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Bilgrami, Irma — Reading the Vent Like an ECG

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Bilgrami, Irma — Reading the Vent Like an ECG

  1. 1. Reading the Ventilator Like An ECG
  2. 2. OBJECTIVES SYSTEM Incorporate ventilator information in patient assessment
  3. 3. Course in mechanical ventilation Advanced course in ventilator waveform analysis Respiratory physiology
  4. 4. WHAT IS NORMAL- in brief HAVE A SYSTEM- like an ECG CASE STUDIES
  5. 5. What is normal??? Ventilators Alarms Ventilator graphics
  6. 6. PRESSURE FLOW VOLUME VENTILATOR GRAPHICS WAVEFORMS LOOPS Pressure vs volume Flow Vs Volume
  7. 7. Volume Mode P CmH20 30 20 10 0 Flow L/min 80 40 0 -40 Vt mls 300 200 100 0 Time(s) Time(s) Time(s) A B C a b c d e f
  8. 8. Time Time Time Pressure Mode Volume Pressure Flow Inspiration Expiration Flow wave form = Decelerating Affected by changes in compliance/ resistance Pressure waveform= rectangular Not affected by change in compliance/ resistance
  9. 9. VOLUME mode Descending Ramp Flow Pattern THIS TALK
  10. 10. Have a System
  11. 11. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings
  12. 12. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt Oxygen Saturations End Tidal CO2 Trace Haemodynamics
  13. 13. B) Technical qualityReport ECG findingsDesc ribe Inter pret Patient Assessme nt Know your ventilator ..and the alarms
  14. 14. C) Report Ventilator findingsReport ECG findingsDesc ribe Inter pret Patient Assessme nt 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ?
  15. 15. 3) Report Ventilator findings VOLUME mode Volume set, pressure variable Pressure mode Pressure set, volume variable 1) Mode?
  16. 16. 2) Parameters set 3) Report Ventilator findings Volume Respiratory rate Inspiratory Flow Rate Inspiratory Time FIO2 PEEP 2) Parameters achieved Peak Pressure Volume-expiratory I:E ratio achieved
  17. 17. 3) Information from waveforms/ manoeuvres 3) Report Ventilator findings
  18. 18. Influenced by Compliance Resistance Flow pattern Values Pattern Curve meet baseline VOLUME MODE Values Pattern Peak pressure
  19. 19. ?Problem with airway resistance or lung compliance HIGH AIRWAY PRESSURES
  20. 20. Inspiratory Hold Manoeuvre Assess Plateau Pressure HIGH PLATEAU PRESSURES Low compliance Gas trapping
  21. 21. Expiratory Hold Manoeuvre Assess Auto-PEEP
  22. 22. Values PIFR Values Pattern Expiratory flow reaches baseline well before expiratory time has ended AUC PEFR Pattern VOLUME MODE Set by the user Decelerating Square Not affected by change in lung characteristics
  23. 23. Values Pattern Tidal volume Values Pattern Return to baseline VOLUME MODE time
  24. 24. 4) Interpretation? C) Report Ventilator findings Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance
  25. 25. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
  26. 26. If you change the ventilator settings REASSESS the patient
  27. 27. New Admissions overnight Matt: Drug overdose Rosa: Severe pneumonia Ms Smith: Asthma
  28. 28. Morning Ward Round Matt 24yr old man Drug overdose
  29. 29. 24year old man Benzodiazepine overdose Currently intubated/ ventilated Weight 70 kg (predicted body weight) History
  30. 30. Examination
  31. 31. Examination INFUSIONS: Propofol 100mg/hour PHYSICAL EXAM ETT Size 8.5 Minimal secretions Unremarkable exam
  32. 32. Investigations
  33. 33. Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
  34. 34. MODE Parameters set The Ventilator Parameters achieved
  35. 35. Information from waveforms The Ventilator
  36. 36. INTERPRETATION IS VENTILATION SAFE? IS OXYGENATION SAFE? Other ISSUES? Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance I:E ratio of 1:1
  37. 37. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
  38. 38. Morning Ward Round ROSA 36yr Lady Pneumonia
  39. 39. PROBLEM WITH LUNG COMPLIANCE? Lung parenchyma Pleura Chest wall
  40. 40. PRESSURE TIME CURVE Volume mode Values Pattern Increased PIP Same shape. Higher pressures Values Pattern Expiratory limb back to baseline
  41. 41. FLOW TIME CURVE Volume mode Values Pattern Increased Expiratory flow rate Flow pattern normal Area under curve same in both Curve finishes earlier Values Pattern No Change
  42. 42. HISTORY Rosa, 36 year old lady with respiratory failure 2’ to Community acquired pneumonia Day 1 ICU Weight= 80 Kg (Predicted body weight) History
  43. 43. EXAM
