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COPD is a disease of resistance during expiration
but
with the consequence of restriction during inspiration.

Ubaidur Rah...
Pressure Volume relationship
of
respiratory system

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
P-V curve of Lung, Chest wall and Respiratory system
Chest wall

Lung

TLC

Vital capacity %

100
Chest wall and Lung
( re...
Resting Volume of Respiratory system

Elastic force of LUNG

=

Elastic force of CHEST WALL

At End Expiration
Functional ...
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
LUNG VOLUMES

5.0
IRV
IC
3.0

VC

TV

TLC

2.5
ERV
1.25

FRC
RV

0

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Luckno...
Pressure, Volume and Flow
relationship
of Respiratory system

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, Ind...
Relationship between intrathoracic pressures

TPP = PA – Ppl
PA = Ppl + Pel
TPP = (Ppl + Pel) – (Ppl) = Pel

TPP = Transpu...
Relationship between intrathoracic pressures

TAP = Paw – Ppl
TAP

Paw

TPP

TAP = Transairway Pressure
Paw = airway press...
End expiration

0
TPP = PA – Ppl

-5

PA = 0

-5

Ppl = -5
TPP = 0 – (-5) = +5
0
-5

-5

Ubaidur Rahaman, Senior Resident,...
Beginning of inspiration

0
TPP = PA – Ppl

Ppl = -7

-7

-7
+5 = PA – (-7)
PA = +5 – 7 = -2
-2

-7

-7

Ubaidur Rahaman, ...
Mid inspiration

0

-7

-7

-1
-7

-7

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
End inspiration

0
TPP = PA – Ppl

Ppl = -7

-7

-7
TPP = 0 – (-7)
TPP= +7
0

-7

-7

Ubaidur Rahaman, Senior Resident, CC...
Beginning of passive expiration

0
TPP = PA – Ppl

Ppl = -5

-5

-5
+7 = PA– (-5)
PA = +2
+2

-5

-5

Ubaidur Rahaman, Sen...
Mid expiration

0
TPP = PA – Ppl

PA = +1

-5

-5
TPP = +1– (-5)
PA = +6
+1

-5

-5

Ubaidur Rahaman, Senior Resident, CCM...
End expiration

0
TPP = PA – Ppl

PA = 0

-5

-5
TPP = 0– (-5)
TPP = +5
0

-5

-5

Ubaidur Rahaman, Senior Resident, CCM, ...
In healthy lung during normal tidal respiration
Throughout the respiratory cycle

TPP and TAP remains positive

keeping th...
Beginning of forced expiration
0
+2
+4

TPP = PA – Ppl

+6
+8

+10

+10

+10

Ppl = +10

+13

+7 = PA– (+10))

+15

PA = +...
forced expiration
0
+2
+4
+6

TAP = Paw – Pp
+8

+10

+10

TAP = (+10) – ( +10) = 0

+10

+13

Equal Pressure Point ( EPP)...
Equal Pressure Point ( EPP)
Point in airway where TAP is zero during expiration

Dynamic Airway Collapse
Point in airway d...
Counter balance of Dynamic Airway Collapse

First 11 generation of airway ( bronchi)
supported by cartilage ring/ plates

...
Equal Pressure Point

Dynamic point

As airway resistance increases
or
Lung volume decreases

Moves closer to Alveoli

Uba...
FORCED EXPIRATION
0

0

+2
+4
+2

+6

+10

+8

+10

+10

+4

+10

+6

+10

+13

+10

+15

+12

+17
+10

+10

Beginning of ...
Expiratory Flow Limitation
can be a manifestation of

Airway disease
COPD, Asthma
Destruction of cartilage of airway

Lung...
IN HEALTHY LUNG

During quiet breathing
There is no dynamic airway collapse
No expiratory flow limitation

During forced e...
Dynamic airway collapse during Coughing

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Flow and Time Relationship
Of
Respiratory system

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Concept of
Closing Volume & Closing Capacity

