Lung-protective ventilation

- 1) Initiate lung-protective ventilation strategy.
  - Tidal volume 6mL/kg ideal body weight (IBW)
    - IBW – Men = 50 kg + (2.3 kg x (height in inches - 60))
    - IBW – Women = 45.5 kg + (2.3 kg x (height in inches - 60))
      - Maintain peak pressure less than 35 mm Hg
      - Maintain SpO2 88-95% or PaO2 55-80 mm Hg
      - Permit Hypercarbia (but keep arterial pH > 7.30)
      - Use ARDSnet protocol. (See Appendix E)
- 2) If ETT must be disconnected from the ventilator for ANY reason, clamp the ETT to prevent decruitment and minimize viral aerosol formation.
- 3) If in-line suction devices are not available, de-recruitment will likely occur with suctioning. Salvage recruitment maneuvers may be necessary.
- 4) On the EMV+ 731 (mode AC-V) a recruitment maneuver can be done as follows:
  - Change upper limit of Peak Inspiratory Pressure (PIP) alarm to 50 cm H20.
  - Decrease tidal volume as low as possible (50mL).
  - Increase PEEP to 30-40 cm H20.
  - Hold for 40 seconds (if signs of hemodynamic instability develop, stop the recruitment maneuver, and resume prior settings).
  - Increase PEEP to 2 cm H20 ABOVE prior PEEP setting.
  - Increase tidal volume back to prior setting.
  - Return upper limit of PIP alarm to prior setting.
  - Monitor for any persistence of hemodynamic instability or persistently high PIP (Although rare, the high PIP encountered during RMs can cause pneumothorax).
- 5) Dry Lung. The mantra “a dry lung is a happy lung” still applies in severe COVID-19 care; over resuscitation is likely to be harmful. Fluid resuscitation should be guided by assessment of volume responsiveness. If available and evacuation is significantly delayed, loop diuretics can be used to attain a net even volume status, providing the patient is hemodynamically stable (i.e. not requiring vasopressor support).