  44. 44. INFUSIONS: Morphine 10mg/hr Midazolam: 10mg/hr Noradrenaline : 5 mcg/min EXAM PHYSICAL EXAM ETT Size 8 Purulent secretions Coarse creps , reduced air entry
  45. 45. Investigations PHYSICAL EXAM ETT Size 8 Purulent secretions Coarse creps , reduced air entry ABG pH 7.33 PaCo2 57 PaO2 65 HCO3 24 BE 0 Sats 85%
  46. 46. Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
  47. 47. MODE Parameters set The Ventilator Parameters achieved
  48. 48. Information from waveforms FT The Ventilator Increase Peak pressure ? Plateau pressure Increase Expiratory flow rate
  49. 49. Inspiratory pause Expiratory pause
  50. 50. INTERPRETATION Severe respiratory failure with P/F ratio of 65 Poor lung compliance, with high plateau pressures IS VENTILATION SAFE? IS OXYGENATION SAFE? Other ISSUES? Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance
  51. 51. MANAGE Patient MANAGE Ventilator Position Sedate / Paralyse Fluid balance Lung protective ventilation Optimum PEEP Consider rescue treatments
  52. 52. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
  53. 53. Morning Ward Round Ms Smith 35yr old Exacerbation of Asthma
  54. 54. PROBLEM WITH Resistance? ET tube Increased airways resistance
  55. 55. PRESSURE TIME CURVE Increased Airway Resistance Values Pattern Increased PIP Rapid rise in PIP. Then tapers down Values Pattern Expiratory limb back to baseline VOLUME MODE
  56. 56. Values Pattern FLOW TIME CURVE Increased Airway Resistance Values Pattern Decreased Expiratory flow rate Increased expiratory time Rises to zero baseline just before next breath VOLUME MODE
  57. 57. FLOW TIME CURVE Auto-PEEP Values Pattern Decreased Expiratory flow rate Increased expiratory time Does not reach baseline AUC exp< inp VOLUME MODE Values Pattern No Change
  58. 58. 35 year old lady with respiratory failure 2’ to exacerbation of Asthma Currently intubated Weight 80kg (Predicted body weight) History
  59. 59. Examination
  60. 60. Examination INFUSIONS: Morphine 10mg/hr Midazolam: 10mg/hr Noradrenaline : 2 mcg/min PHYSICAL EXAM ETT Size 8.5 Trachea midline B/L expiratory wheeze
  61. 61. Investigation
  62. 62. Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
  63. 63. MODE The Ventilator Parameters achieved 15 Parameters set
  64. 64. Information from waveforms The Ventilator Increase Early Peak pressures DECREASE Expiratory flow rate INCREASE Expiratory time
  65. 65. Inspiratory pause Expiratory pause Raised Peak pressure Plateau pressure normal No intrinsic PEEP P cmH20 Time
  66. 66. INTERPRETATION IS VENTILATION SAFE? IS OXYGENATION SAFE? Other problems? Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance INCREASED AIRWAY RESISTANCE NO gas trapping
  67. 67. MANAGE Patient MANAGE Ventilator Bronchodilators Steroids Antibiotics Monitor for gas trap
  68. 68. Emergency buzzer
  69. 69. PHYSICAL EXAM Trachea midline Diminished breath sounds
  70. 70. Parameters achieved Parameters set MODE Volume mode F 18, TV 500, Flow 70, FiO2 35%, PEEP 0 Peak pressure 55, I:E 1:4, Volume 430
  71. 71. Information from waveforms
  72. 72. Expiratory pause
  73. 73. INTERPRETATION IS VENTILATION SAFE? IS OXYGENATION SAFE? Other Problems? Gas trapping Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance Dyssynchrony Equipment
  74. 74. MANAGE Patient MANAGE Ventilator Disconnect patient Consider and correct Hypovolemia, Pneumothorax Disconnect patient. Decreased RR Increase Insp flow rate Prolonged I:E
  75. 75. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
  76. 76. Read Ventilator – daily patient assessment Have a System
  77. 77. Modes of Ventilation Loops Dyssynchrony Waveform abnormalities PEEP/ Recruitment
  78. 78. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
  79. 79. 8th Alfred Advanced Mechanical Ventilation Conference (AAMVC) Waveforms Workshop & Physiotherapy Meeting Wednesday, 16 July, 2014 - Friday, 18 July, 2014
  80. 80. References Critical Care Medicine Tutorials http://www.ccmtutorials.com/rs/mv/ Puritan Bennett™ , 840 Ventilator, User’s Pocket Guide http://www.covidien.com/imageServer.aspx/doc228227.pdf?contentID=26430&contentt ype=application/pdf Curves and loops in mechanical ventilation http://www.draeger.net/media/10/08/41/10084127/rsp_curves_and_loops_booklet_90 97339_en.pdf http://lifeinthefastlane.com/education/ccc/pressure-vs-time-graph/ Oh's Intensive Care Manual, 6e Andrew D Bersten, Neil Soni
  81. 81. Report ECG findingsDesc ribe Inter pret Patient Assessme nt THANK YOU

