bilateral infiltrates on x-ray.infiltrates on x-ray. • ALI – (PaO2/FIO2 <300)ALI – (PaO2/FIO2 <300)  Patients inPatients in early phaseearly phase ARDS, before theARDS, before the onset of fibro-proliferation.onset of fibro-proliferation.  Ventilator Induced Lung Injury patients.Ventilator Induced Lung Injury patients.  Patients that are having troublePatients that are having trouble oxygenating due to the shunting causedoxygenating due to the shunting caused by the injured lung.by the injured lung.
  5. 5. Patient SelectionPatient Selection  Also in non-ARDS patients.Also in non-ARDS patients. • *Patients with Alveolar Collapse.*Patients with Alveolar Collapse. • *Patients with Overnight turn lung*Patients with Overnight turn lung status.status. • Patients with consistent Atelectasis.Patients with consistent Atelectasis.
  6. 6. Types of ARDSTypes of ARDS  Direct (Pulmonary/Primary)-HardDirect (Pulmonary/Primary)-Hard • Effects lung parenchymaEffects lung parenchyma  PneumoniaPneumonia  AspirationAspiration  Lungs are primarily consolidatedLungs are primarily consolidated  Inhalation InjuryInhalation Injury  Lung ContusionLung Contusion  Near DrownNear Drown  Indirect (Extra-Pulmonary/Secondary)Indirect (Extra-Pulmonary/Secondary) • Due to Acute Systemic Inflammatory ResponseDue to Acute Systemic Inflammatory Response  SepsisSepsis  TraumaTrauma  Acute PancreatitisAcute Pancreatitis  Alveolar collapseAlveolar collapse  Drug OverdoseDrug Overdose
  7. 7. Three Compartments of ARDSThree Compartments of ARDS  1.1. Aerated normal lung susceptible toAerated normal lung susceptible to barotrauma induced by inappropriatebarotrauma induced by inappropriate ventilation. Usually located in theventilation. Usually located in the nondependent regions.nondependent regions.  2.2. Areas that are collapsed due toAreas that are collapsed due to interstitial infiltration and are potentiallyinterstitial infiltration and are potentially recruitable.recruitable.  3.3. Airspaces that are filled with exudatesAirspaces that are filled with exudates and not recruitable lung. Usually in theand not recruitable lung. Usually in the dependant lung regions.dependant lung regions.
  8. 8. Adult ARDSAdult ARDS
  9. 9. Lung Protective Strategy PatientsLung Protective Strategy Patients  ARDSNet StudyARDSNet Study • 6 ml/Kg IBW6 ml/Kg IBW • RR up to 35 to maintain a pH > 7.30, then HCO3 if <7.15RR up to 35 to maintain a pH > 7.30, then HCO3 if <7.15 • Plateau Pressure < 30 cm H2OPlateau Pressure < 30 cm H2O • Oxygenation Saturation 88 – 95%Oxygenation Saturation 88 – 95% • PEEP/FIO2 AlgorithmPEEP/FIO2 Algorithm  FIO2FIO2 .3-.4.3-.4 .4-.5.4-.5 .5-.7.5-.7 .7-.8.7-.8 .9.9 1.01.0  PEEPPEEP 55 8-108-10 10-1210-12 12-1412-14 16-1816-18 20-2420-24  Reduces lung inflammation, improves oxygenation andReduces lung inflammation, improves oxygenation and gas distribution, prevents destruction of lung withgas distribution, prevents destruction of lung with repetitive opening and closing of the alveoli.repetitive opening and closing of the alveoli. But…But…mostmost don’t follow the whole protocol!don’t follow the whole protocol!  We have observed that Low Tidal Volume Ventilation…We have observed that Low Tidal Volume Ventilation… without sufficient amounts of PEEP….can cause alveolarwithout sufficient amounts of PEEP….can cause alveolar de-recruitment.de-recruitment.
  10. 10. Different Ways to Recruit the LungDifferent Ways to Recruit the Lung  Use of high CPAP for short periods ofUse of high CPAP for short periods of time. 40/40 ruletime. 40/40 rule  Increased levels of PEEP - arbitraryIncreased levels of PEEP - arbitrary  Sustained inflation maneuversSustained inflation maneuvers  Sigh breathsSigh breaths  Optimal PEEP studyOptimal PEEP study
  11. 11. Pressure Control with PEEPPressure Control with PEEP  Am J Respir Crit Care Med Vol 167. pp 1620-Am J Respir Crit Care Med Vol 167. pp 1620- 1626, 2003. Neiman. (pigs)1626, 2003. Neiman. (pigs)  Peak pressure of 45 cm H2O with a PEEP of 35Peak pressure of 45 cm H2O with a PEEP of 35 cm H2O for 1 minute.cm H2O for 1 minute.  After the Recruitment, he applied either 5 cmH2OAfter the Recruitment, he applied either 5 cmH2O or 10 cmH2O to see which PEEP level createdor 10 cmH2O to see which PEEP level created more stability for the previously collapsed alveoli.more stability for the previously collapsed alveoli.  5 cmH2O of PEEP showed significant instability5 cmH2O of PEEP showed significant instability and the 10 cmH2O of PEEP were stable.and the 10 cmH2O of PEEP were stable.  Concluded that after Recruitment maneuvers,Concluded that after Recruitment maneuvers, inadequate amounts of PEEP permits unstableinadequate amounts of PEEP permits unstable alveoli and may result in ventilator-induced lungalveoli and may result in ventilator-induced lung injury despite improved oxygenation.injury despite improved oxygenation.
