There is a great deal of information that points to the potential efficacy of BCV for acute and chronic respiratory failure as well as ARDS. Some is gathered here with a discussion of the open lung concept with BCV.
Oxygen Therapy is not Beneficial in COPD Patients with Moderate HypoxaemiaGamal Agmy
A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation
The Long-Term Oxygen Treatment Trial Research Group*
N Engl J Med. 2016 October 27; 375(17): 1617–1627
This document discusses non-invasive positive pressure ventilation (NIPPV). It defines NIPPV as ventilation without an invasive airway and notes its increasing use for acute respiratory failure. The document covers the history of NIPPV, indications, goals, advantages, patient selection criteria, initiation procedures, modes (including CPAP, BiPAP, volume vs pressure), and settings. NIPPV can effectively treat various conditions like COPD, heart failure, and respiratory infections while avoiding intubation. Careful patient selection and monitoring are important for successful NIPPV.
HFNC therapy provides high flow oxygen through a nasal cannula. It has several benefits over traditional oxygen delivery methods, including more accurate oxygen delivery, washout of dead space, and generation of positive end-expiratory pressure. HFNC is a well-tolerated therapy that can be used for hypoxemic respiratory failure, pre-intubation, and post-extubation. While promising, further research is still needed to establish clear guidelines for its use.
Recent Advances in NIV
1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases.
2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options.
3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema.
4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher
This document contains multiple choice questions about chronic obstructive pulmonary disease (COPD) and its treatment. It asks questions about the types of emphysema most severe in upper lobes, risk factors for mortality, most significant COPD symptom, best test for exacerbation severity, and accurate treatment statements. It also provides clinical information about COPD pathogenesis, airflow limitation, symptoms by disease severity, rationale for dual bronchodilation, and studies on withdrawing inhaled corticosteroids.
Journal Club- Prone Positioning in Severe ARDSNitish Gupta
1) This study evaluated the effects of early prone positioning on outcomes in patients with severe acute respiratory distress syndrome (ARDS).
2) Patients with ARDS who required mechanical ventilation within 36 hours and had a PaO2/FiO2 ratio <150 were randomized to either remain in the supine position or be placed in the prone position for at least 16 consecutive hours.
3) The primary outcome was 28-day mortality. Mortality at 28 days was lower in the prone position group compared to the supine position group, suggesting prone positioning improves survival in severe ARDS.
1) The document discusses the use of noninvasive ventilation (NIV) to facilitate weaning patients from mechanical ventilation. Several randomized controlled trials have found NIV can successfully facilitate weaning, particularly in COPD patients.
2) NIV is recommended for COPD patients who have failed an initial spontaneous breathing trial but have otherwise recovered from their acute illness. Close monitoring is required when using NIV for weaning.
3) The trials indicate NIV may shorten ventilation time compared to remaining intubated, but the evidence for NIV is strongest for facilitating weaning and not as a rescue therapy for post-extubation respiratory failure.
This document discusses controversial issues in non-invasive ventilation. It begins by explaining the normal ventilatory balance and how respiratory failure causes an imbalance. It then discusses how mechanical ventilation can unload the respiratory muscles.
It defines non-invasive positive pressure ventilation (NPPV) and notes that not all ventilators are suitable for each indication. It reviews different interfaces like facial masks, nasal masks, nasal prongs, and others. It also discusses a study comparing the physiologic effects of different interfaces.
The document continues by looking at the rationale for using positive pressure ventilation in cardiogenic pulmonary edema. It reviews several clinical trials that show benefits of NPPV over standard treatment in acute cardiogenic pulmonary edema and respiratory failure
Oxygen Therapy is not Beneficial in COPD Patients with Moderate HypoxaemiaGamal Agmy
A Randomized Trial of Long-Term Oxygen for COPD with Moderate Desaturation
The Long-Term Oxygen Treatment Trial Research Group*
N Engl J Med. 2016 October 27; 375(17): 1617–1627
This document discusses non-invasive positive pressure ventilation (NIPPV). It defines NIPPV as ventilation without an invasive airway and notes its increasing use for acute respiratory failure. The document covers the history of NIPPV, indications, goals, advantages, patient selection criteria, initiation procedures, modes (including CPAP, BiPAP, volume vs pressure), and settings. NIPPV can effectively treat various conditions like COPD, heart failure, and respiratory infections while avoiding intubation. Careful patient selection and monitoring are important for successful NIPPV.
HFNC therapy provides high flow oxygen through a nasal cannula. It has several benefits over traditional oxygen delivery methods, including more accurate oxygen delivery, washout of dead space, and generation of positive end-expiratory pressure. HFNC is a well-tolerated therapy that can be used for hypoxemic respiratory failure, pre-intubation, and post-extubation. While promising, further research is still needed to establish clear guidelines for its use.
Recent Advances in NIV
1) Non-invasive positive pressure ventilation (NIPPV) can effectively treat acute respiratory failure without the need for intubation in conditions like COPD, obesity, and neuromuscular diseases.
2) Different interfaces like facial masks, nasal masks, and helmets can be used for NIPPV, with nasal masks generally better tolerated than other options.
3) NIPPV reduces mortality and need for intubation compared to standard oxygen therapy alone in acute exacerbations of COPD and cardiogenic pulmonary edema.
4) Factors like pH, comorbidities, respiratory rate and effort predict success or failure of NIPPV. Close monitoring is needed in cases with higher
This document contains multiple choice questions about chronic obstructive pulmonary disease (COPD) and its treatment. It asks questions about the types of emphysema most severe in upper lobes, risk factors for mortality, most significant COPD symptom, best test for exacerbation severity, and accurate treatment statements. It also provides clinical information about COPD pathogenesis, airflow limitation, symptoms by disease severity, rationale for dual bronchodilation, and studies on withdrawing inhaled corticosteroids.
Journal Club- Prone Positioning in Severe ARDSNitish Gupta
1) This study evaluated the effects of early prone positioning on outcomes in patients with severe acute respiratory distress syndrome (ARDS).
