CLINICAL ALGORITHM FOR
THE MANAGEMENT OF
INTUBATED PATIENTS
PRESENTING WITH
CHANGES VISSIBLE
ON CxR
Next step in the algorithm
Assessment of patient
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Changes visible on CxR:
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Increased infiltrates (Suh-Hwa Maa 05; Hodgson 00;
Ntoumenopolous 02) or
Volume loss: Radiographic density: fissure
displacement; mediastinal shift; diaphragmatic
elevation; compensatory hyperinflation (Stiller 96; Raoof
99; Krause 2000; Crowe 2006)

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Evidence of excessive amounts of secretions eg
added breath sounds (Unoki et al 2005)
Decreased oxygenation (Hodgson 00)
RECOMMENDATION 3 (VAP)
RECOMMENDATION 1 (MHI)
RECOMMENDATION 1 (AIRWAY CLEARANCE)
RECOMMENDATION 1 (ATELECTASIS)
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ET tube placement is correct
NO
YES
(Stiller 96)
Notify Consultant
Back to algorithm
Is Pt able to tolerate side lying?
(Stiller 96; Berney et al 2004 )
RECOMMENDATION 3 (VAP)
RECOMMENDATION 1 (MHI)
RECOMMENDATION 1 (AIRWAY CLEARANCE)
RECOMMENDATION 1 (ATELECTASES)
NO
YES
Can pt be positioned in head down
position?
Berney et al 2004
RECOMMENDATION 3 (VAP)
RECOMMENDATION 1 (MHI)
RECOMMENDATION 1 (AIRWAY CLEARANCE)
RECOMMENDATION 1 (ATELECTASES)
NO
YES
Position pt for 15 minutes in gravity assisted
drainage position with affected lung
uppermost (Berney et al 2004; Ntoumenopolous 02; Berney
2002)
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Position pt for 15 minutes in modified PD
position with affected lung uppermost (Stiller
96; Unoki et al 2005; Hodgson 2000; Paratz 2002);
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Is it safe to use a recruitment
maneuver?
Check the cardiovascular stability
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Berney 02; Paratz 06
MAP > 75 mmHg and does not fluctuate more than 15
mmHg with position change
Heart rate is less than 130.
Arterial oxygen saturation SaO2 is not less than 90
No Cardiac arythmias present
Pt is hemodynamically stable as discussed with intensivist
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Is it safe to use a recruitment
maneuver?
None of the following pathologies are present:
Hodgson 00; Hodgson 07

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ARDS; Acute pulmonary edema; Acute head
injury; Acute bronchospasm;
Subcutaneous emphysema; presence of
inetrcostal catheter with a visible air leak
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Is it safe to use a recruitment
maneuver?
Check the state of the pulmonary system
Hodgson
2000; Hodgson 2007; Savian 2006


The peak inspiratory airway pressure is less than
40cmH20;
The patient is not ventilated with PEEP of more
than 10cm H2O
NO
YES


Back to algorithm
Develop a patient specific mobility plan
(refer to mobility algorithm)
Suction of patient based on best practice
suction
Which Equipment to use?

First Choice: Ventilator
(Berney 2004; Savian 2006; Hodgson
2007)


If not possible: use a reservoir bag attached to
spring loaded valve (eg Mapleson C, Mapleson F,
Magill) (Hodgson 2007; Brazier 2003)


RECOMMENDATION 2 (MHI)
RECOMMENDATION 3 (MHI)
another option: Silicone bag eg Laerdal, Air Viva
(Hodgson 2007; Barker 2000)

Previous step in algorithm
RECOMMENDATION 3 (MHI)
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VENTILATOR HYPERINFLATION
Optimal volume / pressures

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In volume control increase the VT in increments
of 200ml (aiming at 130% increase in VT) until a
peak pressure of 40cmH2O is reached.
Maintain baseline PEEP values.
EXPERT OPINION:
CRITERIA USED BY Berney
2002; Savian 2006
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VENTILATOR HYPERINFLATION
Ventilator Settings

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Breath rate of at least 6 breaths / min
inspiratory flow of 20 l/min
Choose a square wave form
2-s end inspiratory pause
Use FiO2 that pt is ventilated on (Hodgson 2007; Hodgson
2000; Rothen 1995)
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EXPERT OPINION:
CRITERIA USED BY Berney
2002; Savian 2006
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VENTILATOR HYPERINFLATION
Technique



Once the Peak pressure is reached, six
mechanical breaths will be delivered to the
patient.
After this, the ventilator is reset to pre-treatment
variables and the patient is rested for 30 s.
Repeat the sequence for a total duration of 20
minutes
EXPERT OPINION:
CRITERIA USED BY Berney
2002; Savian 2006
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MANUAL HYPERINFLATION
Optimal volume / pressures


Manually hyperinflate to a PIP of AT LEAST 35
cmH2O (Paratz 2006; Paratz 2002; Hodgson 2000)
but NOT MORE than 40cmH2O (Hodgson 2007; Denehy
2004; Savian 2006)
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MANUAL HYPERINFLATION
Equipment



Bag must have volume of 2 litres
Attach an in line Manometer (Suh-Hwa 2005)
Use FiO2 that pt is ventilated on – insert blender in circuit
(Hodgson 2007; Hodgson 2000; Rothen 95)


15 liters / min fresh gas flow (Savian 2006; Suh-Hwa 2005)
PEEP valve attached to circuit and set at the same level
of PEEP currently dialed on the mechanical ventilator
(Savian 2006)

expiratory valve – adjust from fully open position but
manually closed during inspiration
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MANUAL HYPERINFLATION
Technique

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two-handed technique
slow inspiration (2 – 3 sec)
inflate until peak pressure of at least 35 cmH2O (Paratz
2006; Paratz 2002; Hodgson 2000) NOT MORE than 40cmH2O as
measured by in-line manometer is reached.
at least 2 sec hold (can hold for as long as 5 sec) Suh-Hwa
2005
expiration passive (1sec duration) with fast release of the
valve to ensure a short expiration while maintaining bag
pressure (Paratz 2006).
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MANUAL HYPERINFLATION
Duration

At least six sets of six hyperinflation breaths
(Berney 2002; Berney 2004; Hodgson 2000)

Follow these hyperinflated breath sets up with six
breaths to a peak airway pressure of 20 cmH2O
(Berney 2002; Berney 2004; Hodgson 2000)

Total duration 20 minutes
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Frequency of intervention

Volume loss on CxR: hourly for 6 hours
(Stiller et al 1996)


RECOMMENDATION 1 (ATELECTASES)
Infiltrates on CxR: twice daily
(Ntoumenopolous et
al 2002)

RECOMMENDATION 3 (VAP)
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Suction Procedure

Refer to Best Practice suction


RECOMMENDATION 2 (VAP)
RECOMMENDATION 2 (AIRWAY CLEARANCE)
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