  12. 12. Injured Alveoli w/ InsufficientInjured Alveoli w/ Insufficient Amounts of PEEPAmounts of PEEP
  13. 13. Injured Alveoli w/ SufficientInjured Alveoli w/ Sufficient Amounts of PEEPAmounts of PEEP
  14. 14. PEEP UsagePEEP Usage  Study by A. Estaban. AJRCCM 2000;161:Study by A. Estaban. AJRCCM 2000;161: 1450-14581450-1458 • PEEP usage in ICUsPEEP usage in ICUs  31% of patients were on ZERO PEEP.31% of patients were on ZERO PEEP.  47% were on 1-5 cmH2O47% were on 1-5 cmH2O  18% were on 6-10 cmH2O18% were on 6-10 cmH2O  3% were on 11-15 cmH2O3% were on 11-15 cmH2O  0.2% were on greater than 15 cmH2O0.2% were on greater than 15 cmH2O
  15. 15. How do you know it worked?How do you know it worked?  Improvements in oxygenation.Improvements in oxygenation. • A 20% change or greater in PaO2/FIO2A 20% change or greater in PaO2/FIO2  Improvements in intrapulmonaryImprovements in intrapulmonary shunting.shunting.  Improvements in lung mechanics.Improvements in lung mechanics.  Greater Tidal Volume for sameGreater Tidal Volume for same pressure in (PC).pressure in (PC).  Same Tidal Volume at less pressureSame Tidal Volume at less pressure in (VC).in (VC).
  16. 16. How do you know it worked?How do you know it worked?  Lower Plateau Pressure for the sameLower Plateau Pressure for the same Vt after a RM has been applied.Vt after a RM has been applied.  *Best after disconnection from*Best after disconnection from ventilator or post suctioning.ventilator or post suctioning.  *Rapidly counters the prolonged*Rapidly counters the prolonged drop in PaO2 post suction.drop in PaO2 post suction.
  17. 17. Potential ProblemsPotential Problems  Hemodynamic instabilityHemodynamic instability • Increased Pleural pressures may adversely effectIncreased Pleural pressures may adversely effect pulmonary vascular resistance and cardiac filling orpulmonary vascular resistance and cardiac filling or performance.performance. • Cardiac Output decreases more profoundly in patientsCardiac Output decreases more profoundly in patients with pneumonia.with pneumonia.  Caution should be used.Caution should be used.  Decrease in OxygenationDecrease in Oxygenation  Cardiac arrhythmiasCardiac arrhythmias  PneumothoraxPneumothorax  Regional Alveolar OverdistentionRegional Alveolar Overdistention  Ideal patient is deeply sedated or paralyzed.Ideal patient is deeply sedated or paralyzed.  Not indicated for awake patients.Not indicated for awake patients.
  18. 18. Oxygenation
  19. 19. Sutter Roseville Medical CenterSutter Roseville Medical Center  230 bed, Level 2 Trauma Hospital.230 bed, Level 2 Trauma Hospital.  75 “Awesome” ICU trained therapists!75 “Awesome” ICU trained therapists!  4 ICUs (2 Trauma, Cardiac and Medical).4 ICUs (2 Trauma, Cardiac and Medical).  All Staff trained in the use of the OpenAll Staff trained in the use of the Open Lung Tool.Lung Tool.  Policy and Procedure in place for PhysicianPolicy and Procedure in place for Physician to order “Open Lung Tool (freq)”.to order “Open Lung Tool (freq)”.  When OLT ordered, *automaticWhen OLT ordered, *automatic abbreviated maneuver performed whenabbreviated maneuver performed when Circuit/PEEP is broken.Circuit/PEEP is broken.
  20. 20. SRMC ProtocolSRMC Protocol  PURPOSE:PURPOSE:  To provide safety and effectiveness guidelines for the use of the Open Lung Tool, toTo provide safety and effectiveness guidelines for the use of the Open Lung Tool, to optimize ventilation by recruiting alveoli with lung recruitment maneuvers, to establish anoptimize ventilation by recruiting alveoli with lung recruitment maneuvers, to establish an alveolar closing pressure, to re-open the lung, and to keep the lung open. The Open Lungalveolar closing pressure, to re-open the lung, and to keep the lung open. The Open Lung Tool protocol is a lung recruitment and best PEEP protocol.Tool protocol is a lung recruitment and best PEEP protocol.  SUPPORTIVE DATA:SUPPORTIVE DATA:  Studies show that Lung Recruitment maneuvers, with a sustained increase in airwayStudies show that Lung Recruitment maneuvers, with a sustained increase in airway pressure, can open collapsed alveoli. Combined with the addition of sufficient PEEP, topressure, can open collapsed alveoli. Combined with the addition of sufficient PEEP, to keep and maintain the alveoli open, the Lung Recruitment maneuvers may improvekeep and maintain the alveoli open, the Lung Recruitment maneuvers may improve outcomes in patients with ARDS. The Open Lung Tool, combined with Lung Protectiveoutcomes in patients with ARDS. The Open Lung Tool, combined with Lung Protective Ventilation Strategies, prevents destruction of the lung due to repetitive opening andVentilation Strategies, prevents destruction of the lung due to repetitive opening and closing of alveoli, reduces lung inflammation, and improves gas distribution andclosing of alveoli, reduces lung inflammation, and improves gas distribution and oxygenation.oxygenation.  POLICY:POLICY:  The Open Lung Tool will be utilized by trained Respiratory Care Practitioners who haveThe Open Lung Tool will be utilized by trained Respiratory Care Practitioners who have demonstrated competency. Upon physician order, the Respiratory Care Practitioners willdemonstrated competency. Upon physician order, the Respiratory Care Practitioners will strictly follow the procedure listed below.strictly follow the procedure listed below.  PROCEDURE:PROCEDURE:  Verify all orders for therapy on the physician order sheet of the patient’s medical record.Verify all orders for therapy on the physician order sheet of the patient’s medical record.  Check the patient's identification bracelet.Check the patient's identification bracelet.  A chest tube tray should be available.A chest tube tray should be available.  Obtain baseline ABG, if there has not been an ABG in the last 8 hours, note pre-therapyObtain baseline ABG, if there has not been an ABG in the last 8 hours, note pre-therapy hemodynamic values, verify with nursing staff that patient has stable values beforehemodynamic values, verify with nursing staff that patient has stable values before performing this procedure, and address any ICP issues at this time.performing this procedure, and address any ICP issues at this time.
