LVRM CBO

Question 1

Add slide 3 in

Question 2

What is the main purpose of a Lung Volume Recruitment Maneuver (LVRM)

Answer 2

• Improve gas exchange
• Attenuate ventilator-induced lung injury (VILI)
• Increase lung compliance
• Minimize Physiologic deadspace

Question 3

How are Lung Volume Recruitment Maneuver (LVRM) performed/entail?

Answer 3

Applying sustained inflation or Intermittent signs

Question 4

What are the aims and goals of sustained inflation?

Answer 4

Aims to cause incremental improvement in oxygenation if pressure are adequate.

• may achieve optimal ventilation lung volumes

Question 5

Why is sustained inflation a preferred method of Lung Volume Recruitment Maneuver (LVRM)?

Answer 5

Minimical complications w/good success prognosis in infants.

• not a definitely superior technique

Question 6

How is optimal PEEP determined?

Answer 6

By comparing the lower and upper (LIP and UIP) of the pressure volume (PV) curve.

• Aim for the best compliance with a driving pressure <15 and linearity of 3 among 3 levels.

Question 7

What are indications for Lung Volume Recruitment Maneuvers (LVRM)?

Answer 7

• After disconnection from the ventilator
• After suctioning
• Evidence of atelectasis
• Low Sats

Question 8

What are contraindications for Lung Volume Recruitment Maneuvers (LVRM)?

Answer 8

Chest tubes or air leak

• evidence of barotrauma, pneumothorax, subcutaneous emphysema, pulmonary intestinal emphysema (PIE)

Question 9

How is sustained inflation performed?

Answer 9

Apply excess of expected alveolar opening pressures for periods of 5-30 secs

• aka apply CPAP for 30s

Question 10

what CPAP levels should be applied during sustained inflation for differing patient weights?

Answer 10

• Less than 10 kg = 30 cmH2O
• 10 – 30 kg = 35 cmH2O
• > 30 kg = 40 cmH2O

Question 11

What is the procedure for Intermittent sighs?

Answer 11

Supplementing several breaths

• PEEP 2-5 cmH2O higher
• PIP around 30 cmH2O (weight dependant)

Question 12

What level of CPAP should be used for Intermittent Sighs?

Answer 12

• Less than 10 kg = 30 cmH2O
• 10 – 30 kg = 35 cmH2O
• > 30 kg = 40 cmH2O

Question 13

When should you discontinue a patients Lung Volume Recruitment Maneuver (LVRM)?

Answer 13

If the patient desaturates or HR changes by 20%

• HR less than 60 or greater than 140
• MAP less than 60 or 20% from baseline
• New arrhythmia
• Desats to less than 80%

Question 14

What should you monitor for a Lung Volume Recruitment Maneuver (LVRM)?

Answer 14

SpO2, EtCO2, and HR.

• May be useful to do low flow inflection point analysis

Question 15

What’s the difference between a TLC breath and LVRM?

Answer 15

TLC breaths prevent atelectasis and help recruit/maintain alveolar expansion.

• TLC breaths are quick large controlled breaths that are synced with the patients effort.
• LVRMs are sustained breaths at higher pressures

Question 16

How are TLC breaths delivered?

Answer 16

Quick breaths that are synced to the patients effort.

• 10 breaths

Question 17

How are LVRM breaths on the bagger performed?

Answer 17

Sets of 3x(3-5) sets of sustained breath stacks

Question 18

Absolute contraindications for LVRMs (5)

Answer 18

1. Chest tube w/current or previous leak
2. Barotrauma evidence by pneumothorax, SubQ, PIE, etc. etc. air leaks
3. Resp failure due to obstructive pulmonary diseases
4. Post op thoracic surgical pts
5. MAP less than 60

Question 19

How do you initiate LVRMs on PS/CPAP?

Answer 19

1. Ensure appropriate alarm settings + backup (if present) is off
2. PEEP to 40
3. PS above PEEP 0
4. count for 40 (or 30)
5. Switch to prior mode, readjust alarm settings/backup

Question 20

How do you P/V tool to perform LVRMs? (only on the c6)

Answer 20

1. Tools -> P/V tool
2. P start = 0
3. P top = 40
4. End Peep = 0
5. Ramp speed = -2
6. T pause = 0 sec

Question 21

On a manual LVRM, how long should the patient hold their breath after stacking breaths?

Answer 21

3-5 seconds