Under Appreciated Signs In Ventilator Monitoring

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Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com

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  • No siempre. Nosotros estudiamos 17 pacientes con distres la mayoría por neumonía, ventilados con una estrategia protectiva con VT < 8 ml/kg y PEEP > LIP, al aplicar la MR (PC 50 y PEEP > UIP) . Como pueden observar la respuesta a la MR fue muy variable entre los diferentes sujetos. 10 de ellos no respondieron a la maniobra y en los 7 restantes el efecto se había perdido a los 15 minutos. ¿Por qué no siempre son efectivas? En los pacientes que no respondían a la MR, representados con triángulos, el deterioro de la oxigenación se relacionaba con un aumento del shunt intrapulmonar lo que sugiere que durante la MR se sobredistienden alveolos sanos comprimiendo los capilares subyacentes y redistribuyendo el flujo pulmonar hacia las zonas enfermas.
  • Figure 7-7: From top to bottom, tracings of airflow (flow), airway pressure (Paw), esophageal pressure (Pes), and tidal volume (volume). Each mark on the time axis denotes one second. Note the marked breath-by-breath variability in inspiratory muscle effort (esophageal pressure swings) and airway pressure profile. There is profound patient-ventilator dysynchrony and numerous inspiratory attempts fail to trigger the ventilator. It is also remarkable how difficult it can be to estimate the end-inspiratory plateau airway pressure in such circumstances.
  • Under Appreciated Signs In Ventilator Monitoring

    1. 1. Lluís Blanch M.D., Ph.D. Consultant Critical Care Scientific Director Corporació Parc Taulí Universitat Autónoma de Barcelona Sabadell, Spain. Cairo 3 - 4 February 2010 Under Appreciated Signs in Ventilator Monitoring 10th Pulmonary Medicine Update Course
    2. 2. Relationship of PaO 2 to True Shunt for Three Values of FiO 2 30 %
    3. 3. The definitions of ARDS and ALI require the use of standard ventilator settings to ensure that patients with consistent levels of lung injury are properly classified as having ARDS or ALI In 170 pts meeting ARDS criteria (PaO 2 /FiO 2 < 200 mmHg ) diferent combinations of FiO 2 & PEEP at VT 7 ml/kg were obtained in Day 0 and in Day 1. PaO 2 /FiO 2 156 mmHg PaO 2 /FiO 2 247 mmHg PaO 2 /FiO 2 370 mmHg
    4. 4. Am J Respir Crit Care Med 2002; 165: 165-170
    5. 5. Relationship between RM-induced changes in PaO 2 /FiO 2 & Qva/Qt in ARDS Am J Respir Crit Care Med 2002; 165: 165-170 r=-0.85 p<0.01 Patients
    6. 6. Normal Volumetric Capnogram Fletcher R, Jonson B, Cumming J, Brew J. Br J Anest 1981;53:77-88 Blanch L, Romero PV, Lucangelo U. Minerva Anesthesiol 2006;72:577-85 Exhaled Volume PCO 2 Phase I Phase II Phase III PaCO 2 PetCO 2 Effective Alveolar Ventilation
    7. 7. Verschuren F et al Intensive Care Med 2004; 30:2129-2132 Volumetric Capnography as a Bedside Monitoring of Thrombolysis in Major Pulmonary Embolism
    8. 8. Crit Care Med 2006;34:1202-8 Odds Ratio of Survival J Trauma 2007;62:1330-8
    9. 9. Components of Exhaled Tidal volume Using a Capnogram Physiologic dead space sub-divided into anatomic dead space and alveolar dead space VD phys /VT = PaCO 2 -P E CO 2 PaCO 2
    10. 10. Bidani A, et al. JAMA 1994; 272:957-962 An increase in dead space represents an impaired ability to excrete CO 2 Target V E in ARDS . Physiologic Consecuences of High V D /V T at Different V E .
    11. 11. Nuckton TJ et al. N Engl J Med 2002; 346:1281. Observed Mortality According to the Quintile of Dead-Space Fraction in 179 Patients with ARDS Mechanisms: 1- Injury of pulmonary capillaries by thrombotic and inflammatory factors. 2- Obstruction of pulmonary blood flow in pulmonary circulation. 3- Lung areas with high V/Q ratio (impaired CO 2 excretion)
    12. 12. Exhaled Volume PCO2 Phase I Phase II Phase III PaCO2 PetCO2 Effective Alveolar Ventilation
    13. 13. Prognostic Value of Volumetric Capnography Indices in Patients with ALI/ARDS receiving Mechanical Ventilation The difference between VAE/VT-48h and VAE/VT-adm (ΔVAE/VT) show SS of 73% and SP of 93% with LR 10.2 and area under ROC curve of 0.83. Physiologic dead space after 48h predicted survival (p = 0.02) with an area under ROC curve of 0.75, LR of 8.8, SS 63% and SP 93%. Lucangelo U et al. Chest 2008;133:62-71 V AE /V T adm-48h 0.83 (0.67-0.93) 0.2 0.4 0.5 0.6 0.7 0.3 Adm 48 h 24 h * * ns p<0.05 V AE /V T S D SS 73% SP 93%
    14. 14. Volumetric Capnography & Lung Recruitment Blanch L, Lucangelo U. Capnography and adjuncts to mechanical ventilation. New York, Cambridge University Press 2004; 163-174.
    15. 15. Volumetric Capnography in Patients with Acute Lung Injury: Effect of PEEP on CO 2 Slope Blanch L et al. Eur Respir Dis 1999;13:1048. CONTROL ALI ARDS
    16. 17. tachycardia intercostal recession supresternal & supraclavicular recession sternomastoid activity diaphoresis & nasal flaring cyanosis tachypnea abdominal paradox Tobin MJ. Principles and Practice of MV. 1994. Dissynchrony between Patient & Ventilator
    17. 18. Paw VT CO 2 ECG Assist Control Ventilation . Double Cycling V .
    18. 19. Pressure support ventilation Double Cycling Paw CO 2 Pes V .
    19. 20. Mancebo J. Assist-control ventilation. In: Principles and practice of mechanical ventilation. 2 nd ed. Tobin MJ, Ed. Mc Graw-Hill. New York, 2006, pp 183-200
    20. 21. PSV: Ineffective Efforts Brochard L. Principles & Practice of Mechanical Ventilation. Tobin M, ed. 2007 <ul><li>Can occur when: </li></ul><ul><li>too much PSV </li></ul><ul><li>- presence of autoPEEP </li></ul>Paw (cmH 2 O) Pes (cmH 2 O) Flow (L/s) Time (s)
    21. 22. ECG Paw VT Pes Pressure support ventilation Dyssynchronies V .
    22. 23. Pressure support ventilation Dyssynchronies Pes CO 2 Paw V .
    23. 24. Intensive Care Med. 2006 Oct;32(10):1515-22.
    24. 25. Technology Employed to Provide Efficient Care of the Critically Ill Patient <ul><li>accurate </li></ul><ul><li>simple to operate </li></ul><ul><li>stable </li></ul><ul><li>reliable in extreme physiologic conditions </li></ul><ul><li>easy user interface </li></ul><ul><li>data available on line and stored in EMR </li></ul><ul><li>improve outcomes </li></ul><ul><li>cost effective </li></ul>

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