  21. 21. SRMC ProtocolSRMC Protocol  Calculate patient Ideal Body Weight using the following formulas:Calculate patient Ideal Body Weight using the following formulas:  Male=50 + 2.3 [height (inches)-60] or 50 + 0.91 [height (cm) -152.4]Male=50 + 2.3 [height (inches)-60] or 50 + 0.91 [height (cm) -152.4]  Female=45.5 + 2.3 [height (inches)-60] or 45.5 + 0.91 [height (cm)Female=45.5 + 2.3 [height (inches)-60] or 45.5 + 0.91 [height (cm) -152.4]-152.4]  Calculate tidal volume for 6cc, 7cc and 8cc of Ideal Body Weight.Calculate tidal volume for 6cc, 7cc and 8cc of Ideal Body Weight.  Note PIP, Vt, Plateau pressure, EtCO2, Compliance, PEEP level andNote PIP, Vt, Plateau pressure, EtCO2, Compliance, PEEP level and SpO2.SpO2.  Change the ventilation mode to Pressure Control. Avoid any otherChange the ventilation mode to Pressure Control. Avoid any other changes to the ventilator settings i.e. FiO2 unless absolutely necessary.changes to the ventilator settings i.e. FiO2 unless absolutely necessary.  Go to Open Lung Tool Screen, adjust the “Breath” count scale at theGo to Open Lung Tool Screen, adjust the “Breath” count scale at the bottom right of the screen by pressing the (+) zoom key until the scalebottom right of the screen by pressing the (+) zoom key until the scale is 62 or 129 breaths.is 62 or 129 breaths.  Simultaneously raise the PEEP, above closing pressure, by increasingSimultaneously raise the PEEP, above closing pressure, by increasing PEEP gradually to 15 – 25 cm H2O, while decreasing the PC level at thePEEP gradually to 15 – 25 cm H2O, while decreasing the PC level at the same increments.same increments. Note:Note: Use PEEP levels 15-20 cm H2O for patients >Use PEEP levels 15-20 cm H2O for patients > 40 years of age that have preexisting lung conditions. Use PEEP levels40 years of age that have preexisting lung conditions. Use PEEP levels 20-25 cmH2O for patients < 40 years of age with no preexisting lung20-25 cmH2O for patients < 40 years of age with no preexisting lung conditions.conditions.  Raise the Pressure Control Level by increments of 5 cm H2O until a PIPRaise the Pressure Control Level by increments of 5 cm H2O until a PIP of 40 cm H2O is reached. Hold that PIP for 2 minutes to recruit theof 40 cm H2O is reached. Hold that PIP for 2 minutes to recruit the lung.lung. Note:Note: At the lowest PEEP level of 15 cm H2O, the PIP may needAt the lowest PEEP level of 15 cm H2O, the PIP may need to be greater than 40 cm H2O if a minimum Vt of 6cc per kg is notto be greater than 40 cm H2O if a minimum Vt of 6cc per kg is not achieved, if Vt is not above 8cc/Kg, or if patient’s Plateau pressures areachieved, if Vt is not above 8cc/Kg, or if patient’s Plateau pressures are high.high. Never go above PIP of 60 cm.Never go above PIP of 60 cm.  Maneuver should be stopped if patient becomesManeuver should be stopped if patient becomes hemodynamicallyhemodynamically unstable .unstable .
