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![•FiO2 - The usual goal is to use the minimum FiO2
required to have a PaO2 > 60 mm Hg or a sat >90%.
Start at 100% and bring down to avoid oxygen
toxicity.
•Trigger – Refers to initiation of breath on ventilator.
This occurs when a certain amount of time has
elapsed [e.g., 5 seconds if the rate is 12 (60 sec/12
b/m = 5 sec)] or when the patient makes an effort. A
patient’s effort may be sensed as a change in
pressure in the circuit (negative deflection) or as a
change in flow. Flow sensors tend to have a more
rapid response time.
Terminology
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More from Shivshankar Badole
Approach to Mechanical ventilation
- 1. Mechanical Ventilation Dr SatyadeoChoubey With special credit to Dr. Rajnish Gupta Chest Specialist 1
- 2. • Mechanical ventilationis a method to mechanically support or replace spontaneous breaths • Used in patients who are unable to sustain the level of ventilation necessary to maintain the gas exchange functions -oxygenation and carbon dioxide elimination • Could be invasive or non-invasive Introduction 2
- 3. ● To facilitateCO2 release and maintain normal PaCO2 (Ventilation) ● To maximize O2 delivery to blood and maintain PaO2 (Oxygenation) Primary Goals 3
- 4. When to Intubate/Ventilate ? ● Acute Ventilatory Failure - pH <7.30, PaCO2 >50 mm Hg ● Impending Ventilatory Failure - Progressive acidosis & hypoventilation to pH <7.30, PaCO2 >50 mm Hg - TV < 3-5 ml/kg - RR > 25 -35/min, laboured or irregular - MV > 10 L/min - VC < 15 ml/kg - Max. Insp. Press. (MIP) < -20 cm H2O - Vital Signs (rise in HR, BP, use of accessory muscles, diaphoresis, cyanosis ● Severe Hypoxaemia - PaO2 < 60 mm Hg on FiO2 50% or >, or PaO2 < 40 mm Hg on any FiO2 ● Prophylactic Ventil. Support - Post anaesth. recovery, prologed shock, head injury , smoke inhalation 4
- 5. Origins of mechanicalventilation •Negative-pressure ventilators (“iron lungs”) • Non-invasive ventilation first used in Boston Children’s Hospital in 1928 • Used extensively during polio outbreaks in 1940s – 1950s •Positive-pressure ventilators • Invasive ventilation first used at Massachusetts General Hospital in 1955 • Now the modern standard of mechanical ventilation The iron lung created negative pressure in abdomen as well as the chest, decreasing cardiac output. Iron lung polio ward at Rancho Los Amigos Hospital in 1953. 5
- 6. Ventilator Settings • Selectmode of ventilation ……… • Set Tidal Volume ……… • Set Respiratory Rate ……… • Set PEEP ……… • Set Inspiratory: Expiratory Ratio ……… • Set FiO2 ……… • Set Alarm Limits ……… • Humidification ……… 6
- 7. Terminology • Tidal Volume(TV) - Amount of gas delivered with each breath. (8-10 ml/kg, 6-8 ml/kg in ARDS based on Ideal Body Weight in kgs) IBW for Man = 50 + 2.3 (Ht in inches – 60) IBW for Woman = 45.5 + 2.3 (Ht in inches – 60) • Minute Ventilation (MV) = TV x Respiratory Rate • Inspiratory:Expiratory (I:E) Ratio - Normally 1:2 to 1:3 (Inverse Ratio in ARDS) • Inspiratory Flow - Varies with TV, I:E and RR. Normally about 60 l/min. Can be increased up to 100- 120 l/min in COPD. 7
- 8. •FiO2 - Theusual goal is to use the minimum FiO2 required to have a PaO2 > 60 mm Hg or a sat >90%. Start at 100% and bring down to avoid oxygen toxicity. •Trigger – Refers to initiation of breath on ventilator. This occurs when a certain amount of time has elapsed [e.g., 5 seconds if the rate is 12 (60 sec/12 b/m = 5 sec)] or when the patient makes an effort. A patient’s effort may be sensed as a change in pressure in the circuit (negative deflection) or as a change in flow. Flow sensors tend to have a more rapid response time. Terminology 8
