The document provides an overview of the step-wise approach in intensive care unit (ICU) management of a patient in respiratory distress by an intensivist. It discusses:
1) Initial clinical assessment of the unstable patient, including evaluation of vital organ functions like airway, breathing, circulation and neurological status.
2) Non-invasive ventilation techniques like bi-level positive airway pressure and high flow nasal cannula to provide respiratory support without intubation.
3) Other interventions for pulmonary hypertension and hypoxemia like epoprostenol inhalation and heliox gas mixtures.
4) Indications, contraindications and settings for the different respiratory support techniques.
Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding shock, types of shock, stages of shock and its management. Highly recommended for II B.Sc Nursing Students.
Precise guide for DGNM, B.Sc Nursing & M.Sc Nursing Students .. regarding shock, types of shock, stages of shock and its management. Highly recommended for II B.Sc Nursing Students.
Status epilepticus (SE) is a medical emergency that starts when a seizure hits the 5-minute mark (or if there’s more than one seizure within 5 minutes).
Convulsive Status epilepticus-
The convulsive type is more common and more dangerous.
It involves tonic- clonic seizures (grand mal seizures)
In the tonic phase ( lasts less than 1 minute), body becomes stiff and person lose consciousness. Eyes roll back into head, muscles contract, back arches, and trouble breathing.
As the clonic phase starts, body spasms and jerks occur. Neck and limbs flex and relax rapidly but slow down over a few minutes.
Once the clonic phase ends, patient might stay unconscious for a few more minutes. This is the postictal period.Non-convulsive Status epilepticus-
Patient lose consciousness but is in an “epileptic twilight” state.
There might not able any shaking or seizing at all, so it can be very hard for someone observing patient to figure out what’s happening.
A non-convulsive seizure can turn into a convulsive episode.
Poorly controlled epilepsy
Low blood sugar
Stroke
Kidney failure
Liver failure
Encephalitis
HIV
Alcohol or drug abuse
Genetic diseases such as Fragile X syndrome and Angelman syndrome
Head injuries
Status epilepticus (SE) is a medical emergency that starts when a seizure hits the 5-minute mark (or if there’s more than one seizure within 5 minutes).
Convulsive Status epilepticus-
The convulsive type is more common and more dangerous.
It involves tonic- clonic seizures (grand mal seizures)
In the tonic phase ( lasts less than 1 minute), body becomes stiff and person lose consciousness. Eyes roll back into head, muscles contract, back arches, and trouble breathing.
As the clonic phase starts, body spasms and jerks occur. Neck and limbs flex and relax rapidly but slow down over a few minutes.
Once the clonic phase ends, patient might stay unconscious for a few more minutes. This is the postictal period.Non-convulsive Status epilepticus-
Patient lose consciousness but is in an “epileptic twilight” state.
There might not able any shaking or seizing at all, so it can be very hard for someone observing patient to figure out what’s happening.
A non-convulsive seizure can turn into a convulsive episode.
Poorly controlled epilepsy
Low blood sugar
Stroke
Kidney failure
Liver failure
Encephalitis
HIV
Alcohol or drug abuse
Genetic diseases such as Fragile X syndrome and Angelman syndrome
Head injuries
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
Follow us on: Pinterest
Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
New Drug Discovery and Development .....NEHA GUPTA
The "New Drug Discovery and Development" process involves the identification, design, testing, and manufacturing of novel pharmaceutical compounds with the aim of introducing new and improved treatments for various medical conditions. This comprehensive endeavor encompasses various stages, including target identification, preclinical studies, clinical trials, regulatory approval, and post-market surveillance. It involves multidisciplinary collaboration among scientists, researchers, clinicians, regulatory experts, and pharmaceutical companies to bring innovative therapies to market and address unmet medical needs.