2) Patients with ARDS who required mechanical ventilation within 36 hours and had a PaO2/FiO2 ratio <150 were randomized to either remain in the supine position or be placed in the prone position for at least 16 consecutive hours.
3) The primary outcome was 28-day mortality. Mortality at 28 days was lower in the prone position group compared to the supine position group, suggesting prone positioning improves survival in severe ARDS.
1) The document discusses the use of noninvasive ventilation (NIV) to facilitate weaning patients from mechanical ventilation. Several randomized controlled trials have found NIV can successfully facilitate weaning, particularly in COPD patients.
2) NIV is recommended for COPD patients who have failed an initial spontaneous breathing trial but have otherwise recovered from their acute illness. Close monitoring is required when using NIV for weaning.
3) The trials indicate NIV may shorten ventilation time compared to remaining intubated, but the evidence for NIV is strongest for facilitating weaning and not as a rescue therapy for post-extubation respiratory failure.
This document discusses controversial issues in non-invasive ventilation. It begins by explaining the normal ventilatory balance and how respiratory failure causes an imbalance. It then discusses how mechanical ventilation can unload the respiratory muscles.
It defines non-invasive positive pressure ventilation (NPPV) and notes that not all ventilators are suitable for each indication. It reviews different interfaces like facial masks, nasal masks, nasal prongs, and others. It also discusses a study comparing the physiologic effects of different interfaces.
The document continues by looking at the rationale for using positive pressure ventilation in cardiogenic pulmonary edema. It reviews several clinical trials that show benefits of NPPV over standard treatment in acute cardiogenic pulmonary edema and respiratory failure
These slides represent how to manage patients on a mechanical ventilator? Easy understanding of using ventilators. indication of mechanical ventilator use. How to wean a patient from a mechanical ventilator? How to fine-tune the ventilator settings?
An elderly woman with multiple comorbidities suffered from COVID 19 moderate disease - was managed conservatively
Case presentation with current treatment modalities
:Weaning from Mechanical Ventilation :Recent UpdatesGamal Agmy
This document summarizes recent updates on weaning from mechanical ventilation. It discusses that 75% of mechanically ventilated patients can be easily weaned, while 10-15% require a weaning protocol over 24-72 hours and 5-10% require gradual weaning over a longer period. Readiness criteria for weaning include improved respiratory status, absence of organ failure, adequate oxygenation and ventilation. Spontaneous breathing trials are used to assess readiness for weaning and extubation. Noninvasive ventilation can help prevent extubation failure, especially in patients with COPD. Diaphragm ultrasound may help predict weaning outcome, with a diaphragm thickness change over 40% associated with successful weaning.
This document discusses rescue therapies for refractory hypoxemia in acute respiratory distress syndrome (ARDS). It reviews evidence on inhaled nitric oxide (iNO), prone positioning, recruitment maneuvers and positive end-expiratory pressure (PEEP) titration, high frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO). Prone positioning and iNO are first-line therapies that improve oxygenation but iNO does not reduce mortality. Recruitment maneuvers combined with PEEP titration may provide a survival benefit in severe ARDS. HFOV and ECMO are second-line therapies that can facilitate lung-protective ventilation but their effects on outcomes are unclear.
This document summarizes a study comparing non-invasive positive pressure ventilation (NIPPV) to high flow oxygen therapy in immunocompromised patients with acute respiratory failure. The study found that early use of NIPPV as compared to oxygen therapy alone did not reduce 28-day mortality or intubation rates. There were also no differences in ICU or hospital length of stay. While NIPPV did not provide benefits, the lower than expected mortality with oxygen therapy alone limited the study's ability to detect differences between the groups.
Ventilator Management In Different Disease EntitiesDang Thanh Tuan
The document discusses ventilator management in different disease entities. It covers indications for mechanical ventilation in conditions like respiratory failure, ARDS, COPD, chest trauma, and head injury. For ARDS specifically, it summarizes the key findings of the NIH ARDS Network trial which demonstrated that a lower tidal volume strategy of 6 ml/kg predicted body weight reduced mortality compared to the traditional higher tidal volume approach.
The assessment of management of stable COPD: an update 2014 by Corlateanu for...Alexandru Corlateanu
The document discusses various approaches to assessing and managing stable COPD, including assessments of severity, phenotypes, and multilateral evaluation. It reviews markers used in different assessment approaches, such as FEV1, symptoms, health status, and exacerbation risk. Non-pharmacological treatments like smoking cessation, pulmonary rehabilitation, and vaccinations are outlined. The efficacy and safety of various pharmacological treatments is summarized based on major randomized controlled trials, including long-acting bronchodilators, inhaled corticosteroids, their combinations, and phosphodiesterase inhibitors. Therapeutic strategies for stable COPD are compared between GOLD guidelines and Spanish guidelines.
Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease characterized by persistent respiratory symptoms and airflow limitation. It includes chronic bronchitis and emphysema. The main risk factor is cigarette smoking. Symptoms include dyspnea, cough, and sputum production. Diagnosis is confirmed by spirometry showing airflow limitation. Management involves smoking cessation, bronchodilators, pulmonary rehabilitation, oxygen therapy, and treating exacerbations with corticosteroids and antibiotics.
1. The document discusses discontinuation of ventilatory support and weaning from mechanical ventilation in critically ill patients. It focuses on challenges in determining the optimal time for withdrawal of ventilation support and strategies to improve weaning outcomes.
2. Weaning from mechanical ventilation is a complex process that requires evaluation of respiratory, cardiac, muscular and cognitive factors. Approximately 20-30% of patients who are deemed ready for weaning trials will fail the initial spontaneous breathing test and require resumed mechanical ventilation.
3. The document reviews various approaches and considerations for evaluating patient readiness, managing weaning, and preventing extubation failure. It emphasizes the need for further research to identify high risk patients and improve weaning techniques.
Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
This document discusses ventilating patients on extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). It recommends a lung rest approach with low tidal volumes, inspiratory pressures below 25 cm H2O, low FiO2 below 30%, and permissive hypercapnia. PEEP should be titrated as high as tolerated. After the first 48 hours, ventilator settings can be gradually reduced as lung function improves with ECMO support. Oxygen saturation should be around 80% to avoid lung injury from high oxygen levels.
