COVID-19 Ventilation Protocol
Adapted from an algorithm developed by The Toronto Centre of Excellence in Mechanical Ventilation (CoEMV)
- Adapted from materials developed at the Toronto Centre of Excellence in Mechanical Ventilation
- Adapted for Calculate by Benjamin Mammon, MD Candidate
Response to PEEP in acute respiratory distress syndrome depends on recruitability (the amount of non-aerated/poorly aerated lung tissue that can be reopened). Toronto CoEMV recommends two bedside approaches to estimate recruitability:<br/><br/> 1. Measure <a href="https://vimeo.com/316788443">airway opening pressure (AOP)</a> to take into account the possibility of airway closure and use a single breath <a href="https://vimeo.com/316708822">recruitability maneuver<a/> to calculate the compliance of the recruited lung. Compare to "baby lung" compliance using the recruitment to inflation ratio (R/I). <br/>R/I ≥0.5 = recruitable. <br/>R/I <0.5 = non-recruitable. <br/><br/> 2. Measure ABGs, hemodynamics, driving pressure, and plateau pressure before and after observing response to 2 different levels of PEEP (separated by at least 5 cmH₂O with all other variables constant).<br/><br/> Recruitable: Significant oxygenation improvement, minimal change in PaCO₂, minimal change in driving pressure or even a decrease. <br/>Enter value ≥0.5.<br/><br/>Non-recruitable: Limited benefit in oxygenation, lower mean arterial pressure at high PEEP, higher PaCO₂ and higher driving pressure. <br/>Enter value <0.5.
This tool provides guidance for initial ventilation management in COVID-19 patients. It is based on an algorithm developed by The Toronto Centre of Excellence in Mechanical Ventilation (CoEMV).
The Toronto CoEMV recommends managing COVID-19 patients based on recruitability.
Non-Recruitable: Recommend low PEEP (10 or even lower) and prone positioning if PaO₂/FiO₂ is ≤150 mmHg.
Note: Prone positioning of the patient is recommended in order to protect the patient's lungs. The process is lengthy, and patience is required to see improvement in oxygenation which may take hours. Consider ECMO if the PaO₂/FiO₂ is consistently below 80. If resources are not available, any other rescue strategy such as inhaled nitric oxide could buy more time. Avoid 100% FiO₂, which favors de-nitrogenation atelectasis. 90%, 80%, or 70% would be better. The difference between 100% and 70%-90% may not drastically change oxygenation in the blood due to a high shunt fraction.
Recruitable: Recommend high levels of PEEP. These patients would still benefit from prone positioning if the PaO₂/FiO₂ ratio remains ≤150 mmHg.
Please see the calculator "Inflation to Recruitment Ratio" for more information on how to assess a patient's recruitability.
- [1]Chen, Lu, et al.: Potential for Lung Recruitment Estimated by the Recruitment-to-Inflation Ratio in Acute Respiratory Distress Syndrome. A Clinical Trial.American Journal of Respiratory and Critical Care Medicine 2020 January 15, 201 (2): 178-187.
- [2]Piraino, Thomas, and Laurent Brochard.: COVID-19 Message to Respiratory Therapists.The Toronto Centre of Excellence in Mechanical Ventilation, 2020.
Results
Real-time automated computation
1. Maintain PEEP 8-10 cmH₂O
2. If PaO₂/FiO₂ <150 mmHg, consider prone positioning (see video below)
3. Target plateau pressure (Pplat) ≤30 cmH₂O
4. If Pplat >30 cmH₂O, reduce VT 1 mL/kg (minimum 4mL/kg) until ≤30 cmH₂O
5. Collect ABGs after 15-20 minutes
6. Management
- Maintain driving pressure <14 cmH₂O
- Adjust resp rate to achieve pH 7.25 - 7.42
- Adjust FiO₂ to achieve PaO₂ >60 mmHg or SpO₂ 88-98%
7. If pH <7.25 consider increasing VT 1mL/kg (maximum 8mL/kg) and return to step #3.
8. If PaO₂/FiO₂ <150 mmHg consider prone positioning
The Toronto CoEMV Recommends:
1. Set higher PEEP to maintain recruitment (based on airway opening pressure, or Express, or decremental PEEP trial, or PEEP FiO₂ table)
2. Target plateau pressure (Pplat) ≤30 cmH₂O
3. If Pplat >30 cmH₂O, reduce VT 1 mL/kg (minimum 4mL/kg) until ≤30 cmH₂O
4. Collect ABGs after 15-20 minutes
5. Management
- Maintain driving pressure <14 cmH₂O
- Adjust resp rate to achieve pH 7.25 - 7.42
- Adjust FiO₂ to achieve PaO₂ >60 mmHg or SpO₂ 88-98%
6. If pH <7.25 consider increasing VT 1mL/kg (maximum 8mL/kg) and return to step #2.
7. If PaO₂/FiO₂ <150 mmHg consider prone positioning (see video below)
This tool provides guidance for initial ventilation management in COVID-19 patients. It is based on an algorithm developed by The Toronto Centre of Excellence in Mechanical Ventilation (CoEMV).
The Toronto CoEMV recommends managing COVID-19 patients based on recruitability.
Non-Recruitable: Recommend low PEEP (10 or even lower) and prone positioning if PaO₂/FiO₂ is ≤150 mmHg.
Note: Prone positioning of the patient is recommended in order to protect the patient's lungs. The process is lengthy, and patience is required to see improvement in oxygenation which may take hours. Consider ECMO if the PaO₂/FiO₂ is consistently below 80. If resources are not available, any other rescue strategy such as inhaled nitric oxide could buy more time. Avoid 100% FiO₂, which favors de-nitrogenation atelectasis. 90%, 80%, or 70% would be better. The difference between 100% and 70%-90% may not drastically change oxygenation in the blood due to a high shunt fraction.
Recruitable: Recommend high levels of PEEP. These patients would still benefit from prone positioning if the PaO₂/FiO₂ ratio remains ≤150 mmHg.
Please see the calculator "Inflation to Recruitment Ratio" for more information on how to assess a patient's recruitability.
- [1]Chen, Lu, et al.: Potential for Lung Recruitment Estimated by the Recruitment-to-Inflation Ratio in Acute Respiratory Distress Syndrome. A Clinical Trial.American Journal of Respiratory and Critical Care Medicine 2020 January 15, 201 (2): 178-187.
- [2]Piraino, Thomas, and Laurent Brochard.: COVID-19 Message to Respiratory Therapists.The Toronto Centre of Excellence in Mechanical Ventilation, 2020.