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
263778731218 Abortion Clinic /Pills In Harare ,sisternakatoto
263778731218 Abortion Clinic /Pills In Harare ,ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group ABORTION WOMEN’S CLINIC +27730423979 IN women clinic we believe that every woman should be able to make choices in her pregnancy. Our job is to provide compassionate care, safety,affordable and confidential services. That’s why we have won the trust from all generations of women all over the world. we use non surgical method(Abortion pills) to terminate…Dr.LISA +27730423979women Clinic is committed to providing the highest quality of obstetrical and gynecological care to women of all ages. Our dedicated staff aim to treat each patient and her health concerns with compassion and respect.Our dedicated group of receptionists, nurses, and physicians have worked together as a teamof receptionists, nurses, and physicians have worked together as a team wwww.lisywomensclinic.co.za/
ARTIFICIAL INTELLIGENCE IN HEALTHCARE.pdfAnujkumaranit
Artificial intelligence (AI) refers to the simulation of human intelligence processes by machines, especially computer systems. It encompasses tasks such as learning, reasoning, problem-solving, perception, and language understanding. AI technologies are revolutionizing various fields, from healthcare to finance, by enabling machines to perform tasks that typically require human intelligence.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Ozempic: Preoperative Management of Patients on GLP-1 Receptor Agonists Saeid Safari
Preoperative Management of Patients on GLP-1 Receptor Agonists like Ozempic and Semiglutide
ASA GUIDELINE
NYSORA Guideline
2 Case Reports of Gastric Ultrasound
Ocular injury ppt Upendra pal optometrist upums saifai etawah
4 2018 Mirza - Step Wise Approach in ICU Management of a patient in Respiratory Distress.pot.pptx
1. Step Wise Approach in ICU Management of
a Patient in Respiratory Distress:
An Intensivist’s Assessment
Omer Mirza, MD, Intensivist - Covenant HealthCare
2. A THING TO REMEMBER
An education isn't how much you have committed to memory, or
even how much you know. It's being able to differentiate between
what you know and what you don't know.
Anatoly France.
3. INTRODUCTION
Clinical assessment of the acutely unstable patient.
Noninvasive ventilation.
High flow nasal cannula.
Epoprostenol
Heliox
And...if we have time.
Mechanical ventilation.
4. CLINICAL ASSESSMENT OF THE ACUTELY
UNSTABLE PATIENT
Why do things go wrong in an acutely unstable patient?
Evaluation of vital organ functions.
Avoiding typical pitfalls.
5. WHY DO THINGS GO WRONG IN THE
ACUTELY ILL PATIENT?
Vital functions have not been evaluated.
Clinical findings cannot be interpreted.
Search for diagnosis supersedes the evaluation of vital functions.
There is a discrepancy between working diagnosis and clinical
status, its evolution goes unnoticed.
Cookbook medicine obscures the importance of evaluation and
support of vital functions.
6. POINTS TO BE CONSIDERED IN THE
EVALUATION OF A POTENTIALLY UNSTABLE
PATIENT.
Is there dysfunction of vital organs or a high risk for vital
organ dysfunction?
Are there immediate therapeutic or supportive interventions
needed?
What is the likely etiology. Is there a specific treatment
available?
What is the expected clinical course?
What is the immediate response to therapeutic interventions?
And what is the need for further treatment?
Where can the necessary treatment best be commenced in
terms of available resources, logistics, and facilities?
7. EVALUATION OF VITAL ORGAN FUNCTIONS
First question. Is there a problem?
Is cardiopulmonary resuscitation needed?
Evaluation of airway and breathing.
Evaluation of circulation.
Evaluation of the central nervous system.
Dysfunction of other vital organs.
Septic shock.
Avoiding typical pitfalls.
8. IS CARDIOPULMONARY RESUSCITATION
NEEDED?
Unconscious, not breathing, no palpable central arterial
pulse.
No clear contraindication.
Known living will.
Documented prolonged lack of circulation.
Terminal illness.
Initiate CPR.
Simple assessment of level of consciousness (verbal and
physical stimulation) simultaneously observing and checking
respiratory movements and airflow and checking the carotid
pulse.
9. EVALUATION OF AIRWAY AND BREATHING
Is the airway open, and is the patient breathing?
Is the patient dyspneic? Also search for objective signs of dyspnea.
Is the patient tachypneic? (or bradypneic)?
Are breathing movements normal and well coordinated? Are
paradoxical movements present? Does the patient reach a relaxed
end-expiratory volume?