1) A large clinical trial found no difference in 7-day or 30-day mortality between patients receiving noninvasive ventilation (CPAP or NIPPV) and standard oxygen therapy for acute cardiogenic pulmonary edema.
2) While noninvasive ventilation improved symptoms and physiological measures more than standard oxygen, these benefits did not translate to improved survival.
3) There were also no differences found between CPAP and NIPPV in terms of efficacy, safety, or effects on mortality.
physiotherapy management for chronic obstructive pulmonary disease Sunil kumar
role of physiotherapy in chronic obstructive pulmonary disease, principles of physical therapy management in copd, physiotherapy assessing and treatment for copd
Weaning from mechanical ventilation is the process of gradually transferring breathing from the ventilator to the patient. It must be individualized and involves assessing patient readiness using criteria like clinical stability, adequate oxygenation and pulmonary function. Weaning success means unassisted breathing for 48 hours after removal from the ventilator. Patients are classified as having simple, difficult or prolonged weaning based on time to successful extubation. Factors that can cause weaning failure include increased airway resistance, decreased lung compliance, and respiratory muscle fatigue due to conditions like cardiac dysfunction, diaphragm weakness or endocrine abnormalities.
Weaning from mechanical ventilation and extubation by dr tareqtareq rahman
Weaning from mechanical ventilation and extubation requires careful assessment of patient readiness and involves gradually reducing ventilator support. While no single protocol can predict successful weaning in all cases, clinical judgment and experience are important. Early weaning when possible can reduce risks like nosocomial infection and improve patient outcomes. Factors such as respiratory status, hemodynamics, oxygen needs and sedation levels must be optimized before attempting weaning through slowly reducing settings on the ventilator. Noninvasive respiratory support like nasal CPAP is preferred after extubation over headbox oxygen. Caffeine, corticosteroids and chest physiotherapy may also improve chances of successful extubation.
Dr. Sujay Halkur Shankar presented on the topic of weaning patients from mechanical ventilation. The presentation covered assessing patient readiness, different weaning methods like spontaneous breathing trials, factors that can cause difficulty weaning like respiratory, cardiac and neuromuscular issues, and post-extubation care. Spontaneous breathing trials are the preferred method of weaning and have higher rates of success than pressure support or intermittent mandatory ventilation. Factors that can contribute to weaning failure include increased respiratory load or drive, decreased respiratory muscle strength, and cardiac dysfunction induced by weaning.
Non-invasive ventilation (NIV) delivers ventilatory support through a mask without using an invasive tracheal tube. The document discusses the history and development of NIV, benefits in pediatric patients, indications, contraindications, modes, and key points for successful use of NIV. It provides details on using NIV to treat acute hypoxemic and chronic hypercapnic respiratory failures in children. Close monitoring and criteria for escalating to invasive ventilation if NIV fails are also reviewed.
This document discusses the use of non-invasive ventilation (NIV) as a physiotherapeutic approach. It defines NIV as the delivery of oxygen via a face mask without an endotracheal tube. NIV works by creating positive airway pressure to force air into the lungs, reducing respiratory effort. There are two main types of NIV: non-invasive positive pressure ventilation and negative pressure ventilation. The document then discusses specific NIV techniques like CPAP and BiPAP and their indications. It also covers contraindications and how NIV can be used to manage acute respiratory failure, improve secretion removal, exercise capacity, and treat chronic respiratory failure.
Ventilatory support in special situations balamugeshDang Thanh Tuan
This document summarizes ventilation strategies for different clinical situations including ARDS, COPD, asthma, and bronchopleural fistula. It discusses ventilator settings such as tidal volume, PEEP, FiO2 and prone positioning that are recommended for ARDS. Non-invasive ventilation options for COPD and asthma exacerbations are also reviewed. Intubation criteria and strategies to deliver aerosol treatments during mechanical ventilation are provided. Managing air leak through bronchopleural fistula with techniques like differential lung ventilation or chest tube use is outlined.
Discontinuing Mechanical Ventilation in ICUGamal Agmy
This document discusses various methods and indices used to assess a patient's ability to be weaned from mechanical ventilation in the ICU, including minute ventilation, maximum inspiratory pressure, respiratory frequency, rapid shallow breathing index, tracheal airway occlusion pressure, and others. It provides recommendations for protocols to minimize sedation, use inspiratory pressure augmentation or preventive noninvasive ventilation for extubation. Diaphragm ultrasound measuring diaphragm thickness change during breathing is also discussed as a potential new method to guide weaning with a cutoff value of over 40% change indicating a likely successful spontaneous breathing trial.
Presentation by Dr. S.K Jindal on "PAP Therapy" | Jindal Chest ClinicJindal Chest Clinic
Positive airway pressure (PAP) therapy is a sleep apnea treatment that uses compressed air to support the airway. It involves wearing a mask and a portable machine blowing pressurized air into the upper airway through a tube connected to the mask. This positive airflow prevents apnea collapse and allows normal breathing. In this presentation "PAP Therapy" has been described including its use, indications, complications, etc. For more information, please contact us: 9779030507.
These slides represent how to manage patients on a mechanical ventilator? Easy understanding of using ventilators. indication of mechanical ventilator use. How to wean a patient from a mechanical ventilator? How to fine-tune the ventilator settings?
An elderly woman with multiple comorbidities suffered from COVID 19 moderate disease - was managed conservatively
Case presentation with current treatment modalities
:Weaning from Mechanical Ventilation :Recent UpdatesGamal Agmy
This document summarizes recent updates on weaning from mechanical ventilation. It discusses that 75% of mechanically ventilated patients can be easily weaned, while 10-15% require a weaning protocol over 24-72 hours and 5-10% require gradual weaning over a longer period. Readiness criteria for weaning include improved respiratory status, absence of organ failure, adequate oxygenation and ventilation. Spontaneous breathing trials are used to assess readiness for weaning and extubation. Noninvasive ventilation can help prevent extubation failure, especially in patients with COPD. Diaphragm ultrasound may help predict weaning outcome, with a diaphragm thickness change over 40% associated with successful weaning.
