Ver el código de «Lung recruitment maneuver»

==Background==
*Controversial in terms of safety and efficacy
**No mortality/morbidity outcome benefits<ref>Guerin C et al. Efficacy and safety of recruitment maneuvers in acute respiratory distress syndrome. Ann Intensive Care. 2011; 1: 9.</ref>
**May be of more benefit to extra-pulmonary ARDS than to pulmonary ARDS
*Multiple methods reported
**Below is only one method (Starcase Recruitment Maneuver)
**Refer to your RT for hospital protocol
**Proning patient is considered a recruitment maneuver
*'''Indication:''' severe [[ARDS]] < 1 wk, before onset of fibro-proliferation<ref>Habashi, NM et al. New Directions in Ventilatory Management from: Advanced Therapy in Thoracic Surgery Chapter 3. pp 24-35. Franco KL, Putnam JB. 1998.</ref><ref>Richards G et al. Oct 2006 last updated. http://www.anaesthetist.com/icu/organs/lung/recruit/Findex.htm.</ref>
*Goals to recruit alveoli, maintain with PEEP at the derecruitment point, prevent cyclic collapse/VILI
**Improving hypoxemia via recruitment
**Decrease [[ventilator-induced lung injury]] (VILI)
*Derecruitment of alveoli occurs due to<ref>Nickson C. Lung Recruitment Maneuvers. 21 Sept 2014. http://lifeinthefastlane.com/ccc/recruitment-manoeuvres-in-ards/</ref>:
**Standard low TV ventilation in ARDS
**Insufficient PEEP
**High FiO2 absorptive atelectasis
*Biotrauma and cytokine release (VILI) occur due to:
**Dependent areas of airway are collapsed throughout TVs
**Cyclic collapse causes shear injury atelectrauma with each breath
**Least dependent areas inflated throughout TVs are also easily hyperinflated causing volutrauma and barotrauma, especially in:
***TVs > 6 cc/kg
***Pplat > 30-35 cmH2O

==Risks==
*May only be temporary benefit
*[[shock|Hemodynamic instability]] with drop off in preload
*[[hypercapnia|CO2 retention]]
*May worsen oxygenation by shunting blood to poorly aerated lung (opposing physiological hypoxic pulmonary vasoconstriction)
*May worsen [[ventilator-induced lung injury]] with volutrauma/barotrauma
*[[Pneumothorax]]
*Contraindications
**Unstable BP
**[[pneumothorax]] or high risk of pneumothorax (blebs, necrotising pneumonia)
**[[ARDS]] > 1 wk (relative contraindication)

==Procedure<ref>Medical College of Georgia. Open Lung Tool Procedure Protocol. Updated 2014.</ref>==
*Goal is to find the '''derecruitment point'''
===Failure===
*Before attempting, know when the maneuver should be stopped
*Stop and return to baseline PCV settings if:
**HR < 60 bpm
**HR > 140 bpm
**New [[dysrhythmia]] on monitor (may indicate significant respiratory acid-base shift)
**SBP < 80 mmHg
**Sustained SaO2 < 85%
**Drop in dynamic compliance (pneumothorax)
===Preparation===
*May require increased sedation or paralysis
*Optimize preload (maneuver decreases preload)
*Maintain a very reliable, good waveform SpO2 (that matches ABG SaO2)
*14 ga needles x2 in case of [[pneumothorax]]
*Record baseline vital signs and initial ventilator settings
**I:E to 1:1
**Adjust FiO2 to SaO2 90-92%
**Take note of dynamic compliance levels
**Pressure control ventilation using current rate, PEEP, FiO2 before maneuver
***Adjust PC level above PEEP to start at TV of 6 cc/kg for 2 minutes
***Then set PC level (Pi) to 15 cmH2O above PEEP and maintain this difference throughout initial recruitment
***Adjust RR to maintain appropriate minute ventilation

===Increasing PEEP===
*Increase PEEP to 15 cmH2O
*Set PC level to 15 cmH2O above PEEP
**Maintain this difference between PEEP and PC level (Pi)
**Increase q2 minutes PEEP to 20 → 30 → 40 cmH2O
***Pi will reach 55 cmH2O
***Note maximum SaO2 obtained
***Treat SBP drops as necessary, but halt procedure if > 20% SBP drop despite pressors/fluids
**Increase PIP as necessary
***Maintain minute ventilation
***Reduce RR before PIP increase since TV will increase

===Reducing PEEP===
*Reduce q3 minutes PEEP to 25 → 22.5 → 20 → 17.5 cmH2O
*Remember that SpO2 monitor displays results up to 1-2 min after clinical change
*Until:
**Decrease in SaO2 of 1% from maximum SaO2 observed, which is the '''derecruitment point'''
**'''OR''' minimum of 15 cmH2O PEEP reached

===Re-recruitment===
*Increase PEEP step-wise q2 minutes to 40 cmH2O again
*Maintain PEEP at 40 cmH2O for 2 minutes
*Return to PEEP level 2-4 cmH2O above '''decruitment point'''
*Adjust TV 4-6 cc/kg and plateau pressures < 30 cmH2O
*Tolerate permissive hypercapnia if pH > 7.15
*May increase RR up to maximum of 38 bpm

==Adjuncts==
*[[Inhaled nitric oxide]] (iNO)
*[[Epoprostenol (prostacyclin)]] (Flolan)
*[[Extracorporeal membrane oxygenation]]
*[[High frequency oscillation ventilation]] (HFOV)

==See Also==
*[[Acute respiratory distress syndrome]]
*[[Ventilator associated lung injury]]

{{Mechanical ventilation pages}}

==References==
<references/>

[[Category:Pulmonary]]
[[Category:Critical Care]]
[[Category:Procedures]]