  22. 22. SRMC ProtocolSRMC Protocol  Decrease PC level until a calculated tidal volume of 6 – 8 cc/kg is achieved. Wait 3 to 4Decrease PC level until a calculated tidal volume of 6 – 8 cc/kg is achieved. Wait 3 to 4 breaths per change until the calculated tidal volume is achieved.breaths per change until the calculated tidal volume is achieved.  Decrease PEEP by 1 – 2 cm H2O, waiting 3 – 4 breaths per change, until alveolar collapse isDecrease PEEP by 1 – 2 cm H2O, waiting 3 – 4 breaths per change, until alveolar collapse is noted. Alveolar collapse is recognized as a large decrease in tidal volume with a smallnoted. Alveolar collapse is recognized as a large decrease in tidal volume with a small decrease in pressure level, a large decrease in dynamic characteristic on the C dyn wavedecrease in pressure level, a large decrease in dynamic characteristic on the C dyn wave form, or a downward spike in VtCO2. Use the cursor to note the PEEP level before collapse.form, or a downward spike in VtCO2. Use the cursor to note the PEEP level before collapse.  Increase the PEEP to pre-lung collapse level, plus 2 – 4 cm H2O.Increase the PEEP to pre-lung collapse level, plus 2 – 4 cm H2O.  Increase PC level by increments of 5 until a PIP of 40 cm H2O is achieved and hold for 2Increase PC level by increments of 5 until a PIP of 40 cm H2O is achieved and hold for 2 minutes to re-recruit the lung.minutes to re-recruit the lung.  Slowly decrease the PC level, waiting 3-4 breaths per change, until a calculated tidalSlowly decrease the PC level, waiting 3-4 breaths per change, until a calculated tidal volume of 6–8 cc/kg is achieved.volume of 6–8 cc/kg is achieved.  At this point, you should see the same, or slightly higher, tidal volume at a lowerAt this point, you should see the same, or slightly higher, tidal volume at a lower ventilating pressure, and an improved lung compliance.ventilating pressure, and an improved lung compliance.  Monitor the patient’s vital signs and ventilator function.Monitor the patient’s vital signs and ventilator function.  Document on the Continuous Ventilation Record. Documentation should include pre andDocument on the Continuous Ventilation Record. Documentation should include pre and post PIP, PEEP, Plateau pressure, VtCo2, compliance, vital signs, SpO2 and any otherpost PIP, PEEP, Plateau pressure, VtCo2, compliance, vital signs, SpO2 and any other pertinent hemodynamic values necessary.pertinent hemodynamic values necessary.  Switch patient back to original mode of ventilation and notify physician of the new PEEPSwitch patient back to original mode of ventilation and notify physician of the new PEEP level.level.  Monitor patient ABG’s as needed.Monitor patient ABG’s as needed.  This procedure may need to be repeated anytime there is a loss of PEEP or a ventilatorThis procedure may need to be repeated anytime there is a loss of PEEP or a ventilator disconnection.disconnection.  Care should be taken to clamp the ET tube to prevent lung collapse. If the patient has aCare should be taken to clamp the ET tube to prevent lung collapse. If the patient has a tracheostomy tube, a flex tube adapter will be added and clamped.tracheostomy tube, a flex tube adapter will be added and clamped.  A post procedure Chest X-ray, if indicated,A post procedure Chest X-ray, if indicated, maymay be obtained after the first Open Lungbe obtained after the first Open Lung maneuver to verify that no pneumothorax has been caused.maneuver to verify that no pneumothorax has been caused.
  23. 23. 8 step open lung picture8 step open lung picture
  24. 24. Sutter Roseville Medical CenterSutter Roseville Medical Center SRMCSRMC RESPIRATORYRESPIRATORY THERAPISTSTHERAPISTS ROCK!!!ROCK!!! So does Adam Morrison!So does Adam Morrison!
  25. 25. John Doe Case StudyJohn Doe Case Study Day OneDay One  36 year old male involved in a Auto36 year old male involved in a Auto vs. Tree accident….The Tree won.vs. Tree accident….The Tree won.  JD was awake at the scene,JD was awake at the scene, developed decreased mental status,developed decreased mental status, was intubated in the field, andwas intubated in the field, and airlifted to SRMC.airlifted to SRMC.  JD arrived at SRMC HypotensiveJD arrived at SRMC Hypotensive 90/38mmHg, HR 127, difficult to90/38mmHg, HR 127, difficult to obtained Pulse Ox, and Decreasedobtained Pulse Ox, and Decreased BS in the Left Lung Fields.BS in the Left Lung Fields.
  26. 26. John Doe Case StudyJohn Doe Case Study Day OneDay One  X-ray obtained and showed a Right Main StemX-ray obtained and showed a Right Main Stem Intubation, Left Atelectasis and lung volumesIntubation, Left Atelectasis and lung volumes very low.very low.  ABG pH 7.008, pCOABG pH 7.008, pCO22 43, HCO43, HCO33 10.3, sO10.3, sO22 78.9%,78.9%, Base deficit of -19.6, Hb 8.6, Lactate level 8.6.Base deficit of -19.6, Hb 8.6, Lactate level 8.6.  ETT pulled back 3 cm.ETT pulled back 3 cm.  Ultrasound revealed free fluid in the abdomen.Ultrasound revealed free fluid in the abdomen.  JD was transfused with packed cells, platelets.JD was transfused with packed cells, platelets.  JD was 250lbs. (114 Kg), moderately obese.JD was 250lbs. (114 Kg), moderately obese.
