Venti

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Venti

  1. 1. MANAGEMENT OFPATIENTS ON MECHANICALVENTILATION <br />DR. PINAKI MAZUMDER<br />Assistant Professor , Dept. of Anesthesiology, Calcutta Medical College.<br />
  2. 2. INDICATIONS OF MECHANICAL VENTILATION Inadequate tissue oxygenation Inadequate tissue perfusion Inadequate ventilation<br />MECHANISM OF OXYGEN TRANSPORT<br />
  3. 3. Inadequate oxygenationBronchospasm Pneumonia Pulmonary edema – ARDS, Heart FailurePneumothorax<br />Inadequate Perfusion<br />Shock<br /><ul><li> Haemorrhagic
  4. 4. Neurogenic (spinal injury)
  5. 5. Septic shock</li></li></ul><li> Inadequate ventilation<br /> Central cause<br /><ul><li> Head injury
  6. 6. CVA
  7. 7. Meningitis/ Encephalitis</li></ul> Peripheral cause<br /><ul><li>Polyneuritis
  8. 8. Neuromuscular weakness
  9. 9. Muscle dystrophy
  10. 10. Neurotoxic snake bite
  11. 11. Organophosphorus poisoning</li></li></ul><li>Purpose of ventilation<br /> Assist respiration<br /> Increase oxygenation<br /> Wash out CO2<br />
  12. 12. Initiation of mechanical ventilation<br /><ul><li>Oral/ Nasal intubation
  13. 13. Tracheostomy for long term ventilation
  14. 14. Size of endotracheal tube
  15. 15. 8.0 to 8.5 mm for adult males
  16. 16. 7.0 to 7.5 mm for adult females</li></li></ul><li>Checklist prior to intubation<br />Pillow or 10 cm height block under the head<br />Self inflating AMBU bag with oxygen supply<br />Face mask<br />Laryngoscope with different size blades<br />Endotracheal tubes<br />Stylet and Gum elastic bougie<br />Oral and nasal airways<br />Laryngeal mask airway<br />Suction apparatus<br />Necessary drugs<br />
  17. 17. <ul><li>Oral tubes are secured at
  18. 18. 21 to 22 cm mark for males
  19. 19. 19 to 20 cm mark for females
  20. 20. Nasal tubes require 5 cm additional length.
  21. 21. Adhesive tape with counter-traction force for tube fixation
  22. 22. Head is kept at neutral position
  23. 23. Confirmation of tube position by x ray, capnography.</li></li></ul><li>Setting up of Ventilatory parameters<br /> Mode of ventilation<br /> Volume cycled <br /> Pressure cycled <br /> Time cycled<br />
  24. 24. Volume/ Pressure cycled ventilation <br /><ul><li>Controlled mode ventilation (CMV): delivers fixed volume/ pressure at fixed rate
  25. 25. Assist Control mode ventilation (ACV): delivers fixed volume/ pressure in response to spontaneous breath.
  26. 26. Synchronized Intermittent Mandatory ventilation (SIMV): delivers fixed volume / pressure at fixed rate synchronized with spontaneous breath.</li></li></ul><li>Initial Ventilator setting<br />Volume controlled ACV most commonly used.<br />parameters to be set <br /><ul><li>Tidal volume :
  27. 27. 8- 10 ml /kg for normal lung
  28. 28. 5 – 8 ml/kg for abnormal lung
  29. 29. Plateau pressure < 30 cm H2O
  30. 30. High volume -> barotrauma/volutrauma
  31. 31. Low volume -> lung collapse</li></li></ul><li>Respiratory rate<br /><ul><li>Normally set at 10 – 14 /min
  32. 32. High rate ( 20 – 25/ min) in ARDS
  33. 33. Low rate for COPD</li></ul>Minute ventilation : 5 – 10 lt/min<br />Inspiration expiration ratio: 1:2 to 1: 3<br />Oxygen concentration :start with 100% , decrease to 60 % to achieve SpO2 >90% or PaO2 > 60 mm Hg<br />
  34. 34. <ul><li> Inspiratory flow rate : 40 – 60 lt/min </li></ul>Positive End Expiratory Pressure (PEEP) : <br /><ul><li> prevents lung collapse and improves oxygenation
  35. 35. used if SpO2 < 90% on FiO2 0.6
  36. 36. start with 3-5 cm H2O , increase up to 15 cm H2O