Does the pulse oximetry suggest hypoxemia? Are the blood gases
abnormal?
Are the other vital organ functions stable (especially the
cardiovascular and central nervous systems)?
10. CLINICAL ALARM SIGNS – RESPIRATORY
Tachypnea and increased inspiratory efforts.
Paradoxical or uncoordinated thoracoabdominal respiratory
movements.
Use of auxiliary respiratory muscles.
Concomitant circulatory instability.
Decreased level of consciousness (preterminal symptom in
respiratory failure)
Hypoxemia and hypercapnia.
Hypoxemia and acidosis.
Hypoxemia and combined respiratory and metabolic acidosis
(preterminal finding).
11. PROBABLE CLINICAL COURSE FOR
RESPIRATORY DYSFUNCTION
Expected clinical course relevant for planning treatment strategy.
Rapid recovery scenarios.
Intoxications and respiratory depression, after general anaesthesia, acute attack of
asthma, cardiogenic acute pulmonary edema, pulmonary embolism.
Prolonged recovery scenarios.
Acute lung injury, ARDS, lung contusion, pneumonia induced respiratory
insufficiency, unstable chest wall.
12. EVALUATION OF CIRCULATION.
Are central pulses present?
Is the cardiac output low?
Is the circulation blood volume low, normal, or high?
Are there symptoms and signs of insufficient tissue perfusion?
13. SIGNS AND SYMPTOMS OF ACUTE
HYPOVOLEMIA (ORDER OF APPEARANCE)
Tachycardia
Reduced capillary perfusion.
Reduced peripheral skin temperature (often a clearly
detectable border between warm and cold skin).
Decreased venous filling (first in the periphery and then
centrally).
Oliguria.
Hypotension.
Decreased level of consciousness.
14. CLINICAL ALARM SIGNS -
CARDIOVASCULAR
Hypotension.
Large respiratory variations of pulse pressure.
Hypotension and concomitant decreased level of consciousness.
15. PROBABLE CLINICAL COURSE OF
CIRCULATORY DUSFUNCTION
Rapid recovery scenarios.
Circulatory failure due to hypovolemia, underlying cause treated. Myocardial
ischemia if addressed by medicines or intervention. Even if due to pulmonary
embolism if treatment commenced early and patient is responsive. Tension
pneumothorax and pericardial tamponade if reversed quickly.
Prolonged recovery scenarios.
Pump failure secondary to prolonged ischemia, basic disease that is not rapidly
reversible (myocarditis, vasculitis, acute or chronic heart failure). Septic shock.
16. EVALUATION OF CENTRAL NERVOUS
SYSTEM
Assess level of consciousness.
Does the patient appear alert and are the eyes open?
How big are the pupils are they symmetric and react to light?
Verbal and motor response check.
Is it sufficient to protect the airway?
Hypoxemia, hypercapnea and hypotension can effect neuro
status. Reevaluation after stabilization of circulation and gas
exchange.
Check hypoglycemia and pCO2 as potentially quickly
reversible.
17. CLINICAL ALARM SIGNS - NEUROLOGICAL
Acute reduction of level of consciousness.
New focal neurological signs.
Stiff neck.
Glasgow Coma Scale of less than 9 (usually needs intubation for
airway protection).
Asymmetric pupils. Concern regarding intracranial pathology like
bleed or large stroke.
18. PROBABLE CLINICAL COURSE OF ACUTE
CENTRAL NERVOUS SYSTEM DYSFUNCTION
Rapid recovery scenarios.
Intoxications, hypoglycemia, epilepsy, mild brain injury (concussion), transient
ischemia, promptly treated stroke, less severe subarachnoid hemorrhage.
Prolonged recovery scenarios.
Prolonged ischemia, infections, severe injuries, metabolic encephalopathies.
19. SEPSIS AND SEPTIC SHOCK
Wide array of unspecific symptoms and signs.
Often misinterpreted and often precede acute instability.
Septic infection produce systemic inflammatory response syndrome.
Not specific to sepsis.