  27. 27. John Doe Case StudyJohn Doe Case Study Day OneDay One  JD was being treated for HemorrhagicJD was being treated for Hemorrhagic Shock, an Avulsion Fracture with Effusion,Shock, an Avulsion Fracture with Effusion, Blunt Head Injury, Abdominal Trauma,Blunt Head Injury, Abdominal Trauma, Acute Respiratory Distress, Orbital andAcute Respiratory Distress, Orbital and Maxillary/Mandible fractures.Maxillary/Mandible fractures.  JD went to surgery for a Transverse ColonJD went to surgery for a Transverse Colon resection, right Hemi-colonectomy, Ortho-resection, right Hemi-colonectomy, Ortho- surgery on his knee, an ICP monitor, andsurgery on his knee, an ICP monitor, and they delayed closing the granulatingthey delayed closing the granulating abdomen wound (packed open).abdomen wound (packed open).  Oh yea, they brought him out 15 litersOh yea, they brought him out 15 liters positive!positive!  History revealed Opiate drug dependency…History revealed Opiate drug dependency… why the tree won.why the tree won.
  28. 28. John Doe Case StudyJohn Doe Case Study Day OneDay One  JD was admitted to the Trauma ICU.JD was admitted to the Trauma ICU.  Initial vent setting on the ServoInitial vent setting on the Servo ii were: PRVC,were: PRVC, RR-20, Vt-850, PEEP-7 and FiORR-20, Vt-850, PEEP-7 and FiO22 100%.100%.  ABG: 7.39/25.2/142/15.2/98% on FiOABG: 7.39/25.2/142/15.2/98% on FiO22 100%100%  HCO3 was given.HCO3 was given.  Ventilator changed to RR-14, Vt-700, PEEP-5.Ventilator changed to RR-14, Vt-700, PEEP-5.  We then settled in for the night trying to keep JDWe then settled in for the night trying to keep JD stable.stable.  The ICU RTs tried to be proactive and suggestThe ICU RTs tried to be proactive and suggest vent changes based on the ABGs.vent changes based on the ABGs.
  29. 29. John Doe Case StudyJohn Doe Case Study Day ThreeDay Three Oh yea, we are dealing withOh yea, we are dealing with Trauma Doctors! Let me explainTrauma Doctors! Let me explain the obvious.the obvious.
  30. 30. John Doe Case StudyJohn Doe Case Study Day ThreeDay Three  JD was stable for two days then the picture turned toward aJD was stable for two days then the picture turned toward a ARDS type patient.ARDS type patient.  Trouble started around 0300. RT noticed that JD’s SpOTrouble started around 0300. RT noticed that JD’s SpO22 dropped from 99% to 96%, the Compliance had dropped anddropped from 99% to 96%, the Compliance had dropped and PIP had gone up to 37 - 40 cmHPIP had gone up to 37 - 40 cmH22O. ABG revealed that JD’sO. ABG revealed that JD’s pOpO22 went from 196 mmHg to 90 mmHg on the same FiOwent from 196 mmHg to 90 mmHg on the same FiO22 of 60of 60 %.%.  The PEEP was raised to 7 cmHThe PEEP was raised to 7 cmH22O.O.  Later in the morning, an X-ray was ordered and showedLater in the morning, an X-ray was ordered and showed “diminished lung volumes with increased densities in the“diminished lung volumes with increased densities in the Lingular area obscuring the Left Heart margin as well as in theLingular area obscuring the Left Heart margin as well as in the Right Middle Lobe consistent with Atelectasis / PNA”.Right Middle Lobe consistent with Atelectasis / PNA”.  JD’s abdomen was also enlarging and his ICPs were going up.JD’s abdomen was also enlarging and his ICPs were going up. The abdomen was decompressed but did not change theThe abdomen was decompressed but did not change the ventilation status. JD’s ICPs remained high.ventilation status. JD’s ICPs remained high.
  31. 31. John Doe Case StudyJohn Doe Case Study Day ThreeDay Three  RTs & OLT to the Rescue!RTs & OLT to the Rescue!  The respiratory staff saw this as a greatThe respiratory staff saw this as a great chance to use the Open Lung Tool to showchance to use the Open Lung Tool to show remarkable results!remarkable results!  The patient needed lower pressures toThe patient needed lower pressures to protect his lungs, needed to keep his lungsprotect his lungs, needed to keep his lungs open from collapse to avoid atelectasis,open from collapse to avoid atelectasis, needed to find the “optimal PEEP” to helpneeded to find the “optimal PEEP” to help Oxygenation and needed instant resultsOxygenation and needed instant results you could see.you could see.
  32. 32. John Doe Case StudyJohn Doe Case Study Day ThreeDay Three  Remember your “Categorizations of ARDS”. ThisRemember your “Categorizations of ARDS”. This falls into the “Indirect (Secondary or Extra-falls into the “Indirect (Secondary or Extra- Pulmonary)” category because of Trauma,Pulmonary)” category because of Trauma, Alveolar Collapse, a Pancreatitis type “bellyAlveolar Collapse, a Pancreatitis type “belly swell”, and the patient had transfusions.swell”, and the patient had transfusions.  We knew, therefore, that he would be easier toWe knew, therefore, that he would be easier to control.control.  ““Indirects” are easier to see results on theIndirects” are easier to see results on the ventilator graphics.ventilator graphics.  JD made for a perfect training candidate!JD made for a perfect training candidate!  We must have had 15 people in the room toWe must have had 15 people in the room to watch the maneuver!watch the maneuver!