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Effect of gravity
+
weight of lung

Vertical gradient
in
Ppl and TTP

Dependent alveoli have lesser volume
than non depend...
PLEURAL PRESSURE AND TPP GRADIENT
(At FRC)

BODY
POSITION

TOP OF
LUNG

BOTTOM OF
LUNG

Ppl

TPP

Ppl

TPP

UPRIGHT

-8

8...
P- V curve of Respiratory system at different Lung volumes
VERTICAL GRANIDIENT

FRC
Ubaidur Rahaman, Senior Resident, CCM,...
P- V curve of Respiratory system at different Lung volumes
VERTICAL GRANIDIENT

TLC

RV

Ubaidur Rahaman, Senior Resident,...
IN HEALTHY LUNG

During forced expiration

Dynamic airway collapse occurs
starting from dependent lung regions

Critical v...
CLOSING CAPACITY

5.0

TLC
In healthy lung
44 years
CC= FRC in supine position

3.0
2.5

1.25

CC

66 years
CC = FRC in up...
Effect of PEEP on CLOSING CAPACITY

5.0

TLC

PEEP

3.0

CC

2.5

FRC

1.25
RV

0

Ubaidur Rahaman, Senior Resident, CCM, ...
TIME CONSTANT

length of time required to fill or empty lung units

Function of
Alveoli = compliance
Airway= resistance

T...
normal

TC ↓
Decreased compliance

TC ↑

Increased resistance
Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, Ind...
Obstructive Airway Disease

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Increased Airway Resistance

dynamic airway collapse

Expiratory Flow Limitation
Air Trapping

Increased End Expiratory Lu...
v

FRC
T

DHI is probably an adaptive response to overcome DAC

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, I...
Initially DHI

Increases elastic recoil of lung ---- opens airway---- improves expiratory flow

But
Comes
At
price
Ubaidur...
P-V CURVE OF RESPIRATORY SYSTEM
Healthy lung- tidal ventilation
V
TLC
IRV
IC
TV
FRC
ERV
RV
P

Ubaidur Rahaman, Senior Resi...
P-V CURVE OF RESPIRATORY SYSTEM
Healthy lung - exercise
V
TLC
IRV
IC
TV
FRV
ERV
RV
P

Ubaidur Rahaman, Senior Resident, CC...
P-V CURVE OF RESPIRATORY SYSTEM
Chronic obstructive airway disease- tidal breathing
V
TLC
IRV
IC
TV
EELV

RV
P

Ubaidur Ra...
P-V CURVE OF RESPIRATORY SYSTEM
Chronic obstructive airway disease- exacerbation
V
TLC
IRV
IC
EELV
EELV

RV
P

Ubaidur Rah...
EFFECT ON GAS EXCHANGE

Increased EELV

More Zone I and II formation

Increased dead space

V/Q mismatch

Increased minute...
EFFECT ON DYNAMIC MECHANICS

Displacement of respiratory system towards upper flatter portion of P-V curve
P-

Altered geo...
EFFECT ON DYNAMIC MECHANICS

Before starting inspiratory flow must overcome this increased elastic load
Effort required to...
EFFECT ON HEMODYNAMICS