- 9. Terminology • Peak InspiratoryPressure (PIP) Pressure used to deliver the tidal volume by overcoming resistance in airways and lungs. Should be kept <45 cm H2O to minimise barotrauma. • Plateau Pressure It is the end inspiratory pressure needed to maintain lung inflation in the absence of air flow. Should be kept <30 cm H2O to minimise barotrauma. • Mean Airway Pressure (MAP) It is the average pressure in the airway during the complete Insp.-Exp. Cycle. Normally < 30 cm H2O. 9
- 10. Terminology • Positive EndExpiratory Pressure (PEEP) - PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase. - PEEP keeps collapsing lung units open and improves oxygenation. - PEEP diminishes work of breathing - PEEP can cause barotrauma and diminish cardiac output. - Usually kept 5 to 10 cm H2O 10
- 11. Terminology • Lung compliance:Is the change in volume per unit change in pressure Compliance = Volume / Pressure • 2 Types: Static compliance (CST) - measured when there is no air flow - CST = Corrected Tidal Volume Plateau pressure-PEEP - Normal Value is 40 to 60 ml/cm H2O - Decreased in Atelectasis, ARDS, Pneumonia, Obesity, Retained secretion Dynamic compliance (CDYN) - measured when there is air flow - CDYN = Corrected Tidal Volume Peak Inspiratory Pressure-PEEP - Normal Value is 30 to 40 ml/cm H2O - Decreased in bronchospasm, kinking of tube, airway obstruction 11
- 12. A. Trigger ……. Whatcauses the breath to begin? ----Patient’s effort B. Limit …… What regulates gas flow during the breath? ----Volume /Pressure/Time C. Cycle ……. What causes the breath to end? ----Volume/Pressure/Time/Flow A B C Basic Variables 12
- 13. Types of Ventilators A.Volume Cycled • Delivers a fixed volume that terminates the breath • Easy to manage and used commonly B. Pressure Cycled • Breath terminated by attainment of specific pressure • Used previously, found difficult to manage C. Time Cycled • Inspiratory phase ends when a set time has elapsed • Used in paediatrics D. Flow Cycled • Not commonly used 13
- 14. Common Modes ControlledMandatory Ventilation (CMV) Assist Control (AC) Intermittent Mandatory Ventilation (IMV) Synchronized Intermittent Mandatory Ventilation (SIMV) Pressure Support Ventilation (PSV) 14
- 15. Controlled mandatory ventilation(CMV) The ventilatordelivers Preset tidal volume (or pressure) at a time triggered (preset) respiratory rate. As the ventilator controls both tidal volume (pressure) and respiratory rate, the ventilator “controls” the patients minute volume. Pressure
- 16.
- 17. Preset VTVolume Cycling Dependent on CL &Raw Time Flow (L/m) Pressure (cmH2O) Volume (mL) Preset Peak Flow Time triggered, Flow limited, Volume cycled Ventilation Controlled mandatory ventilation (Volume- Targeted)
- 18. Flow (L/min) Pressure (cm H2O) Volume (ml) Time (sec) SetPC level Time Triggered, Pressure Limited, Ventilation Controlled mandatory ventilation (Pressure-Targeted)
- 19. Controlled mandatory ventilation (CMV) Patient can not breath spontaneously Patient can not change the ventilator respiratory rate Suitable only when patient has no breathing efforts Disease or Under heavy sedation and muscle relaxants
- 20. Controlled mandatory ventilation(CMV) Asynchronyand increased work of breathing. Not suitable for patient who is awake or has own respiratory efforts Can not be used during weaning
- 21.
- 22. Time (sec) Control ventilation (CMV) Assist /control ventilation Pressure Contr ol Contr ol Assist ed Assist Control Ventilation
- 23. Control ventilation (CMV) Assist /control ventilation Pressure Assist Control Ventilation A set tidal volume (volume control) or a set pressure and time (pressure control) is delivered at a minimum rate Additional ventilator breaths are given if triggered by the patient Mandatory breaths: Ventilator delivers preset volume and preset flow rate at a set back-up rate Spontaneous breaths: Additional cycles can be triggered by the patient but otherwise are identical to the mandatory breath.