  33. 33. Open Lung Tool On JDOpen Lung Tool On JD  Here we go!Here we go!  RTs checked the orders, identified the patient,RTs checked the orders, identified the patient, ensured a chest tube tray was available and got aensured a chest tube tray was available and got a baseline ABG.baseline ABG.  As a practice, I have my RTs calculate the IBWAs a practice, I have my RTs calculate the IBW for 6 ml/Kg, 7 ml/Kg, 8 ml/Kg.for 6 ml/Kg, 7 ml/Kg, 8 ml/Kg.  Do notDo not use the “room board weight”.use the “room board weight”.  IBW:IBW:  Males:Males: 50 + [ 2.3 X (height in inches-60) ]50 + [ 2.3 X (height in inches-60) ]  Females:Females: 45.4 + [ 2.3 X (height in inches-60) ]45.4 + [ 2.3 X (height in inches-60) ]  RTs noted theRTs noted the PRE-PRE-PIP, Vt, Plateau pressure,PIP, Vt, Plateau pressure, VtCO2, Compliance, PEEP and SpO2 level.VtCO2, Compliance, PEEP and SpO2 level.
  34. 34. Open Lung Tool On JDOpen Lung Tool On JD  We started at a PEEP of 18 cmH2O and a PC of 22We started at a PEEP of 18 cmH2O and a PC of 22 mmHg (need to get above 8 ml/Kg)mmHg (need to get above 8 ml/Kg)  We watched the Compliance graphic.We watched the Compliance graphic.  Our protocol is never to go above 60 cmHOur protocol is never to go above 60 cmH22O!O!  We held this for Two Minutes!We held this for Two Minutes!  We then decreased the PC until we achieved aWe then decreased the PC until we achieved a Tidal Volume of 6 ml/Kg.Tidal Volume of 6 ml/Kg.  We then decreased the PEEP by increments ofWe then decreased the PEEP by increments of 1-2 cmH1-2 cmH22O until we saw alveolar collapse.O until we saw alveolar collapse.  JD’s collapse happened at 10 cmHJD’s collapse happened at 10 cmH22O.O.  We saw a decrease in Compliance, in VtCOWe saw a decrease in Compliance, in VtCO22 and inand in Volume.Volume.
  35. 35. Open Lung Tool On JDOpen Lung Tool On JD  Since we just collapsed his lungs, weSince we just collapsed his lungs, we immediately put JD’s PEEP to 12 cmHimmediately put JD’s PEEP to 12 cmH22OO and took the PC up to 28 mmHg to get aand took the PC up to 28 mmHg to get a PIP of 40 cmHPIP of 40 cmH22O and held for 2 minutes.O and held for 2 minutes.  We then decreased the PC until weWe then decreased the PC until we achieved 6 ml/Kg. We switched JD backachieved 6 ml/Kg. We switched JD back to PRVC and everyone went “WOW”.to PRVC and everyone went “WOW”.  JD’s Oxygenation status went from a pOJD’s Oxygenation status went from a pO22 of 90 mmHg to 239 mmHg.of 90 mmHg to 239 mmHg.  JD’s PIP went from 37 cmHJD’s PIP went from 37 cmH22O to 28 cmHO to 28 cmH22O.O.  JD’s Compliance went from 36 ml/cmHJD’s Compliance went from 36 ml/cmH22OO to 46 ml/cmHto 46 ml/cmH22O.O.
  36. 36. Open Lung Tool On JDOpen Lung Tool On JD  The Post-Open Lung Tool X-ray readingThe Post-Open Lung Tool X-ray reading was “improved aeration in both lung fieldswas “improved aeration in both lung fields compared to prior study” and the Traumacompared to prior study” and the Trauma doctor’s note stated “there was dramaticdoctor’s note stated “there was dramatic improvement”.improvement”.  JD had a second Open Lung Tool doneJD had a second Open Lung Tool done seven hours later that day and the RTsseven hours later that day and the RTs were able to keep him progressing andwere able to keep him progressing and decreasing his ventilator settings.decreasing his ventilator settings.  By the next day his ventilator setting wereBy the next day his ventilator setting were all back downall back down  Due to his injuries he went for aDue to his injuries he went for a Tracheotomy.Tracheotomy.  He stayed in the hospital for a total of 11He stayed in the hospital for a total of 11 days and then went to Trauma Rehab.days and then went to Trauma Rehab.
  37. 37. Recruitment ManeuverRecruitment Maneuver
  38. 38. 8 step open lung picture8 step open lung picture
  39. 39. Case Study #1Case Study #1  53 year old female that came to53 year old female that came to Sutter Roseville Medical Center afterSutter Roseville Medical Center after a motor vehicle rollover. At thea motor vehicle rollover. At the scene, she was conscious, anxious,scene, she was conscious, anxious, and complaining of left sided chestand complaining of left sided chest pain. She went into a panic attack,pain. She went into a panic attack, her respiratory status continued toher respiratory status continued to deteriorate, her blood pressuredeteriorate, her blood pressure bottomed out, she went unconscious,bottomed out, she went unconscious, and was intubated.and was intubated.
  40. 40. Case Study #1Case Study #1  Her X-ray revealed focal densities onHer X-ray revealed focal densities on the right side and focal densities leftthe right side and focal densities left lower lobes. Aeration of the rightlower lobes. Aeration of the right lower lobe appeared slightly worse.lower lobe appeared slightly worse. Left sided rib fractures were present.Left sided rib fractures were present. No Pneumothorax was noted.No Pneumothorax was noted. Diffuse air space disease, consistentDiffuse air space disease, consistent with either edema, infection orwith either edema, infection or contusion. Small right pleuralcontusion. Small right pleural effusion.effusion.
