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

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Author: Munir Karjaghli

Date of first publication: 23.03.2020

This article describes step-by-step how to set the ventilator when using the Adaptive Support Ventilation (ASV) mode on ARDS patients.
How to set ASV® correctly for a (COVID-19) ARDS patient

How does ASV work?

ASV targets the optimal respiratory rate for the low compliance of an ARDS patient and already targets low tidal volumes as recommended in the ARDS guidelines (NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary 2008-07.1​).

For any given minute volume, ASV determines the optimal respiratory rate and tidal volume associated with the minimal work of breathing and minimal driving pressure. It applies lung-protective ventilation with low tidal volumes (VT), and limited Pplateau and driving pressure in passive ICU patients with different lung conditions. In ARDS patients, ASV applies individualized lung-protective ventilation (Arnal JM, Saoli MS, Novotni D, Garnero A. Driving pressure automatically selected by INTELLiVENT-ASV in ICU patients. Intensive Care Med Exp 2016; 4 (Suppl 1):A602.2​, Arnal JM, Saoli M, Garnero A. Airway and transpulmonary driving pressures and mechanical powers selected by INTELLiVENT-ASV in passive, mechanically ventilated ICU patients. Heart Lung. 2020;49(4):427-434. doi:10.1016/j.hrtlng.2019.11.0013​).

Settings window on ventilator showing settings for patient height and gender
Figure 1: Enter patient height and select gender
Settings window on ventilator showing settings for patient height and gender
Figure 1: Enter patient height and select gender

Patient information and initial settings

Step 1: Determine patient height and select gender

See Figure 1 above.

Step 2: Initial settings

  • %MinVol setting of 120% (this corresponds to 120 ml/kg IBW/min)
  • PEEP setting of 8 cmH2O
  • Oxygen 100% adjust according to your blood gas examinations

Be aware that tidal volumes delivered by ASV can be limited by means of the pressure limitation (Pasvlimit) setting. Adjust the Pasvlimit according your Pplateau measurement results if needed. Normally a Pasvlimit ≤30 cmH2O is sufficient; in severe cases with low chest wall compliance or high airway resistance, a higher Pasvlimit up to 35 cmH2O might be needed. Verify your PEEP and Pasvlimit settings according to transpulmonary pressure measurement. Keep the driving pressure below 14 cmH20 (Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-755. doi:10.1056/NEJMsa14106394​) and the transpulmonary driving pressure below 10 cmH20.

Adjustments

Step 3: Adjust %MinVol and Pasvlimit

Increase or decrease the %MinVol to reach the target PaCO2 in passive patients. In spontaneously breathing patients, increase or decrease the %MinVol to change the level of pressure support.

Assess recruitability

Step 4: Consider an early recruitability assessment

An RCT (Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators, Cavalcanti AB, Suzumura ÉA, et al. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017;318(14):1335-1345. doi:10.1001/jama.2017.141715​) investigating high PEEP and prolonged high pressure RMs showed harm to the lung, suggesting that the protocol used in this RCT should be avoided. In those trials however, patients were not screened for recruitability and they were exposed to high pressures over a long time. We recommend using the P/V Tool Pro for an early assessment of recruitability; if a patient is a responder, recruitment should be carried out promptly with the P/V Tool Pro.
 

Full citations below: (NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary 2008-07.1​, Arnal JM, Saoli MS, Novotni D, Garnero A. Driving pressure automatically selected by INTELLiVENT-ASV in ICU patients. Intensive Care Med Exp 2016; 4 (Suppl 1):A602.2​, Arnal JM, Saoli M, Garnero A. Airway and transpulmonary driving pressures and mechanical powers selected by INTELLiVENT-ASV in passive, mechanically ventilated ICU patients. Heart Lung. 2020;49(4):427-434. doi:10.1016/j.hrtlng.2019.11.0013​, Amato MB, Meade MO, Slutsky AS, et al. Driving pressure and survival in the acute respiratory distress syndrome. N Engl J Med. 2015;372(8):747-755. doi:10.1056/NEJMsa14106394​, Writing Group for the Alveolar Recruitment for Acute Respiratory Distress Syndrome Trial (ART) Investigators, Cavalcanti AB, Suzumura ÉA, et al. Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial. JAMA. 2017;318(14):1335-1345. doi:10.1001/jama.2017.141715​)

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

NIH NHLBI ARDS Clinical Network Mechanical Ventilation Protocol Summary

Author:

Driving pressure automatically selected by INTELLiVENT-ASV in ICU patients

Authors: JM Arnal, MS Saoli , D Novotni, A Garnero

Airway and transpulmonary driving pressures and mechanical powers selected by INTELLiVENT-ASV in passive, mechanically ventilated ICU patients.

Authors: Jean-Michel Arnal, Mathieu Saoli, Aude Garnero

Driving pressure and survival in the acute respiratory distress syndrome.

Authors: Marcelo B P Amato, Maureen O Meade, Arthur S Slutsky, Laurent Brochard, Eduardo L V Costa, David A Schoenfeld, Thomas E Stewart, Matthias Briel, Daniel Talmor, Alain Mercat, Jean-Christophe M Richard, Carlos R R Carvalho, Roy G Brower

Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Authors: Alexandre Biasi Cavalcanti, Érica Aranha Suzumura, Ligia Nasi Laranjeira, Denise de Moraes Paisani, Lucas Petri Damiani, Helio Penna Guimarães, Edson Renato Romano, Marisa de Moraes Regenga, Luzia Noriko Takahashi Taniguchi, Cassiano Teixeira, Roselaine Pinheiro de Oliveira, Flavia Ribeiro Machado, Fredi Alexander Diaz-Quijano, Meton Soares de Alencar Filho, Israel Silva Maia, Eliana Bernardete Caser, Wilson de Oliveira Filho, Marcos de Carvalho Borges, Priscilla de Aquino Martins, Mirna Matsui, Gustavo Adolfo Ospina-Tascón, Thiago Simões Giancursi, Nelson Dario Giraldo-Ramirez, Silvia Regina Rios Vieira, Maria da Graça Pasquotto de Lima Assef, Mohd Shahnaz Hasan, Wojciech Szczeklik, Fernando Rios, Marcelo Britto Passos Amato, Otávio Berwanger, Carlos Roberto Ribeiro de Carvalho

Effect of Lung Recruitment and Titrated Positive End-Expiratory Pressure (PEEP) vs Low PEEP on Mortality in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.

Authors: Alexandre Biasi Cavalcanti, Érica Aranha Suzumura, Ligia Nasi Laranjeira, Denise de Moraes Paisani, Lucas Petri Damiani, Helio Penna Guimarães, Edson Renato Romano, Marisa de Moraes Regenga, Luzia Noriko Takahashi Taniguchi, Cassiano Teixeira, Roselaine Pinheiro de Oliveira, Flavia Ribeiro Machado, Fredi Alexander Diaz-Quijano, Meton Soares de Alencar Filho, Israel Silva Maia, Eliana Bernardete Caser, Wilson de Oliveira Filho, Marcos de Carvalho Borges, Priscilla de Aquino Martins, Mirna Matsui, Gustavo Adolfo Ospina-Tascón, Thiago Simões Giancursi, Nelson Dario Giraldo-Ramirez, Silvia Regina Rios Vieira, Maria da Graça Pasquotto de Lima Assef, Mohd Shahnaz Hasan, Wojciech Szczeklik, Fernando Rios, Marcelo Britto Passos Amato, Otávio Berwanger, Carlos Roberto Ribeiro de Carvalho

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