This document discusses rescue therapies for refractory hypoxemia in acute respiratory distress syndrome (ARDS). It reviews evidence on inhaled nitric oxide (iNO), prone positioning, recruitment maneuvers and positive end-expiratory pressure (PEEP) titration, high frequency oscillatory ventilation (HFOV), and extracorporeal membrane oxygenation (ECMO). Prone positioning and iNO are first-line therapies that improve oxygenation but iNO does not reduce mortality. Recruitment maneuvers combined with PEEP titration may provide a survival benefit in severe ARDS. HFOV and ECMO are second-line therapies that can facilitate lung-protective ventilation but their effects on outcomes are unclear.
This document summarizes a study comparing non-invasive positive pressure ventilation (NIPPV) to high flow oxygen therapy in immunocompromised patients with acute respiratory failure. The study found that early use of NIPPV as compared to oxygen therapy alone did not reduce 28-day mortality or intubation rates. There were also no differences in ICU or hospital length of stay. While NIPPV did not provide benefits, the lower than expected mortality with oxygen therapy alone limited the study's ability to detect differences between the groups.
Ventilator Management In Different Disease EntitiesDang Thanh Tuan
The document discusses ventilator management in different disease entities. It covers indications for mechanical ventilation in conditions like respiratory failure, ARDS, COPD, chest trauma, and head injury. For ARDS specifically, it summarizes the key findings of the NIH ARDS Network trial which demonstrated that a lower tidal volume strategy of 6 ml/kg predicted body weight reduced mortality compared to the traditional higher tidal volume approach.
The assessment of management of stable COPD: an update 2014 by Corlateanu for...Alexandru Corlateanu
The document discusses various approaches to assessing and managing stable COPD, including assessments of severity, phenotypes, and multilateral evaluation. It reviews markers used in different assessment approaches, such as FEV1, symptoms, health status, and exacerbation risk. Non-pharmacological treatments like smoking cessation, pulmonary rehabilitation, and vaccinations are outlined. The efficacy and safety of various pharmacological treatments is summarized based on major randomized controlled trials, including long-acting bronchodilators, inhaled corticosteroids, their combinations, and phosphodiesterase inhibitors. Therapeutic strategies for stable COPD are compared between GOLD guidelines and Spanish guidelines.
Chronic Obstructive Pulmonary Disease (COPD) is a common lung disease characterized by persistent respiratory symptoms and airflow limitation. It includes chronic bronchitis and emphysema. The main risk factor is cigarette smoking. Symptoms include dyspnea, cough, and sputum production. Diagnosis is confirmed by spirometry showing airflow limitation. Management involves smoking cessation, bronchodilators, pulmonary rehabilitation, oxygen therapy, and treating exacerbations with corticosteroids and antibiotics.
1. The document discusses discontinuation of ventilatory support and weaning from mechanical ventilation in critically ill patients. It focuses on challenges in determining the optimal time for withdrawal of ventilation support and strategies to improve weaning outcomes.
2. Weaning from mechanical ventilation is a complex process that requires evaluation of respiratory, cardiac, muscular and cognitive factors. Approximately 20-30% of patients who are deemed ready for weaning trials will fail the initial spontaneous breathing test and require resumed mechanical ventilation.
3. The document reviews various approaches and considerations for evaluating patient readiness, managing weaning, and preventing extubation failure. It emphasizes the need for further research to identify high risk patients and improve weaning techniques.
Presentation of Dr. Dean Hess at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com
This document discusses ventilating patients on extracorporeal membrane oxygenation (ECMO) for acute respiratory distress syndrome (ARDS). It recommends a lung rest approach with low tidal volumes, inspiratory pressures below 25 cm H2O, low FiO2 below 30%, and permissive hypercapnia. PEEP should be titrated as high as tolerated. After the first 48 hours, ventilator settings can be gradually reduced as lung function improves with ECMO support. Oxygen saturation should be around 80% to avoid lung injury from high oxygen levels.
1) A large clinical trial found no difference in 7-day or 30-day mortality between patients receiving noninvasive ventilation (CPAP or NIPPV) and standard oxygen therapy for acute cardiogenic pulmonary edema.
2) While noninvasive ventilation improved symptoms and physiological measures more than standard oxygen, these benefits did not translate to improved survival.
3) There were also no differences found between CPAP and NIPPV in terms of efficacy, safety, or effects on mortality.
physiotherapy management for chronic obstructive pulmonary disease Sunil kumar
role of physiotherapy in chronic obstructive pulmonary disease, principles of physical therapy management in copd, physiotherapy assessing and treatment for copd
Weaning from mechanical ventilation is the process of gradually transferring breathing from the ventilator to the patient. It must be individualized and involves assessing patient readiness using criteria like clinical stability, adequate oxygenation and pulmonary function. Weaning success means unassisted breathing for 48 hours after removal from the ventilator. Patients are classified as having simple, difficult or prolonged weaning based on time to successful extubation. Factors that can cause weaning failure include increased airway resistance, decreased lung compliance, and respiratory muscle fatigue due to conditions like cardiac dysfunction, diaphragm weakness or endocrine abnormalities.
Weaning from mechanical ventilation and extubation by dr tareqtareq rahman
Weaning from mechanical ventilation and extubation requires careful assessment of patient readiness and involves gradually reducing ventilator support. While no single protocol can predict successful weaning in all cases, clinical judgment and experience are important. Early weaning when possible can reduce risks like nosocomial infection and improve patient outcomes. Factors such as respiratory status, hemodynamics, oxygen needs and sedation levels must be optimized before attempting weaning through slowly reducing settings on the ventilator. Noninvasive respiratory support like nasal CPAP is preferred after extubation over headbox oxygen. Caffeine, corticosteroids and chest physiotherapy may also improve chances of successful extubation.
