CLINICAL ALGORITHM FOR
THE MANAGEMENT
OF A PATIENT
DIAGNOSED WITH
ARDS / ALI
Next step in the algorithm
On evaluation Patient presents with
PaO2: FiO2
<27 KPa/
200mmHg
Bilateral changes
visible on CxR
Of acute onset
PAWP <18
Non - cardiogenic
PaO2: FiO2
>27 KPa/
200mmHg <
40kPa /
300mmHg
Next step in the algorithm
CONTRA INDICATIONS present ?
cerebral perfusion pressure of less than 60 mm Hg,
Intracranial pressure of more than 30mmHg
massive hemoptysis,
broncho-pleural fistula,
tracheal surgery or sternotomy in the last 15days,
MAP of less than 65mmHg with or without vasopressors,
deep venous thrombosis
pacemaker inserted for fewer than 2 days,
unstable fracture; (Guerin et al 2004)
Open chest or abdominal wounds,
advanced pregnancy, and
severe facial trauma or recent ophthalmic surgery
NO
YES
EXPERT OPINION
Leone 2002; Rowe 2004
Develop a PATIENT SPECIFIC MOBILITY PLAN in
consultation with multidisciplinary team members
Monitor patient closely: and Only suction when
clinically indicated
– Coarse breath sounds; noisy breathing; increased or decreased pulse;
increased or decreased respiration; increased or decreased blood
pressure; prolonged expiratory breath sounds; clinically apparent
increased work of breathing
– Use VHI two hyperinflations using the CPAP function of the ventilator to
an airway pressure of 45cmH2O for 20 s, with an interval of 1 min in
between and after suction procedure
RECOMMENDATION 2
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Initiate discussion with multidisciplinary team
Consider the following PRACTICAL CONSIDERATIONS
 Have access to an appropriate pressure-relieving surface
 Patient is adequately sedated and receiving muscle relaxants
 Have a pulse oximeter to monitor heart rate and oxygen saturation
 Sufficient number of staff available to turn patient (initiate and after 6
hours)
EXPERT OPINION
(Ball et al 2001; McCormick et al 2001; Rowe 2004)
Not in place
In place
Develop a PATIENT SPECIFIC MOBILITY PLAN in
consultation with multidisciplinary team members
Monitor patient closely: and Only suction when
clinically indicated
– Coarse breath sounds; noisy breathing; increased or decreased pulse;
increased or decreased respiration; increased or decreased blood
pressure; prolonged expiratory breath sounds; clinically apparent
increased work of breathing
– Use VHI two hyperinflations using the CPAP function of the ventilator to
an airway pressure of 45cmH2O for 20 s, with an interval of 1 min in
between and after suction procedure
RECOMMENDATION 2
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TURN PT PRONE: PREPARATIONS
Temporarily halt the patients’ enteral feed and aspirate nasogastric tube.
Position a sliding sheet in situ
Secure the endotracheal/tracheostomy tube.
Make sure appropriate intubation equipment is immediately available
Suction patient
Disconnect infusion lines, naso-gastric feeds and ECG pads.
Lines / tubes deemed essential by its continued presence must be adequately secured
and flexible enough to accommodate all aspects of the turn. Direct the lines towards the
patients’ head,
Ensure that the eyelids remain closed at all times and appropriate lubrication instilled
RECOMMENDATION 1
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TURN PT PRONE: PROCEDURE
Position pillows across pt chest, pelvis and knees
Ensure patients’ arms are positioned close to their sides, with the
palms facing inwards
One staff member manages the head and tracheal tube and two
members on either side of patient
Pull bottom sheet straight and taut and lay a second sheet across
the patient, ensuring that all corners are matching, effectively
cocooning the patient and pillows inside.
Move the patient towards one side of the bed.
Roll slowly onto flank and then onto abdomen in the direction of the
ventilator.
Position head facing towards the ventilator.
Reconnect the equipment.
EXPERT OPINION
Ball et al 2001; McCormick et al 2001; Rowe 2004; Alsaghir et al 2008
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Check immediately for
ADVERSE REACTIONS
cardiac arrest,
unplanned extubation,
endotracheal tube obstruction,
hemoptysis,
transcutaneous oxygen saturation [SpO2] <85% for more than 5
minutes,
heart rate_<30/min for more than 1 minute,
arterial systolic blood pressure <60 mm Hg for more than 5 minutes,
No adverse reactions
Pt demonstrates
adverse reactions
Immediately return patient to supine and
address appropriately
management
Previous step in the algorithm
POSITION PATIENT
Upper pillow must support the patients’ upper chest, allowing their
shoulders to fall forwards slightly
The middle pillow should be positioned under the patients’ pelvis,
thus maintaining them in an abdomen-free position
Maintain the patient within the swimmers position, ensuring that their
face looks towards the prominent arm, the opposite one being
positioned carefully down by their side
Shoulder position of the prominent arm must be maintained at 80°
abduction, whilst the elbow is flexed to 90° In addition, a small-rolled
pillowcase should be placed in the palm of the prominent hand to
extend the wrist and allow flexion of the fingers.
Once established in the prone position, place the bed in a reverse
Trendelenburg position, i.e. tilted foot down 30–45°
EXPERT OPINION
Ball et al 2001;
McCormick et al 2001; Rowe et al 2004
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Next step in the algorithm
After 6 hours
PaO2:FiO2 increased by at least 20mmhHg
RECOMMENDATION 1
NO
YES
• Return to supine position and manage as
non responder
management
Previous step in the algorithm
Continue in prone position for at least 8
hours to a maximum of 20 hours
RECOMMENDATION 1
Continue for at least 7 days
(Rowe 2004; Alsaghir et al 2008)
META ANALYSIS
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