Symptoms
Fever, tachycardia, hypotension, impaired capillary perfusion, progressing to
hypovolemia, mental status changes (confusion and agitation), hyperventilation,
dyspnea with hypocapnea and frequently hypoxemia
20. SEPSIS AND SEPTIC SHOCK - 2
Lab findings.
Leukocytosis or leukopenia, thrombocytopenia, increased CRP, lactic acid,
metabolic acidosis. Hypothermic, normothermic or febrile.
Fundamental clinical feature. Septic patient is disproportionately
sick compared to other diagnosis with similar change in vital signs.
Suspect sepsis in patient with signs of cardiovascular, respiratory or
mental instability.
21. RAPID ASSESSMENT AT BEDSIDE
Get overall impression of appearance or behavior.
Speak to patient. Check airflow, observe breathing movements and breath
sounds, check pulses,
Check control of eye opening, pupil size and reaction, and level of
consciousness.
Move to patients side and check breathing movements by palpation. Get
an impression of the thorax and abdomen. Evaluate peripheral venous
filling in upper extremities.
Move to patient legs. Check pulses in femorals, check peripheral venous
filling in feet, edema,
Can be quickly completed in 30 -60 seconds.
22. NONINVASIVE VENTILATION
Allows mechanical ventilation without an ET tube.
Main benefits are decreases in intubation rates, mortality rate, and a
number of infectious complications, particularly pneumonia.
Well established in COPD exacerbations, improvement in blood
gases and lung mechanics, decrease in rates of intubation,
pneumonia and length of ICU and hospital stay.
Also established for pulmonary edema. Controversy if better to use
CPAP or PS with PEEP.
Under study for hypoxemic respiratory failure, immunosuppressed
hypoxemic patients, hasten vent weaning, and to avoid reintubation
after unsuccessful extubation.
23. NIV FOR ACUTE HYPERCAPNIC
RESPIRATORY FAILURE – MECHANISM
Respiratory failure occurs after a period of rapid shallow
breathing, increasing dead space-to-tidal volume ratio
with subsequent hypoventilation and respiratory acidosis.
High respiratory centre stimulation together with large
intrathoracic pressure swings generated by respiratory
muscles are insufficient to generate adequate tidal
volumes.
Rapid shallow breathing facilitate an increase in
pulmonary hyperinflation. This worsens muscle-length
tension.
All of the above contributes to increasing pCO2 and
24. NIV IN HYPERCAPNIC RESPIRATORY
FAILURE
Increase in respiratory effort leads to respiratory pump failure
and then eventually respiratory arrest.
Mechanical ventilation allows rest. Pressure support allows
increased tidal volume with same effort, PEEP (counters auto-
PEEP) reduces patients effort to breathe and markedly
modifies the breathing pattern.
Increase in tidal volume and decrease in rate improves alveolar
ventilation. Helps decrease the pCO2.
The pH improvement in the first hours on BiPAP is a success
predictor.
25. NIV IN CARDIOGENIC RESPIRATORY
FAILURE.
CPAP in cardiogenic respiratory failure improves
oxygenation as it increases functional residual capacity.
Favorable CPAP hemodynamic effects are decrease in RV
preload, which may increase RV afterload, decreases in LV
preload, decrease in LV transmural pressure, and decrease
in LV afterload.
With CPAP, improvement in lung compliance, significant
decreases in elastic and resistive components of the work
of breathing, significant reductions in the work of
breathing.
26. INDICATIONS FOR BIPAP
COPD exacerbation
Acute pulmonary edema.
Selected populations of acute respiratory failure
Other indications
Facilitation of weaning
Post operative respiratory failure.
DNR patients.
Community acquired pneumonia.
OSA and OHS patients.
27. CONTRAINDICATIONS FOR NIV
Non-respiratory organ failure:
Encephalopathy
Severe GI bleeding
Hemodynamic instability with or without cardiac ischemia.
Facial trauma or surgery.
Inability to protect airway, risk of aspiration.
Patient intolerance or uncooperative patient.
Claustrophobia.
28. TECHNIQUES, EQUIPMENT AND
VENTILATOR MODES
Full face masks and nasal plugs cause a greater decrease in pCO2
than nasal.