Dr. Sujay Halkur Shankar presented on the topic of weaning patients from mechanical ventilation. The presentation covered assessing patient readiness, different weaning methods like spontaneous breathing trials, factors that can cause difficulty weaning like respiratory, cardiac and neuromuscular issues, and post-extubation care. Spontaneous breathing trials are the preferred method of weaning and have higher rates of success than pressure support or intermittent mandatory ventilation. Factors that can contribute to weaning failure include increased respiratory load or drive, decreased respiratory muscle strength, and cardiac dysfunction induced by weaning.
Non-invasive ventilation (NIV) delivers ventilatory support through a mask without using an invasive tracheal tube. The document discusses the history and development of NIV, benefits in pediatric patients, indications, contraindications, modes, and key points for successful use of NIV. It provides details on using NIV to treat acute hypoxemic and chronic hypercapnic respiratory failures in children. Close monitoring and criteria for escalating to invasive ventilation if NIV fails are also reviewed.
This document discusses the use of non-invasive ventilation (NIV) as a physiotherapeutic approach. It defines NIV as the delivery of oxygen via a face mask without an endotracheal tube. NIV works by creating positive airway pressure to force air into the lungs, reducing respiratory effort. There are two main types of NIV: non-invasive positive pressure ventilation and negative pressure ventilation. The document then discusses specific NIV techniques like CPAP and BiPAP and their indications. It also covers contraindications and how NIV can be used to manage acute respiratory failure, improve secretion removal, exercise capacity, and treat chronic respiratory failure.
Ventilatory support in special situations balamugeshDang Thanh Tuan
This document summarizes ventilation strategies for different clinical situations including ARDS, COPD, asthma, and bronchopleural fistula. It discusses ventilator settings such as tidal volume, PEEP, FiO2 and prone positioning that are recommended for ARDS. Non-invasive ventilation options for COPD and asthma exacerbations are also reviewed. Intubation criteria and strategies to deliver aerosol treatments during mechanical ventilation are provided. Managing air leak through bronchopleural fistula with techniques like differential lung ventilation or chest tube use is outlined.
Discontinuing Mechanical Ventilation in ICUGamal Agmy
This document discusses various methods and indices used to assess a patient's ability to be weaned from mechanical ventilation in the ICU, including minute ventilation, maximum inspiratory pressure, respiratory frequency, rapid shallow breathing index, tracheal airway occlusion pressure, and others. It provides recommendations for protocols to minimize sedation, use inspiratory pressure augmentation or preventive noninvasive ventilation for extubation. Diaphragm ultrasound measuring diaphragm thickness change during breathing is also discussed as a potential new method to guide weaning with a cutoff value of over 40% change indicating a likely successful spontaneous breathing trial.
Presentation by Dr. S.K Jindal on "PAP Therapy" | Jindal Chest ClinicJindal Chest Clinic
Positive airway pressure (PAP) therapy is a sleep apnea treatment that uses compressed air to support the airway. It involves wearing a mask and a portable machine blowing pressurized air into the upper airway through a tube connected to the mask. This positive airflow prevents apnea collapse and allows normal breathing. In this presentation "PAP Therapy" has been described including its use, indications, complications, etc. For more information, please contact us: 9779030507.
This document discusses updates to guidelines from GOLD and GINA. Some key points discussed include:
1. The GOLD guidelines now recommend LAMA/LABA combination therapy as first-line treatment for COPD based on studies showing greater improvement in quality of life compared to individual bronchodilators or placebo.
2. Studies showed the benefits of a single-inhaler triple therapy compared to ICS/LABA therapy for advanced COPD, with reductions in exacerbations.
3. The GINA guidelines now recommend considering ICS for mild asthma to reduce exacerbations based on new evidence. Anti-IL5 monoclonal antibodies like mepolizumab and benralizumab were added as add-
A 58-year-old smoker presents with worsening shortness of breath and difficulty reclining. On examination, he is in respiratory distress using accessory muscles and has wheezes and rhonchi bilaterally, suggesting airway obstruction. He likely has an acute exacerbation of COPD. The best initial treatments are oxygen, bronchodilators, and steroids to improve his condition.
Acute respiratory distress syndrome (ARDS) is a clinical syndrome characterized by rapid onset of bilateral pulmonary infiltrates and hypoxemia leading to respiratory failure. It is caused by acute diffuse inflammatory lung injury from a direct or indirect pulmonary insult. Diagnosis requires excluding left heart failure and evaluating for underlying causes. Pathologically, it involves diffuse alveolar damage and pulmonary edema. Treatment focuses on supportive care including mechanical ventilation, fluid management, and treatment of underlying conditions. While mortality has decreased in recent decades, ARDS still carries a significant risk of death.
Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) are associated with high costs, morbidity, and mortality. They result in enormous healthcare expenditures and lost productivity. AECOPD episodes are also linked to accelerated long-term loss of lung function in continuous smokers. While symptoms may recover within a week, full recovery of health-related quality of life can take months. Noninvasive mechanical ventilation should be tried for patients with respiratory acidosis or increased work of breathing from AECOPD as it reduces intubation rates and improves health outcomes. Preventing and properly managing AECOPD is important for reducing its impacts.
Bronchopulmonar y Dysplasia (BPD) is a chronic lung disease of prematurity. It was historically described in the 1960s and has two forms - classical BPD involving extensive fibrosis and new BPD characterized by arrested lung development. The incidence increases with lower gestational age. Risk factors include genetics, inflammation, infection, oxidative stress, mechanical ventilation, poor nutrition and surfactant dysfunction. Prevention focuses on antenatal steroids, gentle resuscitation with low oxygen, early CPAP/NIPPV, synchronized ventilation, adequate nutrition and fluid restriction to avoid pulmonary edema.
This document discusses guidelines for use of noninvasive positive pressure ventilation (NPPV) in patients with COPD exacerbations. It recommends starting NPPV in severe COPD exacerbations to prevent intubation. Factors that may indicate need for intubation include worsening gas exchange, encephalopathy, inability to clear secretions, or hemodynamic instability. Close monitoring is important to assess NPPV effectiveness and make adjustments or intubate if needed to avoid adverse outcomes. The document also reviews NPPV modes, interfaces, humidification and provides tips for troubleshooting issues that may arise with NPPV.
