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Intro to Mechanical Ventilation for Residents

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An introduction to mechanical ventilation delivered at Nassau University Medical Center on 1/27/2016

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Intro to Mechanical Ventilation for Residents

  1. 1. Mechanical Ventilation David Marcus, MD @EMIMDoc – EMIMDoc.org Emergency Medicine/Internal Medicine/Medical Ethics, LIJ Medical Center Nassau University Medical Center – 1/272016
  2. 2. Goals General principles What to use when Basic settings and modifications Monitoring Trouble Shooting
  3. 3. To vent or not to vent? 85 y/o M c CHF, rales on physical exam, breathing comfortably, O2 sat 90% 45 yr old F, morbidly obese c OSA in extreme respiratory distress 20 y/o F c h/o asthma, multiple intubations in the past, audible wheeze, RR 22 94 y/o F, minimally responsive c HR 32, BP 60/palp, RR 10, O2 sat 95% ORA
  4. 4. On two things the world stands Ventilation Oxygenation RR Vt FiO2 V/Q
  5. 5. Types of mechanical ventilation
  6. 6. Uses of NIPPV • COPD: Fewer intubations, mortality benefit. • CHF: Fewer intubations, mortality benefit • PNA: May use for hypoxia. No clear evidence. • Asthma: Impending respiratory failure. Unclear data. • DNI • OSA • DSI OTHER…
  7. 7. Modes CPAP When CO2 OK, but cannot oxygenate BiPAP For CO2 help (+/- O2 problem) To decrease CO2, increase delta To increase O2, increase i/ePAP
  8. 8. Running the Numbers • Initial BiPAP setting: 10/5 cmH2O • Max iPAP 20-25 cmH2O • Max ePAP 10-15 cmH2O • Start FiO2 at 1.0 and titrate • Back up rate 12-16 / min
  9. 9. Know This! • Contraindications: – Cardiac arrest – MI – Apnea – Sufficiently impaired LOC – Copious secretions/emesis – Facial trauma/impaired AW • Likely to fail in severe acidosis, ARDS
  10. 10. Invasive
  11. 11. Indications for Intubation • Failure to maintain AW (loss of reflexes) • Failure to maintain AW tone • Failure to ventilate • Failure to oxygenate • Clinical course expected to result in any of the above
  12. 12. Contraindications Loss of upper AW anatomy Total upper AW obstruction Relative contraindication: Anticipated difficult AW
  13. 13. Vents • Control mechanisms 1. VCV (fixed volume) 2. PCV (fixed pressure) • Variables: – Trigger (what starts a breath): flow, pressure, time – Limit: Pressure, Flow – Cycle (what ends a breath): Time, flow, Pressure, Volume
  14. 14. Modes 1. CMV – Machine breaths only 2. AC – fixed number of machine breaths + pt triggered breaths at fixed volume. 3. SIMV – fixed rate/volume machine breaths + pt triggered breaths limited by pt effort 4. May use pressure support (PSV) in SIMV or CPAP – provides additional support during spontaneous inspiration (to overcome resistance of system).
  15. 15. Other modes • APRV (airway pressure release ventilation) • PAV (proportional assist ventilation) • Prone positioning • IRV (inverse ratio ventilation) • Permissive hypercapnia (goal = decreased peak AW pressure, i.e. in asthmatics) Via lower RR, lower Vt.
  16. 16. Settings Rate FiO2 Vt PEEP (Pressures) i:e ratio
  17. 17. PEEP – Uses – Risks • Decreased venous return • Barotrauma • Increased ICP • GI Ulceration • Fluid retention (increased ADH vs decreased ANP)
  18. 18. PEEP Benefits • Improved V/Q Matching • Decreased Shunt • Decreased atelectasis • Decreased alveolar trauma • Supported spontaneous breathing
  19. 19. Doctor, what settings would you like? • Mode • Rate (12-14) • FiO2 (Start at 1.0 and titrate down) • PEEP (~5 cmH2O) • Vt (6-8 ml/kg) • (I:E ratio)
  20. 20. Patient Specific Management • 56 yr old M, traumatic PTX/rib fractures • 28 yr old obese F, severe influenza, ARDS • 76 year old M, subarachnoid hemorrhage • 18 yr old F, severe asthma, now intubated • 82 yr old M, septic shock
  21. 21. Monitoring • Clinical Observation • Pulse Oximetry • ABG/VBG • Capnometry (End Tidal CO2) • BMP • Peak and Plateau pressures, Auto-PEEP • Volumes/Air Leak
  22. 22. You’re Doing Great! • Your intubated patient is doing well. • Sats are good, he appears comfortable. • And then…
  23. 23. Don’t Worry – It’s All DOPE(s) Why is the patient is hypoxic? • D – Dislodged Tube/Disconnect • O – Obstructed system • P - Pneumothorax • E – Equipment Failure • (S – Stacked breaths, if asthmatic)
  24. 24. Don’t Worry – It’s All DOPE(s) D O P E S Check connections, confirm tube placement via ETCO2 (+/- direct visualization) Check all tubing, suction deep into ETT Ultrasound or CXR to r/o pneumothorax Disconnect the vent and attach a BVM In asthmatics, disconnect the vent and listen
  25. 25. Though, it’s more like SEDOP • First, disconnect the vent, • then switch to a BVM. • Confirm tube placement, • Suction, check for obstructions • Verify and reconnect tubing • Check for PTX (depending on suspicion)
  26. 26. When to come off the vent? • As soon as possible • Two questions: – Can the pt protect the AW? – Can the pt oxygenate and ventilate?
  27. 27. Decision tools RSBI = RR/Vt(Liters) RSBI>105 = poor prognosis for weaning (PPV 65%, NPV 95%) First --- oxygenating well on low FiO2 and low PEEP Also: • Determine cause of ventilatory dependance • Rectify correctible problems • Address: – Fluid balance – Mental status and psychological factors – Acid-base status – Electrolyte disturbance
  28. 28. Weaning Methods • T tube trial • IMV • PSV • NPPV
  29. 29. Vent complications • PTX • Biotrauma (the injury formerly known as barotrauma): overdistention or rupture, alveolar hypoperfusion, and repetitive shear stresses across alveolar walls • Hemodynamic compromise • VAP
  30. 30. Summary • What’s the patient’s problem? – CO2/O2/AW • NIPPV – Know settings, contraindications! • IPPV – Modes, General vent settings – DOPE(s) • Further reading: Vent strategies for restrictive vs obstructive lung disease
  31. 31. Summary • 45 yr old F, morbidly obese c OSA in extreme respiratory distress? – NIPPV? – IPPV? – No mechanical ventilation?
  32. 32. NIPPV may be used in all of the following, except: 1. COPD 2. CHF 3. CPR 4. Pneumonia 5. Asthma 6. Myesthenia gravis
  33. 33. The most appropriate Mode/Vt for a sedated, ventilated patient with normal lungs: 1. CMV/6-8 ml/kg TBW 2. CMV/6-8 ml/kg IBW 3. AC/10-15 ml/kg TBW 4. AC/6-8 ml/kg IBW
  34. 34. THANK YOU! The slideset is now available at: www.EMIMDoc.org

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