Nasal masks have greater acceptance.
Usually pressure support with PEEP.
May use ICU ventilator.
Allows patient high control of respiratory rate and timing, inspiratory flow, and tidal
volume.
29. HIGH FLOW NASAL CANNULA
O2 is typically delivered via low flow systems (nasal cannula or
masks) or high flow systems (venturi masks or non-rebreathers).
Do not deliver a reliable fraction of inspired O2.
Poorly tolerated for prolonged periods due to inadequate warming
and humidification.
Newer systems reliably deliver warmed and humidified O2 at high
flows through nasal cannulae.
30. HIGH FLOW O2 NASAL CANNULA
Small pliable prongs. Improved comfort.
Warming and humidification of secretions. Facilitates secretion
removal, prevent desiccation and epithelial injury.
Washout of nasopharyngeal dead space. Improved washout allows a
higher fraction of minute ventilation to participate in alveolar gas
exchange.
Continuous positive airway pressure. Buildup of pressure, peak at
end expiration. PEEP effect. Every 10L/min yields 0.7 or 0.35 cm H20
airway pressure.
High flow rates. Minimal entrainment of room air, more accurate O2
delivery.
31. HIGH FLOW NASAL CANNULA
Parameters needing to be set.
FiO2 and Flow rate.
Indications.
Not absolute. Tried in various settings. Observational studies. No definite benefit.
Still used in place of other high flow O2 systems, better tolerated.
In place of NIV, but unlikely to provide sufficient PEEP in moderate to severe ARDS or
adequate ventilation in patients with hypoventilation. May reduce work of breathing less
than NIV.
32. HIGH FLOW NASAL CANNULA
Medical patients with severe hypoxemic respiratory failure.
Improved oxygenation, lower respiratory rate. Decreased MV and comfort.
Tidal volume unchanged. End-expiratory lung volume and dynamic lung compliance
increased.
No consistent or convincing benefit in outcomes.
Post extubation support.
Post operative respiratory failure.
Intubation support.
33. HIGH FLOW NASAL CANNULA -
CONTRAINDICATIONS
Abnormalities or surgery of the face, nose, or airway that preclude
an appropriate-fitting nasal cannula.
Venous thrombosis. Theoretical. Related to high pressure.
Abdominal distension, aspiration, barotrauma (rare, pneumothorax).
Recognition of ARDS may be impacted due to improved p/f ratio.
Delay in intubation.
34. PULMONARY HYPERTENSION AND POOR
OXYGENATION.
Epoprostenol. (Flolan, Veletri).
Strong vasodilator of all vascular beds.
Potent endogenous inhibitor of platelet aggregation. The
reduction in platelet aggregation results from
epoprostenol's activation of intracellular adenylate cyclase
and the resultant increase in cyclic adenosine
monophosphate concentrations within the platelets.
Additionally, it is capable of decreasing thrombogenesis
and platelet clumping in the lungs by inhibiting platelet
aggregation.
35. VASCULAR ENDOTHELIUM DILATATION
Hypoxia secondary to ARDS (off-label use):
Inhalation (off-label): Initial: 0.01 to 0.05 mcg/kg/minute; increase dose in stepwise
fashion based on efficacy and tolerability. Wean by reducing dose by 0.01
mcg/kg/minute every 1 to 2 hours as tolerated.
Also used in pulmonary hypertension.
No dosage adjustment for renal or liver abnorm.
36. HELIOX
Inert, non-toxic gas. Lighter than nitrogen and oxygen.
Does not enable laminar airflow, it can reduce the airflow
resistance of turbulent flow, as resistance is proportional
to the density of the mixture.
Potential use in a variety of disease processes
characterized by airflow limitation.
Optimal helium-oxygen ratio is not known. 80:20/70:30
Mechanical ventilators have to be recalibrated.
39. MODES OF MECHANICAL VENTILATION
Pressure versus volume ventilation.
Volume targeting.
Specific tidal volume is set, flow waveform, and peak flow.
Focus is on ensuring MV is maintained at target level.
Pressure targeting.