  41. 41. X-ray from ER admitX-ray from ER admit
  42. 42. Case Study #1Case Study #1  The Patient was on a FiO2 of 65% with a PaO2 ofThe Patient was on a FiO2 of 65% with a PaO2 of 200mmHg. Ventilator settings were with in Low200mmHg. Ventilator settings were with in Low Volume Ventilation strategy ranges…but..PeepVolume Ventilation strategy ranges…but..Peep was at 5cmH2O.was at 5cmH2O.  Over night, the patient’s oxygenation statusOver night, the patient’s oxygenation status deteriorated to a PaO2 of 48.1mmHg, on 100%deteriorated to a PaO2 of 48.1mmHg, on 100% FiO2, with a oxygen saturation of 84%.FiO2, with a oxygen saturation of 84%.  RT’s to the rescue. The SRMC staff knew that ifRT’s to the rescue. The SRMC staff knew that if we were able to get the Open Lung Protocolwe were able to get the Open Lung Protocol ordered that we could turn the patient.ordered that we could turn the patient.  The protocol was ordered, the RTs used a baseThe protocol was ordered, the RTs used a base PEEP of 20 and PC of 20 cmH2O. The patient’sPEEP of 20 and PC of 20 cmH2O. The patient’s collapse point was found to be 9 cmH2O and thecollapse point was found to be 9 cmH2O and the PEEP was raised to 11 cmH2O.PEEP was raised to 11 cmH2O.
  43. 43. X-Ray after first ManeuverX-Ray after first Maneuver
  44. 44. Case Study #1Case Study #1  The patient’s PaO2 went up to 239mmHgThe patient’s PaO2 went up to 239mmHg after the maneuver.after the maneuver.  The patient was easier to ventilate at aThe patient was easier to ventilate at a lower pressure.lower pressure.  Along with a few more Open LungAlong with a few more Open Lung Maneuvers, the patient’s contusion andManeuvers, the patient’s contusion and left pleural effusion was resolving.left pleural effusion was resolving.  The patient’s progress was dramatic andThe patient’s progress was dramatic and the patient was quickly weaned andthe patient was quickly weaned and extubated.extubated.
  45. 45. Case Study #1Case Study #1
  46. 46. OPEN LUNG TOOL SCREENOPEN LUNG TOOL SCREEN
  47. 47. Sutter Roseville Medical CenterSutter Roseville Medical Center SRMCSRMC RESPIRATORY THERAPISTSRESPIRATORY THERAPISTS ROCK!!!ROCK!!! No….No…. Gonzaga Rocks!!Gonzaga Rocks!!
  48. 48. Case Study #2Case Study #2  19 year old female in a head on collision.19 year old female in a head on collision. She had lung contusions, a lacerated liver,She had lung contusions, a lacerated liver, lower extremity damage.lower extremity damage.  Her PaO2 on her blood gas was 85mmHgHer PaO2 on her blood gas was 85mmHg on a FiO2 of 70% then dropped toon a FiO2 of 70% then dropped to 36.4mmHg on a FiO2 of 95%.36.4mmHg on a FiO2 of 95%.  This is what her initial X-Ray looked like.This is what her initial X-Ray looked like.
  49. 49. Case Study #2Case Study #2
  50. 50. Case Study #2Case Study #2  Patient needed to go through surgeryPatient needed to go through surgery first, so a low tidal volume strategyfirst, so a low tidal volume strategy was used. Her PEEP was at 8cmH2Owas used. Her PEEP was at 8cmH2O and two chest tubes were inserted toand two chest tubes were inserted to drain fluid. After her first round ofdrain fluid. After her first round of surgeries, the RTs asked for thesurgeries, the RTs asked for the Open Lung Protocol. Through dailyOpen Lung Protocol. Through daily OLT maneuvers the RTs were able toOLT maneuvers the RTs were able to get her lung to this position.get her lung to this position.
  51. 51. Case Study #2Case Study #2
  52. 52. Case Study #2Case Study #2  The patient wasThe patient was taken back to dotaken back to do her last surgeryher last surgery and this is whatand this is what she came backshe came back like.like.  Fluid over loadedFluid over loaded with Atelectasiswith Atelectasis complements ofcomplements of Anesthesia.Anesthesia.
  53. 53. Case Study #2Case Study #2  The RTs knew thatThe RTs knew that the Open Lungthe Open Lung could reverse thecould reverse the patient and get herpatient and get her back in shape andback in shape and after 3 maneuversafter 3 maneuvers her was her X-Ray.her was her X-Ray.
  54. 54. Case Study #2Case Study #2  The RTs were very happy to see herThe RTs were very happy to see her turn and their confidence grew.turn and their confidence grew. They were now using the Protocol inThey were now using the Protocol in the right patients at the right timesthe right patients at the right times and the breath to breath analysisand the breath to breath analysis recognition was allowing the RTs torecognition was allowing the RTs to do the procedure in a rapid and safedo the procedure in a rapid and safe way.way.
  55. 55. Sutter Roseville Medical CenterSutter Roseville Medical Center SRMCSRMC RESPIRATORY THERAPISTSRESPIRATORY THERAPISTS ROCK!!!ROCK!!! Adam Morrison forAdam Morrison for President!President!
