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Bilgrami, Irma — Reading the Vent Like an ECG

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SMACC Conference
SMACC Conference

Own the ventilator! Irma Bilgrami lays down a framework for analysis of ventilator settings and waveforms to enhance your daily practise.

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Reading the Ventilator Like An ECG
OBJECTIVES SYSTEM Incorporate ventilator information in patient assessment
Course in mechanical ventilation Advanced course in ventilator waveform analysis Respiratory physiology
WHAT IS NORMAL- in brief HAVE A SYSTEM- like an ECG CASE STUDIES
What is normal??? Ventilators Alarms Ventilator graphics
PRESSURE FLOW VOLUME VENTILATOR GRAPHICS WAVEFORMS LOOPS Pressure vs volume Flow Vs Volume
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
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
VOLUME mode Descending Ramp Flow Pattern THIS TALK
Have a System
A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings
A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt Oxygen Saturations End Tidal CO2 Trace Haemodynamics
B) Technical qualityReport ECG findingsDesc ribe Inter pret Patient Assessme nt Know your ventilator ..and the alarms
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 ?
3) Report Ventilator findings VOLUME mode Volume set, pressure variable Pressure mode Pressure set, volume variable 1) Mode?
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
3) Information from waveforms/ manoeuvres 3) Report Ventilator findings
Influenced by Compliance Resistance Flow pattern Values Pattern Curve meet baseline VOLUME MODE Values Pattern Peak pressure
?Problem with airway resistance or lung compliance HIGH AIRWAY PRESSURES
Inspiratory Hold Manoeuvre Assess Plateau Pressure HIGH PLATEAU PRESSURES Low compliance Gas trapping
Expiratory Hold Manoeuvre Assess Auto-PEEP
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
Values Pattern Tidal volume Values Pattern Return to baseline VOLUME MODE time
4) Interpretation? C) Report Ventilator findings Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance
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
If you change the ventilator settings REASSESS the patient
New Admissions overnight Matt: Drug overdose Rosa: Severe pneumonia Ms Smith: Asthma
Morning Ward Round Matt 24yr old man Drug overdose
24year old man Benzodiazepine overdose Currently intubated/ ventilated Weight 70 kg (predicted body weight) History
Examination
Examination INFUSIONS: Propofol 100mg/hour PHYSICAL EXAM ETT Size 8.5 Minimal secretions Unremarkable exam
Investigations
Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
MODE Parameters set The Ventilator Parameters achieved
Information from waveforms The Ventilator
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
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
Morning Ward Round ROSA 36yr Lady Pneumonia
PROBLEM WITH LUNG COMPLIANCE? Lung parenchyma Pleura Chest wall
PRESSURE TIME CURVE Volume mode Values Pattern Increased PIP Same shape. Higher pressures Values Pattern Expiratory limb back to baseline
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
HISTORY Rosa, 36 year old lady with respiratory failure 2’ to Community acquired pneumonia Day 1 ICU Weight= 80 Kg (Predicted body weight) History
EXAM
INFUSIONS: Morphine 10mg/hr Midazolam: 10mg/hr Noradrenaline : 5 mcg/min EXAM PHYSICAL EXAM ETT Size 8 Purulent secretions Coarse creps , reduced air entry
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%
Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
MODE Parameters set The Ventilator Parameters achieved
Information from waveforms FT The Ventilator Increase Peak pressure ? Plateau pressure Increase Expiratory flow rate
Inspiratory pause Expiratory pause
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
MANAGE Patient MANAGE Ventilator Position Sedate / Paralyse Fluid balance Lung protective ventilation Optimum PEEP Consider rescue treatments
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
Morning Ward Round Ms Smith 35yr old Exacerbation of Asthma
PROBLEM WITH Resistance? ET tube Increased airways resistance
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
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
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
35 year old lady with respiratory failure 2’ to exacerbation of Asthma Currently intubated Weight 80kg (Predicted body weight) History
Examination
Examination INFUSIONS: Morphine 10mg/hr Midazolam: 10mg/hr Noradrenaline : 2 mcg/min PHYSICAL EXAM ETT Size 8.5 Trachea midline B/L expiratory wheeze
Investigation
Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
MODE The Ventilator Parameters achieved 15 Parameters set
Information from waveforms The Ventilator Increase Early Peak pressures DECREASE Expiratory flow rate INCREASE Expiratory time
Inspiratory pause Expiratory pause Raised Peak pressure Plateau pressure normal No intrinsic PEEP P cmH20 Time
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
MANAGE Patient MANAGE Ventilator Bronchodilators Steroids Antibiotics Monitor for gas trap
Emergency buzzer
PHYSICAL EXAM Trachea midline Diminished breath sounds
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
Information from waveforms
Expiratory pause
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
MANAGE Patient MANAGE Ventilator Disconnect patient Consider and correct Hypovolemia, Pneumothorax Disconnect patient. Decreased RR Increase Insp flow rate Prolonged I:E
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
Read Ventilator – daily patient assessment Have a System
Modes of Ventilation Loops Dyssynchrony Waveform abnormalities PEEP/ Recruitment
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
8th Alfred Advanced Mechanical Ventilation Conference (AAMVC) Waveforms Workshop & Physiotherapy Meeting Wednesday, 16 July, 2014 - Friday, 18 July, 2014
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
Report ECG findingsDesc ribe Inter pret Patient Assessme nt THANK YOU

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Bilgrami, Irma — Reading the Vent Like an ECG

Editor's Notes

  1. Provide a system for reading the ventilator Reading the ventilator is just not about the waveforms Interpret findings in context of the clinical situation
  2. 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
  3. DISCLAIMER
  4. Assess your patient… with specific attention to …
  5. Assess your patient… with specific attention to …
  6. Assess your patient… with specific attention to …
  7. Resistance and flow PATTERN affect the peak pressure Compliance and affect the plateau pressure
  8. Change shape
  9. Assess your patient… with specific attention to …
  10. Predicted body weight based on gender and height
  11. Interactions between flow/ IE ratios
  12. Flow: exp limb meet baseline just before next breath ? Secondary to I:E= 1:1
  13. 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
  14. Assess your patient… with specific attention to …
  15. Also important to exlude problems with pelura and chest wall
  16. Same shape Hgher
  17. Predicted body weight based on gender and height
  18. Predicted body weight based on gender and height
  19. Predicted body weight based on gender and height
  20. Predicted body weight based on gender and height
  21. Predicted body weight based on gender and height
  22. Interactions between flow/ IE ratios
  23. 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
  24. Lung protective ventilation TV 6ml/kg (PBW) Increase RR, permissive hypercapnia Aim pH >7.2 Pplat<30 Oxygenation aims Sats>88% Consider rescue treatments
  25. Assess your patient… with specific attention to …
  26. 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
  27. The gas takes a long time to leave patients lungs
  28. The gas takes a long time to leave patients lungs
  29. Predicted body weight based on gender and height
  30. Predicted body weight based on gender and height
  31. Interactions between flow/ IE ratios
  32. 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
  33. 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]
  34. To qunatify degree of autopeep
  35. 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
  36. Lung protective ventilation TV 6ml/kg (PBW) Increase RR, permissive hypercapnia Aim pH >7.2 Pplat<30 Oxygenation aims Sats>88% Consider rescue treatments
  37. Assess your patient… with specific attention to …
  38. Assess your patient… with specific attention to …
  39. Assess your patient… with specific attention to …