Targeted peak airway (= peak alveolar pressure) is set and sometimes inspiratory time.
Tidal volume and gas flow are allowed to vary breath to breath.
Focus on ensuring targeted alveolar pressure is met but never exceeded.
40. RANGE OF VENTILATOR MODES
Classic modes
Assist/control, assist(pressure support) and synchronized intermittent mandatory
ventilation.
Available for more than 20 yrs.
New modes
Designed to improve patient-ventilator synchrony
Most based on pressure ventilation format.
Most can be classified as modes that adjust gas delivery within a given breath.
Computerized control of gas delivery.
41. CONTROL MODE
Original mode
Controls all aspect of gas delivery.
Assumes a passive recipient of mechanical ventilation.
Nowadays achieved by sedation to apnea in OR by anaesthesia.
Controlled ventilation is available in both pressure and ventilation
formats.
42. ASSIST / CONTROL MODE
Essentially control mode with sensitivity set to allow easy patient
triggering of a breath.
Patient determines respiratory rate.
Back up to ensure minimum level of ventilation.
Most commonly used mode.
Set parameters
FiO2, back up rate, sensitivity and PEEP .
Pressure ventilation. Target airway pressure, insp time.
Volume ventilation. Tidal volume, flow waveform, peak flow and inspiratory time.
43. PRESSURE SUPPORT
Allows patient greater control over the process.
Patient triggers a breath and ending is also based on patient
demand.
Only gas delivery set is pressure level and sensitivity.
Back up rate is available.
44. SYNCHRONIZED INTERMITTENT
MANDATORY VENTILATION
Advocates commend benefits of spontaneous breathing between
breaths.
However, work of breathing can be excessive.
Respiratory centre has difficulty rapidly changing outputs based on
ventilatory mode.
May increase patient-ventilator synchrony.
45. PRESSURE-REGULATED VOLUME CONTROL
Targets both a maximum airway pressure and tidal volume.
Variation of pressure assist / control.
Deliver a test breath at low pressure. Measures volume.
Calculated pressure to deliver targeted tidal volume.
On every subsequent breath, tidal volume delivered is reassessed.
Pressure is adjusted 0 – 1 cmH2O.
Concern.
In patients with a strong drive, and added stimulus of
hypoxemia, fevers, sepsis, etc, patient may get little to
no support inappropriately.
46. VOLUME SUPPORT
Operates essentially same as PRVC.
Based on pressure support not pressure assist / control .
Same assessment breath to breath to assess pressure needed to
deliver targeted tidal volume.
Same concern regarding too strong a drive.
Exactly same as setting up pressure support ventilation with
addition of a volume target and maximum pressure.
47. ADAPTIVE SUPPORT VENTILATION
Very unique mode. Operates on pressure ventilation
format.
Adjusts ventilator setting for an 'ideal' ventilatory pattern.
Requiring least amount of patient and ventilator work.
Goal is to provide preset level of minute ventilation while
minimizing the total work of breathing.
Provide patients IBW. And % of minimal MV to be
delivered, between 25% to 350%.
48. AUTOMATIC TUBE COMPENSATION
Sometimes called electronic extubation.
Resistance properties of all sizes of ET and trach in memory and
continually measuring gas flow.
Goal is to provide sufficient support during inspiration and
decompression during exhalation to maintain tracheal pressure
equal to baseline.
Designed only to offload flow resistive properties of the artificial
airway.
49. PROPORTIONAL ASSIST VENTILATION
Similar to ATC.
Mechanics of total respiratory system.
Pressure assist in proportion to patient desired tidal volume and
instantaneous inspired flow.
Automatically adjusted to meet patient demand.
Only useful in patients with stable respiratory drives. And an
acceptable respiratory pattern.
50. VOLUME ASSURED PRESSURE SUPPORT
Also referred to as pressure augmentation.
Combine initial high flow of a pressure limited breath with constant
volume delivery of a volume targeted breath.
Differs from PRVC and volume support as it maintains ventilatory
support independent of patient demand.
51. IN CONCLUSION
How to assess an unstable patient.
Non-invasive ventilation.
Modes of ventilation.