- 24. Assist Control Ventilation Tidalvolume (VT) of each delivered breath is the same, whether it is assisted breath or controlled breath Minimum breath rate is guaranteed (controlled breaths with set VT) Control ventilation (CMV) Assist / control ventilation Pressure
- 25. Assist Control Ventilation (volume) Assist Control Ventilation (Pressure)Assist ControlVentilat ion
- 26. Time Patient / TimeTriggered,Pressure Limited, Press ure Flo w Volu me Set PC level Pt triggered Time triggered Assist Control Ventilation (Pressure)
- 27. Patient / Timetriggered, Flow limited, Volume cycled Ventilation Assist Control Ventilation (Volume) Time (sec) Flow Pressure Volume Preset VT Volume Cycling
- 28. Assist Control Ventilation Asynchrony taken care of to some extent Low work of breathing, as every breath is supported and tidal volume guaranteed Natural breaths are not allowed Hyperventilation Respiratory alkalosis. Control ventilation (CMV) Assist / control ventilation Pressure
- 29. Intermittent Mandatory Ventilation (IMV) Pressure Machine breaths are delivered at a set rate (volume or pressure limit) Time (sec)
- 30. Intermittent Mandatory Ventilation (IMV) Pressure Machine breaths are delivered at a set rate (volume or pressure limit) Patient is allowed to breath spontaneously from either a demand valve or a continuous flow of gases but not offering any inspiratory assistance. Time (sec)
- 31. Intermittent Mandatory Ventilation (IMV) Pressure Patient’s capability determines Tidal volume of spontaneously breaths Some freedom to breath naturally even on mechanical ventilator Time (sec)
- 32. Intermittent Mandatory Ventilation (IMV) Pressure Random chance of breath stacking and asynchrony: Increased WOB Uncomfortable feeling Time (sec)
- 33. Intermittent Mandatory Ventilation (IMV) Pros: Freedom for natural spontaneous breaths even on machine Lesser chances of hyperventilation Cons: Asynchrony Random chance of breath stacking. Increase work of breathing Random high airway pressure (barotrauma) and lung volume (volutrauma) Setting appropriate pressure limit is important to reduce the risk of barotrauma
- 34.
- 35. Synchronized Intermittent Mandatory Ventilation Ventilator delivers either patient triggered assisted breaths or time triggered mandatory breath in a synchronized fashion so as to avoid breath stacking If the patient breathes between mandatory breaths, the ventilator will allow the patient to breathe a normal breath by opening the demand (inspiratory) valve but not offering any inspiratory assistance.
- 36. Synchronization window Pressure Time intervaljust prior to time triggering in which the ventilator is responsive to the patient’s inspiratory effort. Time trigerring Time (sec)
- 37. SIMVPressure If the patientmakes a spontaneous inspiratory effort that falls in sync window, the ventilator is patient triggered to deliver an assisted breath and will count it as mandatory breath Patient trigerred synchronized breath Time trigerred mandatory breath
- 38. SIMVPressure if patient doesnot make an inspiratory effort then ventilator will deliver a time triggered mandatory breath. Patient trigerred synchronized breath Time trigerred mandatory breath
- 39. Synchronized Intermittent Mandatory Ventilation Pressure 3types of breathing: 1. Patient initiated assisted ventilation, 2. Ventilator generated controlled ventilation, 3. Unassisted spontaneous breath.
- 40. Synchronized Intermittent MandatoryVentilation Itallows patients to assume a portion of their ventilatory drive: Weaning is possible Greater work of breathing than AC ventilation and therefore some may not consider it as the initial ventilator mode Friendly cardiopulmonary interaction: Negative inspiratory pressure generated by spontaneous breathing leads to increased venous return, which theoretically may help cardiac output and function
- 41. Pressure Support Ventilation Pressure (or Pressure above PEEP) is the setting variable No mandatorybreaths Applicable on Spontaneous breaths: a preset pressureassist, Flow cycling: terminates when flow drops to a specified fraction (typically 25%) of its maximum. Patient effort determines size of breath and flowrate.
- 42. Pressure Support Ventilation Pressure (or Pressure above PEEP) is the setting variable No mandatory breaths Applicable on Spontaneous breaths: a preset pressure assist, Flow cycling: terminates when flow drops to a specified fraction (typically 25%) of its maximum. Patient effort determines size of breath and flow rate
- 43. Pressure Support Ventilation Pressure (or Pressure above PEEP) is the setting variable No mandatory breaths Applicable on Spontaneous breaths: a preset pressure assist, Flow cycling: terminates when flow drops to a specified fraction (typically 25%) of its maximum. Patient effort determines size of breath and flow rate.
