Mechanical Ventilation and RAD - Prof. K. Chellum Oration / CMC Vellore 26th June 2004

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by the renowned pediatrician, Dr Satish Deopujari,
National Chairperson (Ex)
Intensive Care Chapter I A P
Founder Chairman.....
National conference on pediatric critical care
Professor of pediatrics ( Hon ) JNMC:Wardha
Nagpur : INDIA

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Mechanical Ventilation and RAD - Prof. K. Chellum Oration / CMC Vellore 26th June 2004

  1. 1. Mechanical ventilation and RAD Dr Satish Deopujari Prof. K. Chellum Oration / CMC Vellore 26th June 2004
  2. 2. Incidence of M.V. in RAD in India ? Do we under ventilate these patients.
  3. 3. Aggressive management ……….. Proper oxygenation warmed and humidified Continuous nebulization what dose ? Look for hypokalemia Steroids / Ipatropium bromide / MgSO4 Hydration / Ensure good Hemoglobin level. Avoiding agitation Ketamine Newer modalities
  4. 4. MgSO4  Mechanism of Action  Antagonizes translocation of Ca across cell membrane, leads to SM relaxation and Inhibits degranulation of mast cells  Decreases release of ACH (decreases excitability of muscle fibre membranes)  Side Effects:  Facial warmth/flushing, hypotension, nausea, emesis, muscle weakness, sedation, loss of DTRs, resp depression  Dose:  20-40mg/kg IV over 30 min
  5. 5. • The decision to intubate pt in SA , is made on the basis clinical deterioration, • Altered level of consciousness • Exhaustion / P. paradoxus • Inability to protect airway • Increasing arterial PCO2. • Quiet chest, absence of audible wheezing • PaO2 < 60 mmHg : not responding to adequate oxygenation • PaCO2 > 50 mmHg and rising more than 5 mmHg/ hour
  6. 6. • Zimmerman et al, reported that one or more complications occurred in 46% of intubated asthmatics. • More than one-third of all complications occurred during intubation. • 47 % of complications during the intensive care unit stay • Difficult and esophageal intubations occurred in about 15% of all patients
  7. 7. Standard preparation for rapid sequence intubation .  cardio-respiratory and blood pressure monitoring  Assistance  monitoring of oxygen saturation  careful aspiration of oropharynx  bag and mask ventilation with 100% oxygen  emptying of the stomach by nasogastric tube  benzodiazepine should be considered (e.g., midazolam 0.1 - 0.2 mg/kg) permitting relaxation during preoxygenation
  8. 8. Ketamine hydrochloride (1 to 3 mg/kg) Good choice for its sedative and analgesic effects as well as its bronchodilating characteristics. Concomitant use of a benzodiazepine can suppress the dysphoric effects of Ketamine. Ketamine increases laryngeal secretions but does not block pharyngeal and laryngeal reflexes, increasing the risk of laryngospasm and aspiration in the preintubation period
  9. 9. Endotracheal tube…………….  largest endotracheal tube….. lower airflow resistance Suctioning of thick mucosal secretions Fiber optic bronchoscopy : facilitated  A cuffed endotracheal tube Sometimes useful even in small children (<5 years) when insufflation pressures become very high (Hubert 1996).
  10. 10. Intubation…………. oxygenation H2 blockers , prokinetics . atropine Lignocaine 4 % neb. 4mg / kg ( 1ml = 40 mg ) Sedation midazolam + ketamine / cricoid pressure Paralysis ( Vecuronium .1 to .2 mg / kg ) Intubation Suction Confirmation of tube and proper fixation Avoid positive pressure V. without cricoid P. Proper monitoring Oxygenation & Circulation status
  11. 11. Fluid bolus for circulation Lt heart pumps what the right heart gives it
  12. 12. Ventilatory strategy Permissive hypercapnia low rate 50 % for the age low pressure Avoiding barotrauma low pressure Minimal PEEP Intrinsic PEEP Dynamic hyperinflation (DHI)
  13. 13. PEEP Controversies remain about the role of PEEP in status asthmaticus. Majority of cases, no PEEP should be applied during mechanical ventilation (0 3 cm H2O maximum)
  14. 14. PEEP
  15. 15. Intrinsic PEEP Air leak syndrome
  16. 16. A 'rapid sequence' for extubation is justified by the risk of further bronchoconstriction induced by the presence of the endotracheal tube.
  17. 17. • Adding adjuvant therapy despite lack of evidence is reasonable given the risks associated with intubation and mechanical ventilation • More research is required in childhood status asthmaticus!
  18. 18. M. Ventilation is a BLEND of Art and science THANKS
  19. 19. • Adding adjuvant therapy despite lack of evidence is reasonable given the risks associated with intubation and mechanical ventilation • More research is required in childhood status asthmaticus!
  20. 20. Mechanical ventilation • Less than 5% of patients with SA required intubation and MV, “braman et al, jama 1990” • Indications: • To decrease work of breathing. • To maintain adequate oxygenation . • Augment alveolar ventilation in face of airway edema and diffuse mucus plugging of of the small airways…
  21. 21. Indications of mechanical ventilation Not governed by numbers but by the clinical conditions. PaO2 < 60 mmHg or cyanosis not corrected by oxygen administration PaCO2 > 50 mmHg and rising more than 5 mmHg/ hour The decision to intubate and ventilate a child with status asthmaticus is primarily based on clinical criteria: respiratory muscle fatigue, obvious exhaustion, disappearance of pulsus paradoxus diminution of thoracic amplitude during respiratory movements diminution of air entry in the lungs : quiet chest, absence of audible wheezing pulsus paradoxus > 20 - 40 mmHg (inspiratory decline in systolic blood pressure) deterioration of mental status (lethargy, agitation, confusion, coma) diaphoresis in recumbent position
  22. 22. •ideal ventilator settings reduce dynamic hyperinflation (DHI): limited minute ventilation (MV) using an appropriately low but adequate tidal volume (Vt) and respiratory rate, with an extended expiratory time (TE)

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