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Respiratory Support

Continue to monitor clinical goals following resolution of shock

  • Wean FiO2 to keep Sp)2 92-97%

  • Continue lung protective strategies

  • Consider diuretics or dialysis if fluid overload > 10-15%

  • PRBCs if Hgb < 7g/dL

  • Wean hydrocortisone when vasoactive infusions no longer required

  • Monitor culture results and reassess antibiotic coverage

  • Consult ID if culture negative sepsis to determine negative sepsis to determine antibiotic duration PT/OT consult, consider PM&R consult

Respiratory support

Begin age-appropriate oxygen therapy regardless of SpO2

Indications for intubation:

  • Hypoxemia or inadequate oxygen delivery

  • Left heart failure or refractory shock

  • To facilitate safety during invasive catheter placement


Initial respiratory assessment


Respiratory rate

Pulse oximetry

Work of breathing (WOB)

Breath sounds


Normal for age

SpO2 92-97%

Minimal, normal



SpO2 < 92%

Increased WOB

Inadequate gas exchange



  • High Flow Nasal Cannula

  • Noninvasive positive pressure ventilation

Gas exchange:

Monitor ABG or noninvasive TcPCO2


Respiratory reassessment

Monitor all assessment items in Initial Respiratory Assessment plus:

Venous SCVO2





> 70%

< 4 mmol/L


SpO2 < 92%

Increased WOB

Arterial pH < 7.25

SCVO< 70%



  • Intubation

  • Invasive mechanical ventilation


Reassess mechanical ventilation goals


Pulse oximetry

Arterial pH




SpO2 92-98%

> 7.25

> 70%

< 4 mmol/L


Meets Goals?


Lung-Protective Strategy

Tidal volume < 7 mL/kg

PIP < 35 cm H2O

FiO2 < 60%

Wean FiO2 if SpO2 > 98%


Oxygenation Index (OI)

PaO2 / FiO2


Alternative Ventilator Strategies

Airway Pressure Release Ventilation (APRV)

High Frequency Oscillator Ventilation (HFOV)


Oxygenation Index (OI)

Assesses the intensity of ventilator support required to maintain oxygenation (lower is better).


Pa02/FiO2 Ratio

Indicates severity of arterial blood hypoxemia given FiO2 only, used in defining ARDS.

Interpretation of OI:

Very good < 5

Medium 10-20

Poor > 25

Interpretation of Pa02/FiO2 Ratio:

Normal 452

Mild ARDS 201-300

Moderate ARDS 101 - 200

Severe ARDS < 100

OI calculator:



Reconceptualized from:

These guidelines do not establish a standard of care to be followed in every case. It is recognized that each case is different and those individuals involved in providing health care are expected to use their judgment in determining what is in the best interests of the patient based on the circumstances existing at the time. It is impossible to anticipate all possible situations that may exist and to prepare guidelines for each. Accordingly these guidelines should guide care with the understanding that departures from them may be required at times.