CLINICAL ALGORITHM FOR THE MANAGEMENT OF A PATIENT DIAGNOSED WITH ARDS / ALI

1. CLINICAL ALGORITHM FOR THE MANAGEMENT OF A PATIENT DIAGNOSED WITH ARDS / ALI Next step in the algorithm

2. 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

3. 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 chestor abdominal wounds, • advanced pregnancy, and • severe facial trauma or recent ophthalmic surgery EXPERT OPINION Leone 2002; Rowe 2004 NO YES

4. 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 Back to algorithm

5. Initiate discussion with multidisciplinary team • Consider the followingPRACTICAL 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

6. 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 Back to algorithm

7. 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 Previous step in the algorithm Next step in the algorithm

8. 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 Previous step in the algorithm Next step in the algorithm

9. 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

10. management Immediately return patient to supine and address appropriately Previous step in the algorithm

11. 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 Previous step in the algorithm Next step in the algorithm

12. After 6 hours • PaO2:FiO2 increased by at least 20mmhHg RECOMMENDATION 1 NO YES

13. management • Return to supine position and manage as non responder Previous step in the algorithm

14. 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 Back to algorithm