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Emergency lectures - Ventilation lecture
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Emergency lectures - Ventilation lecture

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  • 1. Ventilation Assisted Breathing
  • 2. Ventilation
  • 3. Basics
    • Inhalation
      • Oxygen is 21% of the air we breath
      • The rest is mostly nitrogen
    • Exhalation
      • Mostly carbon dioxide and nitrogen exiting
    • Individual alveoli are responsible for gas exchange
  • 4. Basics
    • Oxygenation
      • Oxygenating the blood is determined by how much air is in the lungs
        • More filled alveoli equals more oxygen available
    • Ventilation
      • How many breaths per minute determines how much carbon dioxide leaves the blood
  • 5. Lung Structure
  • 6. Basics
    • Lung Volume – how much air fills the lungs
      • Usually 10-15 mL per kg
        • Adults: 500-700mL
        • Pediatrics: Neonatal 60-100mL
      • May need to decrease volume depending if both lungs are working
        • Check for excessive chest rise on one side
  • 7. Basics
    • Compliance
      • How easily the lungs expand
        • May need increased pressures for poor compliance to get adequate chest rise
      • Poor compliance
        • Asthma, pneumonia, TB
        • Anything that causes the lungs not to expand normally
  • 8. Basics
    • PEEP - Positive End Expiratory Pressure
      • Pressure to keep alveoli open after expiration
        • We do this automatically by closing the epiglottis at the end of expiration
      • This can be done with a bag by not letting all the air out at the end or using a PEEP valve
  • 9. Basics
    • Pulse oximetry
      • Use to determine the adequacy of bagging
      • Very low pulse ox may be due to low oxygen in the blood, or due to where the pulse ox is located
      • If pulse ox reads very low but patient looks well, it may be a bad reading
  • 10. Basics
    • Air leak – air leaking from around the ETtube
      • May need increased air volume if a large amount of air is leaking out before going into lungs
      • Usually want to hear some air around the tube before taking the tube out, if no leak you may need steroids to avoid airway swelling
  • 11. Basics
    • Wheezing and poor compliance
      • Use decreased tidal volumes
      • Use albuterol on a regular basis
  • 12. Initial Airway management
    • Secure Endotracheal tube (ET tube)
      • Usually distance at lips is 3 times the size of tube
      • Check for bilateral breath sounds to avoid right sided tube
      • Check for bilateral chest rise and fall
      • Check a chest x-ray
    • Suction airway
      • May need to suction every 10-30 min initially, then every few hours to keep tube open and mucous low
  • 13. Ventilation
    • Start bagging at smallest volume that allow chest rise and fall
      • You want 10-15mL per kg tidal volume
      • You want both sides of chest equal
    • Breath rates
      • Neonatal: 20-25 breaths per minute
      • Young children: 15-20 breath per minute
      • Adult: 10-15 breaths per minute
  • 14. Ventilation
    • If patient is breathing try to give breath when patient inhales
    • Try to allow complete exhalation to avoid air stacking
  • 15. Complications
    • Immediate change in status
      • Pneumothorax: popping the lung causing collapse of one lung
      • Tube dislodgement : usually after moving patient or pulling on tube
      • Mucous plugging : needs immediate suctioning and maybe removal of tube
  • 16. Pneumothorax
  • 17. Pneumothorax
  • 18. Complications
    • Accumulative damage
      • Barotrauma: damage to alveoli due to high pressures
      • Overbagging: causing alkalosis due to decreased carbon dioxide (blowing off all the CO2)
      • Pneumonia: Infection due to collapsed alveoli
  • 19. Troubleshooting
    • Poor chest rise
      • Recheck breath sounds
      • Suction tube
      • Increase inspiratory pressure
  • 20. Troubleshooting
    • Low Pulse Ox
      • Check for cyanosis/pulse ox misplaced
      • Check breath sounds
      • May need to increase respiratory rate
      • May need oxygen supplementation
  • 21. Troubleshooting
    • Difficult to bag
      • Check breath sounds
      • Ensure tube is not in right bronchus
      • Suctioning
      • If patient is fighting against you try to bag with patient and consider further sedation
  • 22. Right Main Bronchus
  • 23. Case 1
    • 1 year old with pneumonia
      • Has difficulty breathing and was just intubated
      • What do you do first
  • 24. Case 1
    • What size tube was used?
      • At 1 yrs old use equation (age+16)/4
        • Normally 4.0
    • So where should the tube be placed?
      • 3 x 4.0 = 12cm
  • 25. Case 1
    • You do not hear breath sounds on left, what happened?
      • Likely the tube is in the right bronchus
      • Pull back tube 1 cm and listen again
  • 26. Case 1
    • As you bag there is lots of mucous in the tube and the pulse ox is low at 85%
      • Be sure to suction regularly to open the tube and recruit alveoli
      • Consider chest physical therapy to break up mucous and or pneumonia
  • 27. Case 1
    • The next day all of a sudden the pulse ox drop to 75% and there is only chest rise on the left with poor breath sounds on the right… What happened?
  • 28. Case 1
    • Possibly a pneumothorax versus a mucous plug
      • Try to suction first
      • If no improvement with suctioning, you need to think pneumothorax which may need needle decompression
  • 29. Pneumothorax
  • 30. Case 2
    • A 40 year old man is intubated due to COPD with lots of wheezing and you have difficulty bagging the patient, what can you do?
  • 31. Case 2
    • You add albuterol but it is still hard to bag the patient and now it seems he is not exhaling completely, what should you do?
  • 32. Case 2
    • You can decrease the volume and allow a longer period of time for exhalation (1:2)
  • 33. Case 2
    • After moving the patient to change the sheets you notice that now only the right side of the chest is moving and there are diminished breath sounds on the left, what may have happened?
  • 34. Case 2
    • Check for where the tube is placed, be sure it has not moved down past the carina
    • Try suctioning, try moving tube back 1 cm
  • 35. Case 2
    • When you move the tube back 1 cm you now hear breath sounds on both sides and the chest wall is moving bilaterally

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