- 44. Pressure Support Ventilation It augments spontaneous VT decreases spontaneous rates and WOB Used in conjunction with spontaneous breaths in any mode of ventilation. No guarantee of tidal volume with changing respiratory mechanics, No back up ventilation in the event of apnea.
- 45. Pressure Support Ventilation Provides pressure support to overcome the increased work of breathing imposed by the disease process, the endotracheal tube, the inspiratory valves and other mechanical aspects of ventilatory support Allows for titration of patient effort during weaning. Helpful in assessing extubation readiness
- 46. SIMV + PSVentilationPressure Spontaneous breath with PS
- 47. Volume Controlled Ventilation •CMV • Every breath is fully supported by the ventilator which ensures that the patient receives the set tidal volume at set rate. • Time triggered, volume limited, volume cycled • Assist Control • Like CMV with a trigger. • Patient can trigger the ventilator and his breath is fully supported with a set volume and flow over and above the set rate. • Pressure/ Flow triggered, volume limited, volume cycled • CMV & Assist Control are Controlled Modes. The patient CANNOT generate spontaneous breaths, volumes, or flow rates. • Ventilator delivers a fixed volume at set rate. Pressure varies Patient’s Effort 47
- 48. Volume Controlled Ventilation •IMV • Pt receives a set number of ventilator breaths. • Pt can initiate own (spontaneous) breaths. Thus different from Control. • Spontaneous breaths are not supported by machine with a fixed TV. Thus different from Assist. • Ventilator always delivers breath, even if pt is exhaling. • SIMV • Spontaneous breaths of pt and mandatory ventilatory breaths are synchronized. Patient’s Effort • IMV & SIMV are Partially Controlled. The patient can have spontaneous breaths in between the mandatory ventilator breaths. • Triggered by Pressure/Flow (Assist) or Time (Control), limited and Cycled by Volume48
- 49. Control Mode • Everybreath is supported regardless of “trigger” • Can’t wean by decreasing rate SIMV Mode • Vent tries to synchronize with pt’s effort • Patient takes “own” breaths in between (+/- PS) Control Mode vs SIMV Mode 49
- 50. Pressure Controlled Ventilation AControlled Mode. No participation by patient •Parameters • Triggered by time • Limited by pressure • Cycled by time • Affects inspiration only •Disadvantage • Patient may hyoventilate or hyperventilate • Requires frequent adjustments to maintain adequate MV 50
- 51. Pressure Limited • Controlsoxygenation (FiO2 and MAP) • Decelerating flow pattern (lower PIP for same TV) • Tidal volume may change suddenly leading to hypoventilation or overexpansion of lung Volume Limited • Controls minute ventilation • Square wave flow pattern • PIP may rise to any level Pressure Limited vs Volume Limited 51
- 52. Pressure Limited – Mode(PCV) – FiO2 (100%) – Rate (12-16 BPM) – I-time (Inverse Ratio +/-) – PEEP (5-10 cmH2O) – PIP (30-35 cm H2O) (Tidal Volume & MV Varies) Volume Limited – Mode (CMV) – FiO2 (100%) – Rate (12-16 BPM) – Tidal Volume (8-10 ml/kg; 6-8 ml/kg in ARDS) – PEEP (5-10 cmH2O) – I- time (1:2 to 1:3 (PIP & MAP Varies) Initial Settings {Flow /Pressure Trigger is set in A-C Mode} 52
- 53. Pressure Support Ventilation •A purely spontaneous mode. Ventilator provides only pressure support. • Patient determines RR, Minute Ventilation & Inspiratory Time. • Decreases work of breathing by increasing inspiratory flow that overcomes the resistance of tubing and helps to generate larger tidal volume • Parameters • Triggered by pt’s own breath • Limited by pressure • Cycled by flow • Affects inspiration only • Uses • Used with other volume- cycled modes e.g. SIMV • Used alone during weaning now • Used as BiPAP (CPAP plus PS) 53
- 54. Advanced Modes • PressureRegulated Volume Control (PRVC) • Inverse Ratio Ventilation (IRV) • Airway Pressure Release Ventilation • Volume Assured Pressure Support (VAPS) • Proportional Assist Ventilation (PAV) • High Frequency Ventilation 54