  56. 56. Case Study #3Case Study #3  43 year old male43 year old male that came in forthat came in for fever andfever and Pneumonia. HerePneumonia. Here was his initial X-was his initial X- Ray.Ray.
  57. 57. Case Study #3Case Study #3  The patient wasThe patient was admitted to ouradmitted to our floor for care andfloor for care and then went intothen went into respiratoryrespiratory distress. The nextdistress. The next day, his x-rayday, his x-ray looked like this.looked like this.
  58. 58. Case Study #3Case Study #3  The patientThe patient continued downcontinued down the slippery slopethe slippery slope and now lookedand now looked like this.like this.  He got intubatedHe got intubated and had highand had high ventilating andventilating and plateau pressures.plateau pressures.
  59. 59. Case Study #3Case Study #3  The patient’s PaO2 was 47.9mmHg whenThe patient’s PaO2 was 47.9mmHg when the RTs finally got the OK to do the Openthe RTs finally got the OK to do the Open Lung Protocol. The Rt’s had been askingLung Protocol. The Rt’s had been asking for a day and a half.for a day and a half.  The patient’s PaO2 went from 47.9mmHgThe patient’s PaO2 went from 47.9mmHg to 148.0 mmHg with the first maneuver.to 148.0 mmHg with the first maneuver. The RTs identified the new PEEP settingThe RTs identified the new PEEP setting and kept the patients lung open toand kept the patients lung open to improve oxygenation and to lower theimprove oxygenation and to lower the ventilating pressures.ventilating pressures.
  60. 60. Case Study #3Case Study #3  Here is the X-RayHere is the X-Ray after theafter the Maneuver.Maneuver.  This was followedThis was followed by maneuversby maneuvers every shift for 24every shift for 24 hours.hours.
  61. 61. Case Study #3Case Study #3
  62. 62. Sutter Roseville Medical CenterSutter Roseville Medical Center SRMCSRMC RESPIRATORY THERAPISTSRESPIRATORY THERAPISTS ROCK!!!ROCK!!! Go ZAGS!Go ZAGS!
  63. 63. What have we learned doing all ourWhat have we learned doing all our Open Lung Tool maneuvers?Open Lung Tool maneuvers?  We have learned to get as many people involvedWe have learned to get as many people involved with every OLT maneuver you do.with every OLT maneuver you do.  We needed to review how long the maneuver wasWe needed to review how long the maneuver was taking. Before 24 hours.taking. Before 24 hours.  If you have a really high Plateau Pressure youIf you have a really high Plateau Pressure you willwill notnot see the big “compliance change”. Look forsee the big “compliance change”. Look for the VT & VtCOthe VT & VtCO22..  If you have a high Plateau pressure you mightIf you have a high Plateau pressure you might have to go to 60 cmHhave to go to 60 cmH22O to get about 8 ml/Kg!O to get about 8 ml/Kg!  If you don’t have the OLT screen down to 62- 129If you don’t have the OLT screen down to 62- 129 breaths the RTs might go too high trying to seebreaths the RTs might go too high trying to see the change.the change.
  64. 64. What have we learned doing all ourWhat have we learned doing all our Open Lung Tool maneuvers?Open Lung Tool maneuvers?  Train the RTs to watch the Ventilator, theTrain the RTs to watch the Ventilator, the Patient and the Monitor! NO “deer in thePatient and the Monitor! NO “deer in the head lights!”head lights!”  Teach your RTs that when you go too highTeach your RTs that when you go too high on the PC, the Compliance graphic will goon the PC, the Compliance graphic will go down not up. Do not keep going up ondown not up. Do not keep going up on the PC to try to turn it the other way. Inthe PC to try to turn it the other way. In this case, you are so distended that therethis case, you are so distended that there is no room for the lungs to expand whichis no room for the lungs to expand which decreases compliance.decreases compliance.  This happens if you use the “room boardThis happens if you use the “room board weight” to calculate the IBW.weight” to calculate the IBW.
  65. 65. What have we learned doing all ourWhat have we learned doing all our Open Lung Tool maneuvers?Open Lung Tool maneuvers?  In our Policy and Procedure, there is aIn our Policy and Procedure, there is a note about where to start the PEEP levels:note about where to start the PEEP levels: Use PEEP gradually to 15-20 cmH2O forUse PEEP gradually to 15-20 cmH2O for patients>40 years of age that havepatients>40 years of age that have preexisting lung conditions. Use PEEPpreexisting lung conditions. Use PEEP levels 20-25 cmH2O for patients<40 yearslevels 20-25 cmH2O for patients<40 years of age with no preexisting lung conditions.of age with no preexisting lung conditions.  We now use this in all ICUs, and on ARDSWe now use this in all ICUs, and on ARDS and Non-ARDS patients.and Non-ARDS patients.  If doctors make changes in the middle,If doctors make changes in the middle, end the protocol and protect your RTs.end the protocol and protect your RTs.  Pick a Protocol and stick to it!Pick a Protocol and stick to it!
  66. 66. Recruitment ManeuverRecruitment Maneuver
  67. 67. 8 step open lung picture8 step open lung picture
  68. 68. Sutter Roseville Medical CenterSutter Roseville Medical Center SRMCSRMC RESPIRATORYRESPIRATORY THERAPISTSTHERAPISTS ROCK!!!ROCK!!!

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