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Mechanical ventilation

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  • 1. MECHANICAL VENTILATION Marc Charles Parent
  • 2. Presentation
    • Different settings to consider
    • Monitoring of the patient
    • Different type of patient
      • COPD, Asthma
      • ARDS
    • Trouble shooting
  • 3. Ventilator settings
  • 4. Ventilator settings
    • Ventilator mode
    • Respiratory rate
    • Tidal volume or pressure settings
    • Inspiratory flow
    • I:E ratio
    • PEEP
    • FiO2
    • Inspiratory trigger
  • 5. CMV
  • 6. A/CV
  • 7. SIMV
  • 8. PSV(pressure support ventilation)
    • Spontaneous inspiratory efforts trigger the ventilator to provide a variable flow of gas in order to attain a preset airway pressure.
    • Can be used in adjunct with SIMV.
  • 9. Respiratory Rate
    • What is the pt actual rate demand?
  • 10. Tidal Volume or Pressure setting
    • Maximum volume/pressure to achieve good ventilation and oxygenation without producing alveolar overdistention
    • Max cc/kg? = 10 cc/kg
    • Some clinical exceptions
  • 11. Inspiratory flow
    • Varies with the Vt, I:E and RR
    • Normally about 60 l/min
    • Can be majored to 100- 120 l/min
  • 12. I:E Ratio
    • 1:2
    • Prolonged at 1:3, 1:4, …
    • Inverse ratio
  • 13. FIO2
    • The usual goal is to use the minimum Fio2 required to have a PaO2 > 60mmhg or a sat >90%
    • Start at 100%
    • Oxygen toxicity normally with Fio2 >40%
  • 14. Inspiratory Trigger
    • Normally set automatically
    • 2 modes:
      • Airway pressure
      • Flow triggering
  • 15. Positive End-expiratory Pressure (PEEP)
    • What is PEEP?
    • What is the goal of PEEP?
      • Improve oxygenation
      • Diminish the work of breathing
      • Different potential effects
  • 16. PEEP
    • What are the secondary effects of PEEP?
      • Barotrauma
      • Diminish cardiac output
      • Regional hypoperfusion
      • NaCl retention
      • Augmentation of I.C.P.?
      • Paradoxal hypoxemia
  • 17. PEEP
    • Contraindication:
      • No absolute CI
      • Barotrauma
      • Airway trauma
      • Hemodynamic instability
      • I.C.P.?
      • Bronchospasm?
  • 18. PEEP
    • What PEEP do you want?
      • Usually, 5-10 cmH2O
  • 19. Monitoring of the patient
  • 20. Look at your patient
    • Question your pt
    • Examine your pt
    • Monitor your pt
    • Look at the synchronicity of your pt breathing
  • 21. Pressures
  • 22. Compliance pressure (Pplat)
    • Represent the static end inspiratory recoil pressure of the respiratory system, lung and chest wall respectively
    • Measures the static compliance or elastance
  • 23. Pplat
    • Measured by occluding the ventilator 3-5 sec at the end of inspiration
    • Should not exceed 30 cmH2O
  • 24. Peak Pressure (Ppeak)
    • Ppeak = Pplat + Pres
    • Where Pres reflects the resistive element of the respiratory system (ET tube and airway)
  • 25. Ppeak
    • Pressure measured at the end of inspiration
    • Should not exceed 50cmH2O?
  • 26. Auto-PEEP or Intrinsic PEEP
    • What is Auto-PEEP?
      • Normally, at end expiration, the lung volume is equal to the FRC
      • When PEEPi occurs, the lung volume at end expiration is greater then the FRC
  • 27. Auto-PEEP or Intrinsic PEEP
    • Why does hyperinflation occur?
