Lung Recruitment Maneuver Flashcards
When Can Lung Volume Recruiment be Performed
This lung recruitment maneuver will be performed automatically on any ventilated patients who meet the criteria
A physician’s order is not necessary.
Lung Volume Recruiment Inclusion Criteria
- Patient with acute lung injury (ALI) demonstrating
- Bilateral diffuse pulmonary infiltrates
- Oxygenation Index (OI) >12
- Patients who are obese as defined by BMI (Body Mass Index) ≥ 30
- Patients who are on PEEP ≥ 10 cmH20 and demonstrate deterioration in oxygenation with any disconnection from the mechanical ventilator.
Oxygenation Index Equation
(Mean Airway Pressure x FiO2 ) x 100
PaO2
Absolute Contra-Indications for Lung Recruitment Maneuver
Chest tube with current or previous air leak
Barotrauma as evidenced by pneumothorax, subcutaneous emphysema, pneumomediastinum, pulmonary interstitial emphysema (PIE)
Respiratory failure due to Obstructive pulmonary disease
Post operative thoracic surgical patient
Mean Arterial Pressure < 60 mmHg
Relative Contra-Indications for Lung Recruitment Maneuver
Consult a physican about these conditions
COPD complicated by ALI/ARDS
Unstable chest wall
Head injury or suspicion of elevated intracranial hypertension
Pregnancy
Patients without an arterial line
If Criteria is met or as ordered by a physician, the recruitment maneuver will be performed
At the time of the scheduled Q4H ventilator monitoring.
Post patient transport.
Prior to initiation of the high frequency oscillatory ventilator (HFOV).
Post tracheal tube suctioning.
How Often Should the Patient Be Assessed for Lung Recruitment
The patient will be assessed daily for meeting inclusion criteria, need of continuing with lung recruitment procedures, and need for requiring recruitment maneuvers more frequently
An order must be obtained from the physician to increase the frequency of the recruitment maneuvers.
Pt Level of Consiousness for LRM
It is recommended that a patient receiving this maneuver be adequately sedated (paralysis optional). This is to decrease patient asynchrony and limit the risk of barotrauma as a result of the patient fighting or coughing during the procedure
What Determines if the LRM has Been Successful
The maneuver is deemed to be of benefit if the patient SpO2 improves by 2% or more. This increase in SpO2 should be seen within approximately 10 minutes after completion of the maneuver and may be sustained for up to 4 hours. If the SpO2 falls or fails to increase by 2% or more suspend further maneuvers and reassess the patient the next day.
The maneuver should also improve the ∆V/∆P relationship indicating that lung compliance has increased.
Derteroriation of Pt after LVR
Deterioration in patients oxygenation within 4 hours post maneuver may be an indication that set PEEP is below optimal level. Therefore, they may benefit from an additional recruitment maneuver in conjunction with an increase in PEEP (2-3 cmH2O increments)
Optimal PEEP
Optimal PEEP is influenced by chest wall compliance and therefore patients at risk of intra-abdominal hypertension (as measured by bladder pressure) may require much higher levels of distending airway pressures (trans-pulmonary) to maintain adequate oxygenation.
During the lung recruitment maneuver, monitor the patient. Terminate the procedure if any of the following criteria are met:
Heart rate <60 or >140 beats/min or a 20% change from baseline
MAP <60 mmHg or a 20% change from baseline
New arrhythmia
Desaturation to ≤80%
PROCEDURE USING DRAGER EVITA 4 AND EVITA XL
Set the patient’s mode of ventilation to APRV or with the following settings
Silence the alarm to avoid unnecessary nuisance alarms.
Apnea alarm 60 seconds
FiO2 – leave at current setting
Phigh- 40 cmH20
Plow- current set PEEP level
Thigh- 20 seconds
Tlow- 0.10 seconds
Perform maneuver for 2 cycles (40 seconds)
LVRM PROCEDURE USING THE PURITAN BENNETT 840
Changeapneaintervalto60seconds.Setwaveformsweepspeedto48seconds.Set low total minute volume and low mandatory exhaled tidal volume alarms to their minimum. Set high peak pressure alarm to 50 cmH2O.
PressVentSetup,selectBiLevelModeandthenpresscontinue.
Enter the following parameters making sure NOT to press ACCEPT until all the settings are accurate and confirmed.
Frequency to 2.9
Lock I:E ratio
Set I:E ratio to 102:1
Set PEEP Hi to 40 cmH2O
Set Psupp to 0 cmH2O
Set PEEP low to 35 cmH2O
FiO2 – Leave at current setting
Double check settings, press ACCEPT to begin the recruitment maneuver
Theaboveresultsinapproximatelytwo20secmaneuversatapressureof40cmH2O interrupted by a brief (0.2 sec) drop in pressure to 35 cmH2O. After the second drop in pressure, immediately press Vent Setup, select Previous Setup and then press ACCEPT.
LVRM PROCEDURE USING THE MAQUET SERVO i
Press Alarm profile. Set high pressure limit to 50 cmH2O, set high PEEP to 40 cmH2O and set low exhaled minute volume to minimum. Press accept.
Pressmodekey:
Select BiVent
Set P high to 40 cmH2O
Set P PEEP to 35 cmH2O
Set T high to 10 seconds
Set T PEEP to 0.2 seconds
Press accept to begin the 40 second maneuver (4 cycles of 10 seconds at 40 cmH2O each interrupted by a short 0.2 second drop to a pressure of 35 cmH20).
Begin to prepare for ending maneuver during the fourth 10 second cycle. As soon as this cycle ends select show previous mode and press accept to end maneuver.