- 55. Advanced Modes PRVC • Basicallya volume controlled mode (assured MV) with the benefits of a pressure mode (a lower PIP). •Delivers a set tidal volume with each breath at the lowest possible peak pressure. Delivers the breath with a decelerating flow pattern, that is less injurious. Inverse Ratio Ventilation • I:E > 1 used commonly with a Pressure Control Mode • Can increase MAP without increasing PIP; improves oxygenation and limits barotrauma • Risk for air trapping • Patient will need to be sedated and paralyzed 55
- 56. Adjunctive Therapies Prone Positioning •Re-expands collapsed dorsal areas of the lung • Heart moves away from the lungs • Net result is usually improved oxygenation • Suctioning difficult Inhaled Nitric Oxide •Vasodilates blood vessels that supply ventilated alveoli and thus improve V/Q • No systemic effects due to rapid inactivation by binding to hemoglobin •Does not improve outcome 56
- 57. Complications • Ventilator InducedLung Injury -Oxygen toxicity -Barotrauma / Volutrauma • Cardiovascular Complications -Impaired venous return to RH -Bowing of the Interventricular Septum -Decreased left sided afterload (good) -Altered right sided afterload (Cardiac output may decrease) • Other Complications -Ventilator Associated Pneumonia -Sinusitis -Risks from associated devices (CVLs, A-lines) -Unplanned Extubation 57
- 58. Recording and Monitoring •Consciousness • Vitals (Pulse, BP, Temperature, RR) • Oxygen Saturation, ABG, CXR • Intake/Output Charting • Ventilator Settings • Airway Pressures • Compliance • Suctioning • Humidification • Dates of intubation & catheterisation (CVP, Foley’s) • Central Venous Pressure, Blood Sugar Monitoring • Treatment (Drug Chart and RT Feeding Chart) 58
- 59.
- 60. Troubleshooting • Anxious Patient •Pain & Discomfort • Fighting or Asynchrony with Ventilator • Distress and high RR • Ventilator alarming 60
- 61.
- 62. • Check patencyof all connections • Check circuit leaks, tube position & cuff pressure • Check vitals, oxygen saturation • Need to suction / nebulise • Check if patient biting the tube • Communicate with patient in order to allay anxiety, look for cause and assure • Call a doctor Troubleshooting (Assessment & Interventions) 62
- 63. Troubleshooting (Assessment & Interventions) •Assess PIP and Plateau Pressures • May need to perform a CXR or an ABG 63
- 64. Troubleshooting (Assessment & Interventions) •May need to rule out a VENTILATOR MAL-FUNCTION on a Test Lung - Will need to remove pt from ventilator - Initiate manual ventilation with ambu bag connected to an oxygen flowmeter with oxygen supply on - Re-connect on ventilator • Assess & manage accordingly • NEVER TRY TO SILENCE THE ALARM (LOOK FOR THE CAUSE) 64
- 65. Weaning Weaning is thegradual withdrawal of mechanical ventilation 65
- 66. •Resolution or stabilizationof disease process •Normal ABG on FiO2 of 0.5 (except in COPD) •Normal electrolytes •No significant pulmonary infection, pulmonary oedema, atelectasis or AW obstruction •Intact cough/gag reflex •Spontaneous respirations •Patient alert and cooperative •Haemodynamically stable & off inotropic support •No fever, seizures or organ failure •Nutritional and neuromuscular status needs assessment Clinical Considerations 66
- 67. Bedside Weaning Parameters NumericalParameters Normal Range Weaning Threshold PaO2/FiO2 > 400 > 200 Tidal volume 5 - 7 ml/kg 5 ml/kg Respiratory rate 14 - 18 breaths/min < 40 breaths/min Vital capacity 65 - 75 ml/kg 10 ml/kg Minute ventilation 5 - 7 L/min < 10 L/min Greater Predictive Value Normal Range Weaning Threshold NIF (Negative Inspiratory Force) > - 90 cm H2O (F) > - 120 cm H2O (M) > - 25 cm H2O RSBI (Rapid Shallow Breathing Index) RSBI = RR / TV (in litres) < 50 breaths/min/L <100 br/min/L FiO2 of 0.5 or < and PEEP of 5cm H2O or < 67