1. ARDS is a respiratory condition characterized by diffuse pulmonary edema and hypoxemia that develops rapidly within one week of a known clinical insult.
2. The Berlin Definition from 2011 revised the diagnostic criteria for ARDS, requiring an onset within 1 week of a known clinical insult, bilateral opacities on chest imaging not fully explained by cardiac failure or fluid overload, and a ratio of arterial oxygen partial pressure to fractional inspired oxygen of ≤300 mm Hg for mild ARDS or ≤200 mm Hg for moderate/severe ARDS.
3. Management of ARDS involves mechanical ventilation with low tidal volumes, conservative fluid management to avoid pulmonary edema, and treating the underlying cause of lung injury while minimizing additional lung injury from
Noninvasive ventilation may provide benefits as a weaning strategy compared to invasive weaning from mechanical ventilation. A systematic review and meta-analysis of randomized controlled trials found that noninvasive weaning significantly reduced mortality, rates of weaning failure and ventilator-associated pneumonia. It also decreased length of stay in the ICU and hospital as well as total duration of mechanical ventilation compared to invasive weaning. Subgroup analysis showed greater reduction in mortality for patients with COPD using noninvasive weaning.
Hepatopulmonary syndrome by Albin JosephAlbin Joseph
Hepatopulmonary syndrome (HPS) is characterized by liver disease, intrapulmonary vascular dilatations, and impaired oxygenation. It has a prevalence of 4-47% in adults with liver disease. The pathophysiology involves dilated pulmonary capillaries leading to ventilation-perfusion mismatching. Clinical features include cyanosis, clubbing, and low oxygen saturation. Diagnosis involves abnormal arterial blood gases and bubble echocardiography demonstrating intrapulmonary shunting. While liver transplantation effectively treats HPS, the case presentation describes a patient's complex postoperative course including nitric oxide supplementation and tracheostomy who ultimately was successfully decannulated.
Bpd,nnf kerala,march 2019 - Dr Karthik Nageshkarthiknagesh
This document provides information about Dr. N. Karthik Nagesh, including his professional designations, affiliations, awards, publications, and special interests in neonatal intensive care and respiratory disorders. It also includes summaries of current strategies for the prevention and management of bronchopulmonary dysplasia (BPD) in preterm infants, such as the use of antenatal steroids, continuous positive airway pressure (CPAP), minimal invasive surfactant therapy, targeted volume ventilation, and inhaled steroids.
The document discusses chronic obstructive pulmonary disease (COPD). Some key points:
- COPD affects over 210 million people globally and is a leading cause of death. The burden is increasing and may affect over 4.5 million deaths annually by 2030.
- In India, the burden of COPD has more than doubled from 14.84 million cases in 1971 to over 30 million estimated current cases. Patients often present at moderate to severe stages.
- The 2017 GOLD guidelines updated the COPD definition and treatment paradigm to focus on relieving symptoms and reducing exacerbation risk through dual bronchodilation.
Non Invasive Ventilation (NIV) involves delivering mechanical ventilation without the use of an endotracheal tube or surgical airway, instead using a tight-fitting face or nasal mask. NIV has been used since the 1940s but became more widely used starting in the 1980s for conditions like sleep apnea. It is now commonly used to treat acute respiratory failure from COPD exacerbations and cardiogenic pulmonary edema. NIV can be delivered via CPAP or BiPAP and involves optimizing settings like IPAP, EPAP, respiratory rate and oxygen flow to improve ventilation and oxygenation without the need for intubation. Proper patient selection, interface choice, and monitoring are important for successful NIV treatment.
1) Noninvasive ventilation (NIV) refers to respiratory support provided without an endotracheal tube and allows spontaneously breathing patients. 2) NIV modalities like CPAP and BiPAP raise functional residual capacity and splint alveoli open, reducing work of breathing and increasing oxygen levels. 3) Studies show NIV effectively treats respiratory failure types 1 and 2, pulmonary edema, and as an adjunct in COPD exacerbations by decreasing intubation need, mortality, and length of stay. However, effectiveness in milder COPD, pneumonia, and asthma requires further research.
Chronic obstructive pulmonary disease (COPD) is a common lung disease characterized by airflow limitation and tissue destruction due to chronic inflammation from smoke exposure. Symptoms include cough, dyspnea, and sputum production that worsen over time. The diagnosis is confirmed by spirometry showing airflow limitation that is not fully reversible with treatment. Management includes smoking cessation, pulmonary rehabilitation, inhaled bronchodilators and corticosteroids to control symptoms and reduce exacerbations.
Similar to Biphasic Cuirass Ventilation for Respiratory Failure and ARDS (20)
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2. Open Lung Concept
With BCV
• Optimizing lung volume by recruiting and
stabilizing unstable airways and lung units with
negative lung inflation
• Most homogeneous distribution of ventilation
possible
• Benefits:
– Improved pulmonary compliance
– Improved gas exchange
– Decreased work of breathing
– Better flow of secretions
– Decreased shunt and deadspace
– Improved pulmonary perfusion
3. Acute/Chronic Respiratory Failure
• pO2 <60 mm Hg or SpO2 (pulse oximetry)
<91% breathing room air
• pCO2 >50 mm Hg and pH <7.35 (hypercapnic)
• pH partially or fully compensated if chronic
and advancing from stable to unstable with
increased symptoms
• P/F ratio (pO2 / FIO2) <300
• pO2 decrease or pCO2 increase by 10 mm Hg
from baseline (if known).
https://acphospitalist.org/archives/2013/11/coding.htm
5. COPD Case Study
• 75 yo f
• Hx chronic respiratory failure, COPD, Cor Pulmonale
• Admitted with respiratory distress
• CO2 retention and dyspnea increased on floor
• Moved to ICU with high potential intubation-trach
• Severe mask intolerance
• BCV initiated with near immediate improvement of
dyspnea
• BCV utilized through to acute discharge, intubation/trach
avoided
• BCV utilized at LTAC then SNF
• High potential for short term readmission avoided
6.