  37. 37. Activate all the alarms ( high pressure , low pressure , apnoea)</li></li></ul><li>Monitoring during ventilation<br />Oxygenation : SpO2 > 90% , Pa O2 > 60 mm Hg<br />Ventilation: PaCO2 35- 40 mm Hg<br />Tissue perfusion : <br /><ul><li> Arterial pH 7.35 to 7.45
  38. 38. Base excess
  39. 39. Plasma lactate</li></li></ul><li>Airway pressure <br />Peak Inspiratory Airway Pressure ( PiAP)<br />End Inspiratory Plateau Pressure ( PiEP)<br /> When peak pressure increases but plateau pressure is unchanged , it indicates increased airway resistance; manage with tube suction with or without bronchodilator nebulization.<br />If peak and plateau pressure both are increased it indicates decreased lung or chest wall compliance.<br />
  40. 40. Additional monitoring<br /><ul><li>Flowchart of vital signs
  41. 41. Ventilatory settings
  42. 42. Tidal volume
  43. 43. Respiratory rate
  44. 44. Minute volume
  45. 45. Peak and Plateau pressure
  46. 46. Static and Dynamic compliance
  47. 47. Gas exchange parameters- PaO2. FiO2</li></ul> periodically recorded.<br />
  48. 48. Goal of Ventilation<br />Adequate oxygenation and ventilation<br />Prevent oxygen toxicity by using FiO2 < 0.6<br />Use PEEP in refractory hypoxia<br />Maintain normal blood volume, pump function, cardiovascular parameters.<br />Adequate Hb concentration<br />Humidification of the inspired gas<br />Frequent aseptic tracheo-bronchial suction<br />Good physiotherapy and Organ support.<br />
  49. 49. Problems during Ventilation<br />Asynchrony between patient and ventilator :<br />Reassure the patient , give sedative analgesic.<br />Increase minute ventilation<br />Give higher FiO2<br />Increase inspiratory flow rate <br />Manually ventilate with 100% oxygen for 5 minutes- if severe resistance felt, change the tube.<br />Rule out associated problems- acidosis, electrolyte disorders, pain, fever , shock, full bladder or stomach.<br />Neuromuscular blocker - as last resort.<br />
  50. 50. Managing alarm system<br /><ul><li> Low airway pressure alarm
  51. 51. Disconnection/ leak in circuit
  52. 52. Leakage in cuff
  53. 53. Ventilator malfunction
  54. 54. High airway pressure alarm
  55. 55. Kinking /Blockade of ET tube/ tracheostomy tube
  56. 56. Bronchospasm
  57. 57. Decreased lung compliance
  58. 58. Oxygen alarm
  59. 59. Apnoea alarm</li></li></ul><li>Hypotension <br /><ul><li>due to high inflation pressure , PEEP , COPD .
  60. 60. Preexisting hypovolemia Rx : fluid, vasopressors</li></ul>Infection control<br /><ul><li> Hand washing
  61. 61. Aseptic suction
  62. 62. Physiotherapy
  63. 63. Postural drainage
  64. 64. Sterilization of humidifier/breathing circuit</li></li></ul><li>Gastro intestinal complications<br /> Gastric distension<br /> GI bleeding<br />Water retention<br />Pressure sore<br />
  65. 65. Weaning from ventilator<br />Patient clinically stable ,underlying disease improved<br />PaO2 > 70 mmHg , PCO2 < 45 mm Hg on FiO2 0.4 , acid base status, electrolytes, blood biochemistry, and chest x ray are near normal <br />Hemodynamically stable<br />No fever or Organ failure or Bleeding<br />Nutritional status is good<br />Neuromuscular function is adequate.<br />bedside test: if respiratory rate > 30 or tidal volume < 300 ml then continue ventilation<br />
  66. 66. Modes of weaning<br />Patient connected to ventilator<br /> Pressure Support Ventilation (PSV)<br /> SIMV with gradual decrease of rate.<br />Patient removed from ventilator<br /> Daily T piece trial of 60 mins or initial 15 – 30 mins trial followed by progressive increase in trial duration over the whole day.<br />Extubate if no respiratory distress / clinically stable.<br />
  67. 67. Thank you.<br />

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