Increased EELV

Increased ventilatory drive

Increased TPP

More negative pleural pressure

↓ prel...
EFFECT ON PATIENT

Increased
ventilatory drive

Increased
WOB

anxiety

Neuromechanical
discoupling

VQ mismatch

Worsenin...
forced expiration
( obstructive airway disease)
0

0
+3

+4

+4

+2

+4

+4

+4
+5

+2

+4
+5

+6
+4

+6
+4

+4

+4

Purse...
MANAGEMENT
GOAL

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
CORRECTION OF GAS EXCHANGE
REDUCTION OF WOB

CORRECTION OF
LUNG MECHANICS

TREATMENT OF BASELINE DISEASE

Ubaidur Rahaman,...
CORRECTION OF LUNG MECHANICS

Prevention of DHI

Reduce airway resistance
Treatment of disease

PPV
PEEP
•Easy Inspiratory...
Positive Pressure Ventilation

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
PEEP
For easy inspiration

+7

o

-11
+10

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India

-4
+10
Beginning of inspiration

0
TPP = PA – Ppl

Ppl = -7

-7

-7
+5 = PA – (-7)
PA = +5 – 7 = -2
+10

-7

-7

Ubaidur Rahaman,...
PEEP
For easy expiration
+3

+4

+4

+4
+5

+6
+4

+4
PEEP

Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
Setting total cycle time
Flow rise
cycling
Calculation of expiratory time
Calculation of TCT

Ubaidur Rahaman, Senior Resi...
the difficulty lies, not in new ideas,
but escaping old ones,
which ramify, for those brought up with them,
as most of us ...
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Expiratory flow limitation_diseases

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Expiratory flow limitation_diseases