- 68. Method of Weaning •AbruptWithdrawal Method (T-Piece Weaning) - The inhaled gas is delivered at a high flow rate through T- piece (preferably with venturi mask) •Gradual Withdrawal Method (IMV Weaning) - The number of machine breaths are gradually decreased over variable time depending upon the patient’s condition - PS often added to assist spontaneous breathing (to counter the resistance of ventilator circuit) - SIMV with PS often used in past for weaning • Current practice is weaning by PS mode Note: A Spontaneous Breathing Trial can be given with either T-Piece, CPAP or PS 68
- 69. Tracheostomy - Need •Advantages •Better clearance of secretions • Decreases work of breathing • Continued vocal cord injury avoided • Helps extubation •Disadvantages • Long term risk of tracheal stenosis • Procedure-related complication rate (4% - 36%) Prolonged intubation may injure airway and cause airway edema 1 - Vocal cords. 2 - Thyroid cartilage. 3 - Cricoid cartilage. 4 - Tracheal cartilage. 5 - Balloon cuff. 69
- 70. Difficult Weaning Causes Treatment Anxiety/AgitationBenzodiazepines or haldol Infection Appropriate antibiotics Electrolyte abnormalities (K+, PO4-) Correction Pulmonary edema, cardiac ischemia Diuretics, nitrates Under/Overnutrition Appropriate correction Neuromuscular disease Bronchopulmonary hygiene, early consideration of trach Increased intra-abdominal pressure Semirecumbent positioning, NGT Excessive auto-PEEP (COPD, asthma) Bronchodilator therapy, extrinsic PEEP 70
- 71. Extubation • Pre-Extubation Preparation •Check vitals and ABG • Assure the patient • Nebulise and do ET & oral suctioning • Keep prior intubation set, emergency tray, oxygen delivery system and NIV ready • Extubation Process • Bulb deflated and extubation done with simultaneous ET suctioning to prevent aspiration of secretions above cuff • Send ET tip for culture • Post-Extubation Care • Chest physiotherapy to clear secretions • Oral hygiene • Encourage cough • Watch vitals and ABG • Use NIV 71
- 72. Self-Extubation • Immediately putan oxygen face mask on the patient’s face and attach with an ambu bag connected to the oxygen flowmeter with O2 on. Ventilate the patient with the Ambu bag. • Try possible conservative measures (Nebulisation, physiotherapy etc.) • Use NIV • Monitor consciousness, vitals, oxygen sat., ABG (About 50% patients do not require re-intubation) 72
- 73.
- 74. NON-INVASIVE VENT. (NIV)in Operation Hose Pipe BIPAP Head Gear Mask 74
- 75. NIV – Setting •Choosebetween a BIPAP (Bi-level Positive Airway Pressure) or a CPAP (Continous Positive Airway Pressure) non-invasive ventilator •Set Mode- Spontaneous / Spont.-Timed /Timed - Patient needs to be conscious in spont. & S/T modes • Choose interface - Nasal / Facial Masks, Nasal Pillows - Used in different sizes and materials - Face mask used in pt. with mouth breathing •Usually set with IPAP of 8 cms and EPAP of 4 cms with a minimum difference of 4 cms. 75
- 76. •IPAP and EPAPincreased by 1-2 cm as per requirement. For hypoxaemia, EPAP and IPAP are increased at a time. For hypercapnia, IPAP is increased that increases the IPAP-EPAP gap. • High pressures can produce air leaks from mouth decreasing machine effectiveness and tolerance. •Clinical signs, ABG and pulse oximetry should be monitored periodically. •Oxygen supplementation should be given as required. •Heated humidification should be given to prevent dryness. NIV Titration 76
- 77.
- 78. •Inability to maintainO2 saturation around 90 % •Haemodynamic instability •Worsened sensorium •Inability to clear secretions •Intolerance to device •Extreme distress or anxiety Discontinue NIV 78
- 79. Conclusions •A patient inrespiratory failure should be put on mechanical ventilator if NIV and other supportive measures fail to improve the condition. •Controlled mode (CMV) is used initially, while weaning is done by Pressure Support mode. •Regular recording, charting and monitoring of the patient’s vitals, oxygen saturation and the ventilator (or NIV) settings helps to detect problems early and prevent complications. • In all cases of troubleshooting, the doctor should be called immediately. 79
- 80.