      • Airflow limitation because of dynamic collapse
      • No time to expire all the lung volume ( high RR or Vt)
      • Expiratory muscle activity
      • Lesions that increase expiratory resistance
  • 28. Auto-PEEP or Intrinsic PEEP
    • Auto-PEEP is measured in a relaxed pt with an end-expiratory hold maneuver on a mechanical ventilator immediately before the onset of the next breath
  • 29. Auto-PEEP or Intrinsic PEEP
    • Adverse effects:
      • Predisposes to barotrauma
      • Predisposes hemodynamic compromises
      • Diminishes the efficiency of the force generated by respiratory muscles
      • Augments the work of breathing
      • Augments the effort to trigger the ventilator
  • 30. Different types of patient
  • 31. COPD and Asthma
    • Goals:
      • Diminish dynamic hyperinflation
      • Diminish work of breathing
      • Controlled hypoventilation (permissive hypercapnia)
  • 32. Diminish DHI
    • Why?
  • 33. Diminish DHI
    • How?
      • Diminish minute ventilation
        • Low Vt (6-8 cc/kg)
        • Low RR (8-10 b/min)
        • Maximize expiratory time
  • 34. Diminish work of breathing
    • How:
      • Add PEEP (about 85% of PEEPi)
      • Applicable in COPD and Asthma.
  • 35. Controlled hypercapnia
    • Why?
      • Limit high airway pressures and thus diminish the risk of complications
  • 36. Controlled hypercapnia
    • How?
      • Control the ventilation to keep adequate pressures up to a PH > 7.20 and/or a PaCO2 of 80 mmHg
  • 37. Controlled hypercapnia
    • CI:
      • Head pathologies
      • Severe HTN
      • Severe metabolic acidosis
      • Hypovolemia
      • Severe refractory hypoxia
      • Severe pulmonary HTN
      • Coronary disease
  • 38. A.R.D.S.
    • Ventilation with lower tidal volume as compared with traditional volumes for acute lung injury and the ARDS
    • The Acute Respiratory Distress Syndrome Network
    • N Engl J Med 2000;342:1301-08
  • 39. Methods
    • March 96 – March 99
    • 10 university centers
    • Inclusion:
      • Diminish PaO2
      • Bilateral infiltrate
      • Wedge < 18
    • Exclusion
    • Randomized
  • 40. Methods
    • A/C 28d or weaning
    • 2 groups:
      • 1. Traditional Vt (12cc/kg)
      • 2. Low Vt (6cc/kg)
    • End point:
      • 1. Death
      • 2. Days of spontaneous breathing
      • 3. Days without organ failure or barotrauma
  • 41. Results
    • The trails were stopped after 861 pt because of lower mortality in low Vt group
  • 42. Trouble Shooting
  • 43. Trouble Shooting
    • Doctor, doctor, his pressures are going up!!!
    • What is your next step?
  • 44. Trouble Shooting
    • Call the I.T., he will take care of it!
    • Where is the staff?
    • I dont know this pt, and run!
    • Ask which pressure is going up
  • 45. Trouble Shooting
    • Ppeak is up
      • Look at your Pplat
  • 46. Trouble Shooting
    • If your Pplat is high, you are faced with a COMPLIANCE problem
    • If your Pplat is N, you are faced with a RESISTIVE problem
    • DD?
  • 47. Trouble Shooting
  • 48. Trouble Shooting
    • Doctor, doctor, my patient is very agitated!
      • What is your next step?
  • 49. Trouble Shooting
    • Give an ativan to the nurse!
    • Give haldol 10mg to the patient!
    • Take 5mg of morphine for yourself!
    • Look at your pt!
  • 50. Trouble Shooting
    • At the time of intubation, fighting is largely due to anxiety
    • But what do you do if pt is stable and then becomes agitated?
  • 51. Trouble Shooting
    • Remove pt from ventilator
    • Initiate manual ventilation
    • Perform P/E and assess monitoring indices
    • Check patency of airway
    • If death is imminent, consider and treat most likely causes
    • Once pt is stabilized, undertake more detailed assessement and management
  • 52. Trouble Shooting
  • 53. Conclusion