  1. 1. (;3,5$725< )/2: /,0,7$,21 ',6($6( SKVLRSDWKRORJ 8EDLGXU 5DKDPDQ 6HQLRU 5HVLGHQW &&0 6*3*,06 /XFNQRZ ,QGLD
  2. 2. COPD is a disease of resistance during expiration but with the consequence of restriction during inspiration. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  3. 3. Pressure Volume relationship of respiratory system Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  4. 4. P-V curve of Lung, Chest wall and Respiratory system Chest wall Lung TLC Vital capacity % 100 Chest wall and Lung ( respiratory system) 75 50 25 FRC RV 0 -20 0 20 Pressure ( cm H2O) Ppl, Pcw, Prs Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  5. 5. Resting Volume of Respiratory system Elastic force of LUNG = Elastic force of CHEST WALL At End Expiration Functional Residual Capacity (FRC) Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  6. 6. Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  7. 7. LUNG VOLUMES 5.0 IRV IC 3.0 VC TV TLC 2.5 ERV 1.25 FRC RV 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  8. 8. Pressure, Volume and Flow relationship of Respiratory system Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  9. 9. Relationship between intrathoracic pressures TPP = PA – Ppl PA = Ppl + Pel TPP = (Ppl + Pel) – (Ppl) = Pel TPP = Transpulmonary Pressure PA = Alveolar Pressure Ppl = Pleural Pressure Pel = lung elastic recoil pressure Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  10. 10. Relationship between intrathoracic pressures TAP = Paw – Ppl TAP Paw TPP TAP = Transairway Pressure Paw = airway pressure Ppl = Pleural Pressure Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  11. 11. End expiration 0 TPP = PA – Ppl -5 PA = 0 -5 Ppl = -5 TPP = 0 – (-5) = +5 0 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  12. 12. Beginning of inspiration 0 TPP = PA – Ppl Ppl = -7 -7 -7 +5 = PA – (-7) PA = +5 – 7 = -2 -2 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  13. 13. Mid inspiration 0 -7 -7 -1 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  14. 14. End inspiration 0 TPP = PA – Ppl Ppl = -7 -7 -7 TPP = 0 – (-7) TPP= +7 0 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  15. 15. Beginning of passive expiration 0 TPP = PA – Ppl Ppl = -5 -5 -5 +7 = PA– (-5) PA = +2 +2 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  16. 16. Mid expiration 0 TPP = PA – Ppl PA = +1 -5 -5 TPP = +1– (-5) PA = +6 +1 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  17. 17. End expiration 0 TPP = PA – Ppl PA = 0 -5 -5 TPP = 0– (-5) TPP = +5 0 -5 -5 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  18. 18. In healthy lung during normal tidal respiration Throughout the respiratory cycle TPP and TAP remains positive keeping the alveoli and airways patent Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  19. 19. Beginning of forced expiration 0 +2 +4 TPP = PA – Ppl +6 +8 +10 +10 +10 Ppl = +10 +13 +7 = PA– (+10)) +15 PA = +17 +17 +10 +10 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  20. 20. forced expiration 0 +2 +4 +6 TAP = Paw – Pp +8 +10 +10 TAP = (+10) – ( +10) = 0 +10 +13 Equal Pressure Point ( EPP) +15 Dynamic airway Collapse ( DAC) +17 +10 +10 Expiratory Flow Limitation Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  21. 21. Equal Pressure Point ( EPP) Point in airway where TAP is zero during expiration Dynamic Airway Collapse Point in airway distal to EPP, TAP becomes negative, causing airway to collapse No amount of effort will increase the expiratory flow Expiratory Flow limitation Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  22. 22. Counter balance of Dynamic Airway Collapse First 11 generation of airway ( bronchi) supported by cartilage ring/ plates 12th generation and beyond ( bronchioles) supported by tethering effect of elastic recoil of surrounding lung parenchyma Patency of airways is a function of cartilagenous support in bronchi Lung volume in bronchioles Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  23. 23. Equal Pressure Point Dynamic point As airway resistance increases or Lung volume decreases Moves closer to Alveoli Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  24. 24. FORCED EXPIRATION 0 0 +2 +4 +2 +6 +10 +8 +10 +10 +4 +10 +6 +10 +13 +10 +15 +12 +17 +10 +10 Beginning of forced expiration +10 +10 Mid forced expiration Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  25. 25. Expiratory Flow Limitation can be a manifestation of Airway disease COPD, Asthma Destruction of cartilage of airway Lung parenchyma disease leading to reduced lung volume collapse, lung destruction, pneumonectomy Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  26. 26. IN HEALTHY LUNG During quiet breathing There is no dynamic airway collapse No expiratory flow limitation During forced expiration Small degree of dynamic airway collapse can occur (Upto 40% reduction in cross sectional area of airway) Because of invagination of posterior membrane of tracheo bronchial tree Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  27. 27. Dynamic airway collapse during Coughing Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  28. 28. Flow and Time Relationship Of Respiratory system Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  29. 29. Concept of Closing Volume & Closing Capacity Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  30. 30. Effect of gravity + weight of lung Vertical gradient in Ppl and TTP Dependent alveoli have lesser volume than non dependent alveoli Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  31. 31. PLEURAL PRESSURE AND TPP GRADIENT (At FRC) BODY POSITION TOP OF LUNG BOTTOM OF LUNG Ppl TPP Ppl TPP UPRIGHT -8 8 -2 2 SUPINE -4 4 0 0 PRONE -3.5 3.5 0 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  32. 32. P- V curve of Respiratory system at different Lung volumes VERTICAL GRANIDIENT FRC Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  33. 