|
| WEANING IN ARDS |
|
| (1) Control of the Illness (reducing inflammation) |
| (2) PaO2/FiO2>200 and PEEP≤10 cmH2O |
| (3) Evaluate: |
| (a) Pulmonary mechanics during the spontaneous ventilation test: |
| (i) Measure TV e DP – caution TV>8ml/kg and/or DP>13 [56] |
| (ii) If available – monitoring Pes [42, 57] |
| (iii) Bedside alternative for the evaluation of pulmonary mechanics: Administration of small doses of sedatives and short-acting NMB (propofol 10mg IV and if necessary succinylcholine 2-4mg IV) and change to VCV to measurements [58] |
| (b) Asynchrony and Ventilatory Drive: |
| (i) Asynchrony Index (failure if>10%)[59] |
| (ii) P0.1 (consider high drive if>3.0)[44, 45] |
| (c) Imaging Monitoring: |
| (i) EIT (tidal variation of impedance (TIV), the changes in end-expiratory lung impedance (ΔEELI) – failure if global inhomogeneity index (GI) value>40 [53] |
| (ii) US (lung score >17 is predictive of postextubation distress [49, 60]) |
| (iii) Echocardiography (qualitative right ventricular failure and diastolic dysfunction)[49] |
| (4) Management with High TV, DP, Asynchrony Index, P0.1 or worse of regional aeration: |
| (i) Eliminate stress factors (pain, anxiety and delirium) and sedation adjustment – try dexmedetomidine or propofol. Avoid bolus of fentanyl (can lower RR and increase TV) |
| (ii) Test increment in PEEP to 12cmH2O |
| (iii) Alternative ventilatory modes to improve asynchronies – PAV [61] or NAVA [62] |
| (iv) Patients with refractory weaning: use partial NMB [63] and ECMO [64] |
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