7. Readmission Prevention
• Long-term effects of a hospital-based PR program coupled with NPV support in
patients with COPD on clinical outcomes evaluated.
• One hundred twenty-nine patients with COPD were followed up for more than 5
years
• NPV group receiving the support of NPV (20–30cm H2O delivery pressure for 60
min) and unsupervised home exercise program of 20 to 30 min daily walk
• Control group only received unsupervised home exercise program.
• Pulmonary function tests and 6 min walk tests (6MWT) were performed every 3 to
6 months. Emergency room (ER) visits and hospitalization with medical costs were
recorded.
• ER exacerbations and hospitalizations decreased by 66% (P<0.0001) and 54%
(P<0.0001) in the NPV group, respectively.
• Patients on PR program coupled with NPV had a significant reduction of annual
medical costs
• Our hospital-based multidisciplinary PR coupled with NPV reduced yearly decline
of lung function, exacerbations, and hospitalization rates, and improved walking
distance and medical costs in patients with COPD during a 5-year observation
11. Carpagnano GE, Sabato R, Lacedonia D, Di Gioia
R, Saliani V, Vincenzi U, Foschino-Barbaro MP
Department of Medical and Surgical Sciences, Institute of Respiratory
Diseases, University of Foggia, ItalybIntermediate Intensive
Respiratory Disease Unit, D'Avanzo Hospital, Foggia, Italy
New non invasive ventilator strategy applied to
COPD patients in acute ventilator failure
Pulmonary Pharmacology & Therapeutics (2017), doi: 10.1016/j.pupt.2017.08.009
12. • Abstract Introduction: There is no evidence in the literature regarding the
combined use of positive ventilation with negative ventilation. A recent study
reported that the two techniques can be combined in patients with ARDS, who
undergo ventilatory support for severe acute respiratory failure (ARF). There is
experience of non-invasive ventilation in patients with chronic respiratory
diseases and ARF. The aim of this study was to test the efficacy of a non-
invasive ventilatory strategy based on the combined use of negative (N) and
positive ventilation (P) in bi-level mode (PN). Methods: We enrolled 8 patients
with severe COPD exacerbations and exacerbated chronic respiratory failure
admitted in a monitored setting of an intermediate-intensive respiratory Unit.
Results: Patients underwent combined positive/negative ventilation and at
different times, in place of the two singular ventilation modes (P and N). After
each cycle, in the combined P/N ventilatory mode, gas exchanges were
significantly increased compared to the two singular P/N mode: pH (7.42 vs
7.40 and 7.40); PCO2 (85.01 vs 72.05 and 66.81 mmHg); FiO2/PO2 (488.75 vs
352.62 and 327.87). All patients well tolerated the application of the double
ventilation mode. Conclusions: In conclusion, the use of dual mode ventilation
appears well tolerated and superior to the individual modes in patients with
COPD exacerbations and ARF.
Carpagnano GE, Sabato R, Lacedonia D, Di Gioia R, Saliani V, Vincenzi U, Foschino-Barbaro MP, New non invasive ventilator strategy applied to COPD patients in
acute ventilator failure, Pulmonary Pharmacology & Therapeutics (2017), doi: 10.1016/j.pupt.2017.08.009.
14. Findings
• Gas exchanges were significantly increased
compared to the two singular
• All patients well tolerated the application of the
double ventilation mode
• Conclusion: The use of dual mode ventilation
appears well tolerated and superior to the
individual modes in patients with COPD
exacerbations and ARF
Pulmonary Pharmacology & Therapeutics (2017), doi: 10.1016/j.pupt.2017.08.009
16. BCV cited as a Benefit for Asthma
#K59 - INVESTIGATION OF THE EFFICACY OF BIPHASIC CUIRASS
VENTILATION FOR CHILDREN HOSPITALIZED WITH A MODERATE
BRONCHIAL ASTHMA ATTACK
Minato TM.1, Okada KO.2
1. Pediatrics, Toyooka Hospital Toyooka, Japan
2. Pediatrics, Okada Kodomonomori Clinic Saitama, Japan
We have seen that the combination of CN and SC modes can
deliver rapid and effective relief for moderate exacerbations of
bronchial asthma (BA), characterized by limited airflow due to
contraction of bronchial smooth muscle, swelling of respiratory
mucosa, and increased secretions. Therefore, we investigated
the efficacy of BCV.
PEDIATRIC PULMONOLOGY Volume 51 • Supplement 43 • June 2016 Proceedings #K59 pp S83
17. BCV cited as a Benefit for Asthma
14 patients admitted to our hospital for moderate BA
attacks and subsequently treated with BCV as an add-
on to conventional BA therapy (Group A).
The results of these patients were compared to those
of a control group consisting of 15 patients hospitalized
for moderate BA attacks before the hospital had
introduced the use of BCV (Group B).
PEDIATRIC PULMONOLOGY Volume 51 • Supplement 43 • June 2016 Proceedings #K59 pp S83
18. Results:
•The BCV group showed a significant improvement in both
HR Group A: 26.2/min Group B:13.9/min
RR Group A: 13.3 /min Group B: 6.4 /min
•Number of days on oxygen was significantly shorter in BCV
group
O2 days Group A: 2.9 ± 1.3 days Group B: 5.2 ± 1.8 days
•Length of hospitalization was significantly shorter in the
BCV group
Hosp days Group A: 5.7 ± 1.7 days, Group B: 7 ± 1.4 days
PEDIATRIC PULMONOLOGY Volume 51 • Supplement 43 • June 2016 Proceedings #K59 pp S83
19. BCV cited as a Benefit for Asthma
Discussion:
BCV as an add-on to conventional therapy for pediatric
BA attacks enabled significant stabilization of the
patients’ cardio respiratory condition from the day after
commencement.
Furthermore, BCV reduced the length of hospitalization
and oxygen administration and proved useful from a
health economic perspective.
Conclusion: BCV is effective for moderate BA attacks.