33. P- V curve of Respiratory system at different Lung volumes VERTICAL GRANIDIENT TLC RV Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  34. 34. IN HEALTHY LUNG During forced expiration Dynamic airway collapse occurs starting from dependent lung regions Critical volume of lung during expiration to prevent dynamic airway collapse CLOSING CAPACITY Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  35. 35. CLOSING CAPACITY 5.0 TLC In healthy lung 44 years CC= FRC in supine position 3.0 2.5 1.25 CC 66 years CC = FRC in upright position FRC CC RV Smoking, ageing, obesity, supine position Increases CC 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  36. 36. Effect of PEEP on CLOSING CAPACITY 5.0 TLC PEEP 3.0 CC 2.5 FRC 1.25 RV 0 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  37. 37. TIME CONSTANT length of time required to fill or empty lung units Function of Alveoli = compliance Airway= resistance TC = C R 1 TC = 63% of lung unit fill/ empty 3 TC = 95% “ “ “ 5 TC = 99% “ “ “ Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  38. 38. normal TC ↓ Decreased compliance TC ↑ Increased resistance Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  39. 39. Obstructive Airway Disease Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  40. 40. Increased Airway Resistance dynamic airway collapse Expiratory Flow Limitation Air Trapping Increased End Expiratory Lung Volume ( EELV) DYNAMIC HYPERINFLATION (DHI) Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  41. 41. v FRC T DHI is probably an adaptive response to overcome DAC Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  42. 42. Initially DHI Increases elastic recoil of lung ---- opens airway---- improves expiratory flow But Comes At price Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  43. 43. P-V CURVE OF RESPIRATORY SYSTEM Healthy lung- tidal ventilation V TLC IRV IC TV FRC ERV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  44. 44. P-V CURVE OF RESPIRATORY SYSTEM Healthy lung - exercise V TLC IRV IC TV FRV ERV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  45. 45. P-V CURVE OF RESPIRATORY SYSTEM Chronic obstructive airway disease- tidal breathing V TLC IRV IC TV EELV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  46. 46. P-V CURVE OF RESPIRATORY SYSTEM Chronic obstructive airway disease- exacerbation V TLC IRV IC EELV EELV RV P Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  47. 47. EFFECT ON GAS EXCHANGE Increased EELV More Zone I and II formation Increased dead space V/Q mismatch Increased minute ventilation requirement Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  48. 48. EFFECT ON DYNAMIC MECHANICS Displacement of respiratory system towards upper flatter portion of P-V curve P- Altered geometry of the chest wall Flattened and lowered diaphragm, more horizontal rib cage Respiratory muscles operating at higher lung volumes Increased elastic loading of inspiratory muscles at end expiration Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  49. 49. EFFECT ON DYNAMIC MECHANICS Before starting inspiratory flow must overcome this increased elastic load Effort required to generate tidal volume is more than the muscle can generate at that lung volume Expiratory muscles axis of contraction is altered paradoxical indrawing of lower ribs– hoover sign ribs– •Decreased ventilatory capacity •Functional muscle weakness and fatigue •Increased WOB Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  50. 50. EFFECT ON HEMODYNAMICS Increased EELV Increased ventilatory drive Increased TPP More negative pleural pressure ↓ preload and ↑ afterload of RV ↑ RV preload in face of ↑ RV afterload Series ventriclular interdependence Parallel ventricular interdependence ↓ LV stroke volume LV filing compromised Hypotension LV dysfunction and failure Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  51. 51. EFFECT ON PATIENT Increased ventilatory drive Increased WOB anxiety Neuromechanical discoupling VQ mismatch Worsening hemodynamics Neural drive= Increased RR = decreased expiratory time Expiratory flow limitation = need for increased expiratory time dyspnoea Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  52. 52. forced expiration ( obstructive airway disease) 0 0 +3 +4 +4 +2 +4 +4 +4 +5 +2 +4 +5 +6 +4 +6 +4 +4 +4 Pursed lip breathing PEEP Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  53. 53. MANAGEMENT GOAL Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  54. 54. CORRECTION OF GAS EXCHANGE REDUCTION OF WOB CORRECTION OF LUNG MECHANICS TREATMENT OF BASELINE DISEASE Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  55. 55. CORRECTION OF LUNG MECHANICS Prevention of DHI Reduce airway resistance Treatment of disease PPV PEEP •Easy Inspiratory flow •Prevention of DAC PPV Adequate expiratory time Neuro muscular recoupling sedation,anti anxiety Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  56. 56. Positive Pressure Ventilation Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  57. 57. PEEP For easy inspiration +7 o -11 +10 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India -4 +10
  58. 58. Beginning of inspiration 0 TPP = PA – Ppl Ppl = -7 -7 -7 +5 = PA – (-7) PA = +5 – 7 = -2 +10 -7 -7 Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  59. 59. PEEP For easy expiration +3 +4 +4 +4 +5 +6 +4 +4 PEEP Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  60. 60. Setting total cycle time Flow rise cycling Calculation of expiratory time Calculation of TCT Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India
  61. 61. the difficulty lies, not in new ideas, but escaping old ones, which ramify, for those brought up with them, as most of us have been, into every corner of our minds. - John Maynard Keynes Thank you Ubaidur Rahaman, Senior Resident, CCM, SGPGIMS, Lucknow, India

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