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22 09-12 how do i ventilate normal lung

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Ventilation,Normal lung,more art than science

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22 09-12 how do i ventilate normal lung

  1. 1. How do I ventilate normal lung? Dr Anand.Tiwari F.N.B Critical care medicine. Consultant neuro-intensive care Ruby hall clinic
  2. 2. History 2012 1950
  3. 3. When do I ventilate a normal lung? Brainstem Spinal cord Nerve rootAirway Nerve Neuromuscular junction Respiratory muscle Lung Pleura Chest wall EXTRAPULMONARY Components
  4. 4. Choosing the interface
  5. 5. Increased vascular resistance Decreased venous return Decreased distensibility Decreased distensibility Decreased venous return Alveoli Septal displacement Heart- Lung Interaction Physiology
  6. 6. Volume / Compliance Flow x Resistance Pressure=flow x resistance Alveolar pressure=volume/compliance + PEEP Airway pressure=Flow x Resistance + volume/compliance + PEEP Flow=volume/time B (P A LV)A (P AW) Physics of Positive pressure ventilation
  7. 7. 3 key ventilator phase variables When the breath is delivered What limits gas delivery what end the gas delivery Trigger Limit cycle
  8. 8. Assisted Mode (Volume-Targeted Ventilation) Time (sec)Time (sec) Flow (L/m) Pressure (cm H2O) Volume (mL) Preset VT Volume Cycling Patient triggered, Flow limited, Volume cycled Ventilation
  9. 9. Assisted Mode (Pressure-Targeted Ventilation) Pressure Flow Volume (L/min) (cm H2O) (ml) Set PC level Time (sec)Time (sec) Time-Cycled Patient Triggered, Pressure Limited, Time Cycled Ventilation
  10. 10. SIMV +PS
  11. 11. Pressure support
  12. 12. Physiological PEEP
  13. 13. Case scenario!! • 25 yr old female admitted with history of BZD and antidepressant,no past medical history in. Registrar calls you in evening 7p.m patient is unwell gurgling sounds, mild airway obstruction drowsy .Respiration appears shallow ? • U advise -ABG ? • NIV ? Invasive ventilation.?
  14. 14. Goals during Positive pressure ventilation • Adequacy of ventilation • Oxygenation • Decreased work of breathing • Patient comfort • Synchrony with ventilator • Avoiding complication-VILI,VAP • Early wean ability What mode ?? Which setting ??
  15. 15. Settings • Fio2 • R.r • Tidal volume • I:E ratio • Trigger • Peep • Set alarms
  16. 16. Monitoring during ventilation • Pulse oximetry - 95 % • ABG – pH. 7.32 – PCO2- 55 – Po2 414 – HCO3 28 • EtCo2 -50 • Chest x ray Vitals- P-120/min B.p- 90/60 Note—no replacement to a vigilant Intensivist bedside
  17. 17. Hypovolemia
  18. 18. What next? • Wake up call for consultant? • Registrar reports increase in pressure alarm repeatedly ? U Advice • A)Suction • B)Nebulization • C) Chest X ray
  19. 19. PIP vs Pplat NormalNormal High RHigh Rawaw High FlowHigh Flow Low ComplianceLow Compliance Time (sec)Time (sec) Paw(cmHPaw(cmH22O)O) PIPPIP PPPlatPlat PIPPIP PIPPIP PIPPIP PPPlatPlat PPPlatPlat PPPlatPlat Interpretation of Ventilator Graphics v.1 ©2000 RespiMedu
  20. 20. Complications • Related to intubation and extubation. Ventilator related • Extra pulmonary – gut ischemia, Water ADH +
  21. 21. • F • A • S • T • H • U • G anand tiwari Ancillary care Give your patient a fast hug (at least) once a day* Jean-Louis Vincent, MD, PhD, FCCM
  22. 22. Day 3 patient start to wake up trigger ventilator frequently some breath stacking,vitals stable • Restless ,bites the tube intermittently restless • As reported by the nurse and physiotherapist. • You suggest— • A)weaning • B) Sedate and ventilate ABCDE bundle
  23. 23. Mechanical Ventilation Weaning: Predictors (Parameters) • Respiratory Rate < 30/min • Spontaneous Vt > 4 ml/kg • Inspiratory Pressure > - 20 cm H2O • Breathing Index (f/Vt) < 105 • PEEP < 8 cmH2O • PaO2/FIO2 > 200 • FIO2 < .50
  24. 24. Winning modes Esteban, N Engl J Med 1995; 332:345
  25. 25. Summary of recommendations of weaning • Protocol-directed - favorable outcome • SBT or PS trials than-- SIMV • 30min and 120min trials are equally successful • Twice daily SBT no advantage over once daily • Sedation vacation better outcome. • Early compared to late tracheostomy leads to better outcomes
  26. 26. So mechanical ventilation of normal lung should not end up in an abnormal lung… think & act!!!!!!!!

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