Inpatient and PICU Clinical Pathway for Management of Patients with Neuromuscular Compromise and Respiratory Failure
Admitted to
Medical/Surgical Unit
Medical/Surgical Unit
Admitted to PICU with
Acute Respiratory Failure
Acute Respiratory Failure
Pre-procedure gene therapy or Post-op or non-respiratory failure diagnosis
Respiratory
distress
distress
Continue baseline settings and secretion clearance therapies
- Peri-extubation to NIV
- Immediate Post-extubation Airway Clearance
- Frequent MI-E (CoughAssist) treatments may be needed
- CAT call if:
- Increased PEEP by 2cmH2O
- Acute FiO2 > 40% for > 1 hr, despite PRN secretion clearance
- Unable to sprint BID for 2 hrs
- Clinician Concern
Maximize Non-Invasive Ventilation (NIV)
Consider Invasive Ventilation
Initially or after maximizing NIV based on trajectory
Initially or after maximizing NIV based on trajectory
Artificial Airway
- Persistent tachycardia
- Fatigue
- Diaphoresis
- Increased airway clearance needs
- Impaired gas exchange
- FiO2 40-60% not weaning
- IPAP > 24 / EPAP > 10 or above baseline
- Core Assessments and Management
- Consults, nursing considerations, nutrition, postop care, initial respiratory assessment
- Airway Clearance Management
- Mechanical Strategies:
MI-E (CoughAssist), IPV, CPT, Suction, HFCWO (Vest) - Pharmacologic Strategies:
Mucolytic Agents - Oxygenation Goals:
Sp02 > 95% in room air
- Mechanical Strategies:
Definitions
- IPAP: Inspiratory positive airway pressure
- EPAP: Expiratory positive airway pressure
-
HFCWO/HFCWC (Vest®):
High-frequency chest wall oscillation/high-frequency chest wall compression - IPV: Intrapulmonary percussive ventilation
- CPT: Chest physiotherapy
- MI-E: Mechanical insufflation-exsufflation (CoughAssist)
- Pe: Exsufflation pressure
- Pi:Insufflation pressure
Transition to chronic management: Determine long term plan for airway clearance
First- and Second-line Management Strategies
First- and Second-line Management Strategies
Posted: October 2017
Revised: May 2022
Authors: O. Mayer, MD; H. Panitch, MD; L. Rhodes, RRT; C. Dominick, RRT; H. Wolfe, MD; K. Martin, MD; N. McGowan, RRT; M. Bernstein, RN
Revised: May 2022
Authors: O. Mayer, MD; H. Panitch, MD; L. Rhodes, RRT; C. Dominick, RRT; H. Wolfe, MD; K. Martin, MD; N. McGowan, RRT; M. Bernstein, RN