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How to set INTELLiVENT-ASV for a (COVID-19) ARDS patient

Article

Author: Matthias Himmelstoss

Date of first publication: 07.04.2020

Last change: 07.04.2020

Addition of images
This article gives you step-by-step instructions on how to set the ventilator when using the ventilation mode INTELLiVENT®-ASV® on ARDS patients.
How to set INTELLiVENT-ASV for a (COVID-19) ARDS patient

  • Connect SpO2 and CO2 sensors and activate Oxygenation and Ventilation controllers.
  • Activating the “ARDS” patient condition results in higher starting values for the Oxygenation and Ventilation controllers (see Figure 1).
  • Individualize alarm settings according to the patient condition. 
  • Start ventilation.
  • Monitor blood gases (no later than 30 min after the start of ventilation) and adjust PetCO2- and SpO2-target shifts for INTELLiVENT-ASV (Not available in the US and some other marketsA​) to reach your target PaCO2 and SpO2. Perform another ABG as soon as INTELLiVENT-ASV brings the patient (yellow cross) into the target range (see Figure 2 below).
  • PEEP limitation: Be aware that higher PEEP settings are beneficial in moderate and severe ARDS patients. Assess recruitability and the PEEP setting using the P/V Tool. If you decide on higher PEEP, you can limit the INTELLiVENT-ASV Oxygenation controller to higher PEEP values. You can set the range for the PEEP controller limits by setting the minimum and maximum PEEP limits as shown below (see Figure 3).
  • It is also possible to set the PEEP controller to manual and select the optimal PEEP for your patient resulting from a recruitment maneuver and decremental PEEP trial focusing on oxygenation (Hodgson CL, Cooper DJ, Arabi Y, et al. Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial. Am J Respir Crit Care Med. 2019;200(11):1363-1372. doi:10.1164/rccm.201901-0109OC1​).  Note: High PEEP values can affect your patient’s hemodynamics. 
  • Select your low FiO2 limit as well as your PEEP limits for the controller.
  • Ensure you avoid leakages at the endotracheal tube cuff, as the applied pressures (PEEP and inspiratory pressures) might require adjustments to the cuff pressure (use the IntelliCuff pressure controller if possible).
Screenshot of display showing patient settings
Figure 2: Set patient height and select gender
Screenshot of display showing patient settings
Figure 2: Set patient height and select gender

For additional information on COVID-19:

WHO guidelines: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/technical-guidance

ESICM information: https://www.esicm.org/resources/coronavirus-public-health-emergency/

Current evidence about COVID-19: https://jamanetwork.com/journals/jama/pages/coronavirus-alert

Centers for Disease Control and Prevention, CDC: https://www.cdc.gov/coronavirus/2019-ncov/hcp/clinical-guidance-management-patients.html

Footnotes

  • A. Not available in the US and some other markets

References

  1. 1. Hodgson CL, Cooper DJ, Arabi Y, et al. Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial. Am J Respir Crit Care Med. 2019;200(11):1363-1372. doi:10.1164/rccm.201901-0109OC

Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial.

Hodgson CL, Cooper DJ, Arabi Y, et al. Maximal Recruitment Open Lung Ventilation in Acute Respiratory Distress Syndrome (PHARLAP). A Phase II, Multicenter Randomized Controlled Clinical Trial. Am J Respir Crit Care Med. 2019;200(11):1363-1372. doi:10.1164/rccm.201901-0109OC

Rationale: Open lung ventilation strategies have been recommended in patients with acute respiratory distress syndrome (ARDS).Objectives: To determine whether a maximal lung recruitment strategy reduces ventilator-free days in patients with ARDS.Methods: A phase II, multicenter randomized controlled trial in adults with moderate to severe ARDS. Patients received maximal lung recruitment, titrated positive end expiratory pressure and further Vt limitation, or control "protective" ventilation.Measurements and Main Results: The primary outcome was ventilator-free days at Day 28. Secondary outcomes included mortality, barotrauma, new use of hypoxemic adjuvant therapies, and ICU and hospital stay. Enrollment halted October 2, 2017, after publication of ART (Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial), when 115 of a planned 340 patients had been randomized (57% male; mean age, 53.6 yr). At 28 days after randomization, there was no difference between the maximal lung recruitment and control ventilation strategies in ventilator-free days (median, 16 d [interquartile range (IQR), 0-21 d], n = 57, vs. 14.5 d [IQR, 0-21.5 d], n = 56; P = 0.95), mortality (24.6% [n = 14/56] vs. 26.8% [n = 15/56]; P = 0.79), or the rate of barotrauma (5.2% [n = 3/57] vs. 10.7% [n = 6/56]; P = 0.32). However, the intervention group showed reduced use of new hypoxemic adjuvant therapies (i.e., inhaled nitric oxide, extracorporeal membrane oxygenation, prone; median change from baseline 0 [IQR, 0-1] vs. 1 [IQR, 0-1]; P = 0.004) and increased rates of new cardiac arrhythmia (n = 17 [29%] vs. n = 7 [13%]; P = 0.03).Conclusions: Compared with control ventilation, maximal lung recruitment did not reduce the duration of ventilation-free days or mortality and was associated with increased cardiovascular adverse events but lower use of hypoxemic adjuvant therapies.Clinical trial registered with www.clinicaltrials.gov (NCT01667146).

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