Page 531 - Clinical Application of Mechanical Ventilation

Critical Care Issues in Mechanical Ventilation 497

TABLE 15-4 Decremental Recruitment maneuver (Rm) to Determine optimal PEEP

Step Notes

1. Sedation Until no spontaneous breathing effort
(During procedure all vital signs are monitored and supported)
2. Continue sedation Apply F O 100% for 20 min
I
2
Do not disconnect patient from ventilator, use inline suction system
3. Initial Recruitment Apply F O 100% & CPAP 40 cm H O, up to 40 sec
2
I
2
Maneuver (RM) (Discontinue recruitment if one of the following occurs: SpO , 88%;
2
HR . 140/min or , 60/min; MAP , 60 mm Hg or . 20% from
baseline; arrhythmia)
4. Immediately after Initiate PCV at 15 cm H O and PEEP at 20 cm H O (for a total of 35 cm
2
2
initial RM H O of peak pressure)
2
Go to next step if PaO increases by 20% of the pre-RM value (RM may
2
be repeated up to 3 times if PaO does not increase by 20% of the
2
pre-RM value)
5. Following initial RM F O is decreased gradually by 5% to 20% until SpO stabilizes
I
2
2
between 90% and 94%
6. Following initial RM PEEP is decreased by 2 cm H O every 15 to 20 min until SpO drops
2
2
below 90%
7. Optimum PEEP The PEEP immediately preceding the SpO drops below 90%
2
8. Final RM Apply F O 100% & CPAP 40 cm H O for 40 sec
2
2
I
9. After final RM Initiate mechanical ventilation using F O (from step 5) and optimal
2
I
PEEP (from step 7)
(Girgis et al., 2006.)
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VEnTILAToR-ASSoCIATED PnEumonIA (VAP)

Ventilator-associated pneumonia (VAP) is a severe form of hospital-acquired
ventilator-associated pneu-
monia (VAP): A severe form of infection. It is defined as a newly acquired infection of the lung parenchyma
hospital-acquired infection of the that develops within 48 hours after intubation and initiation of mechanical
lung parenchyma that develops
within 48 hours after intubation and ventilation.
initiation of mechanical ventilation.

Incidence of VAP

VAP affects 10 to 25% of mechanically ventilated patients. Approximately 25% of
all infections acquired in intensive care units are due to VAP. The mortality rates of

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