Editor's Notes

  • Provide a system for reading the ventilator
    Reading the ventilator is just not about the waveforms
    Interpret findings in context of the clinical situation
  • Pragmatic talk. My system for incorporating information from vent in patient assessment

    Case based discussions

    Test your knowledge

    NOT: mechanical vent/ waveform/ modes of ventilation
  • DISCLAIMER
  • Assess your patient… with specific attention to …
  • Assess your patient… with specific attention to …
  • Assess your patient… with specific attention to …
  • Resistance and flow PATTERN affect the peak pressure
    Compliance and affect the plateau pressure
  • Change shape
  • Assess your patient… with specific attention to …
  • Predicted body weight based on gender and height
  • Interactions between flow/ IE ratios
  • Flow: exp limb meet baseline just before next breath
    ? Secondary to I:E= 1:1
  • Parameters + Waveforms
    Safe ventilation= No
    Safe oxygenation= No

    Other complications:
    Severe respiratory failure with P/F ratio of 65
    Poor lung compliance, with high plateau pressures
  • Assess your patient… with specific attention to …
  • Also important to exlude problems with pelura and chest wall
  • Same shape
    Hgher
  • Predicted body weight based on gender and height
  • Predicted body weight based on gender and height
  • Predicted body weight based on gender and height
  • Predicted body weight based on gender and height
  • Predicted body weight based on gender and height
  • Interactions between flow/ IE ratios
  • Parameters + Waveforms
    Safe ventilation= No
    Safe oxygenation= No

    Other complications:
    Severe respiratory failure with P/F ratio of 65
    Poor lung compliance, with high plateau pressures
  • Lung protective ventilation
    TV 6ml/kg (PBW)
    Increase RR, permissive hypercapnia
    Aim pH >7.2
    Pplat<30

    Oxygenation aims
    Sats>88%

    Consider rescue treatments
  • Assess your patient… with specific attention to …
  • I am expecting lady with COPD to have bronchospasm--- leading to high resistnce and Pressure. In this setting impotant to exclude other causes of high P- ETT
  • The gas takes a long time to leave patients lungs
  • The gas takes a long time to leave patients lungs
  • Predicted body weight based on gender and height
  • Predicted body weight based on gender and height
  • Interactions between flow/ IE ratios
  • Parameters + Waveforms
    Safe ventilation= No
    Safe oxygenation= No

    Other complications:
    Severe respiratory failure with P/F ratio of 65
    Poor lung compliance, with high plateau pressures
  • Dynamic hyperinflation
    The phenomenon that occurs when a new breath begins before the lung has reached the static equilibrium volume is called dynamic hyperinflation.[1]
  • To qunatify degree of autopeep
  • Parameters + Waveforms
    Safe ventilation= No
    Safe oxygenation= No

    Other complications:
    Severe respiratory failure with P/F ratio of 65
    Poor lung compliance, with high plateau pressures
  • Lung protective ventilation
    TV 6ml/kg (PBW)
    Increase RR, permissive hypercapnia
    Aim pH >7.2
    Pplat<30

    Oxygenation aims
    Sats>88%

    Consider rescue treatments
  • Assess your patient… with specific attention to …
  • Assess your patient… with specific attention to …
  • Assess your patient… with specific attention to …

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