PEDIATRIC PULMONOLOGY Volume 51 • Supplement 43 • June 2016 Proceedings #K59 pp S83
20. Negative-Pressure Ventilation Better
Oxygenation and Less Lung Injury
• Francesco Grasso, Doreen Engelberts, Emma
Helm, Helena Frndova, Steven Jarvis, Omid
Talakoub, Colin McKerlie, Paul Babyn, Martin
Post & Brian P. Kavanagh from Hospital for Sick
Children in Toronto
• American Journal Of Respiratory And Critical
Care Medicine VOL 177 pp412-418, 2008
21. Negative-Pressure Ventilation Better
Oxygenation and Less Lung Injury
• Rationale: Conventional positive-pressure ventilation
delivers pressure to the airways; in contrast, negative
pressure is delivered globally to the chest and abdomen.
• Objectives: To test the hypothesis that ventilation with
negative pressure results in better oxygenation and less
injury than with positive pressure.
• Methods: Anesthetized, surfactant-depleted rabbits were
ventilated for 2.5 hours in pairs (positive or negative).
Tidal volume was 12 ml /kg, normocapnia was
maintained by adjusting respiratory rate, and FIO2 was
1.0.
22. Lung Inflation via TPP
In Healthy Lungs
= TPP = Same VT
whether TPP
– or +
23. In Sick Lungs
Not So Simple
• Lung inflation is mal-distributed due to
heterogeneous lung obstruction and injury
patterns
• Much more so with + lung inflation than - lung
inflation
• Same volume exchange with + lung inflation
more injurious than - lung inflation
• Same volume exchange with - lung inflation
results in better oxygenation
24. 5 Experimental Series Were Performed
• Series 1: Lung Injury and Oxygenation
• Series 2: Global Pulmonary Perfusion
• Series 3: Regional Pulmonary Perfusion
• Series 4: Transpulmonary Pressures, Lung
Volumes, and Oxygenation
• Series 5: CT Scan
25. Series 1: Lung Injury and Oxygenation
With Negative Lung Inflation
• Oxygenation significantly better
• Significantly decreased PaCO2-PetCO2
gradient due to decreased dead space
ventilation
• Composite histologic lung injury score
significantly lower
26.
27.
28. Series 2: Global Pulmonary Perfusion
“with the negative pressure chest device, the global
pulmonary perfusion was significantly greater”
29. Series 3: Regional Pulmonary Perfusion
• Cuirass could conceivably augment right ventricular
preload thereby increase lung perfusion and
improve oxygenation
30. Series 4: Transpulmonary Pressures,
Lung Volumes, and Oxygenation
• The transpulmonary pressure generated by
negative end expiratory pressure was consistently
less than that generated for a comparable level of
PEEP.
• For given levels of transpulmonary pressure, the
overall EELV achieved was consistently greater
when distension was negative versus positive
pressure.
• Finally, for a given level of EELV, the resultant
PaO2 was greater where the EELV was achieved
by NPV compared with PPV
31. Series 5: CT Scan
• The spatial differences were striking, with dependent
atelectasis persisting over most of the respiratory cycle in
PPV. Such patterns have previously been reported in
patients undergoing PPV in the setting of acute lung injury
• In contrast, with NPV, we observed a different topographic
distribution, in which normally aerated lung volumes were
greater and atelectasis was reduced.
• The findings in the current study are similar to the altered
distribution of lung volume as has been demonstrated for
ventilation in the prone versus supine position
33. Clinical Implications
• The clinical implications of any approach that
improves oxygenation or diminishes lung
injury are potentially very great.
34. Conclusion
• Use-or incorporation- of NPV should be
reinvestigated in the clinical context in which
oxygenation is problematic or lung injury is
likely
35. BCV Case Studies
• 84 y.o. M with laryngeal cancer and R apical mass with nearly complete R
lung atelectasis on AM chest X-ray.
• BCV initiated with goal of increasing aeration of R lung and improving
atelectasis.
• BCV started with CNEP of -30 for 30 minutes to initiate lung recruitment.
• Secretion clearance treatment executed for 35 minutes with results of
production of copious amounts of dark beige sputum.
• CNEP resumed after secretion clearance at -20 for 1.5 hrs at which time
secretion clearance and cough assist was repeated.
• Sputum production: large volumes of cream colored suctioned.
• Patient was maintained on CNEP of -28 pending afternoon chest X-ray.
• Pre and post 3.5 hours of BCV rad studies below.
37. P/F Ratio
• PO2/FiO2
• P/F ratio <300 is equivalent to a pO2 <60 mm
Hg on room air (acute respiratory failure)
• P/F ratio <250 is equivalent to a pO2 <50 mm
Hg on room air (severe respiratory failure)
• P/F ratio <200 is equivalent to a pO2 <40 mm
Hg on room air (extreme respiratory failure)
https://acphospitalist.org/archives/2013/11/coding.htm
38. Types of respiratory failure.
C. Roussos, and A. Koutsoukou Eur Respir J 2003;22:3s-14s
39.
40.
41. The Role of Biphasic Cuirass
Ventilation in Acute Respiratory
Failure
• Retrospective review of 41 cases of patients with
Respiratory Failure ventilated with BCV
• From various sources including a patient with
ARDS with a VAP for whom bronchoscopic
suctioning would not clear obstruction, but BCV
with secretion clearance was able to recruit the
lung
• CNEP was able to prevent intubation for COPD
patients probably due to decreased WOB and
deadspace ventilation
46. Intubation Avoidance 95%
• 258 consecutive patients with acute respiratory failure on chronic
respiratory disorders
• (77%) were treated exclusively with non-invasive mechanical
ventilation (40% with NPV, 23% with NPPV, and 14% with the
sequential use of both)
• In patients in whom NPV or NPPV failed, the sequential use of the
alternative non-invasive ventilatory technique allowed a significant
reduction in the failure of non-invasive mechanical ventilation (from
23.4 to 8.8%, p=0.002, and from 25.3 to 5%, p=0.0001, respectively)
• the hospital mortality (21%) was lower than that estimated by
APACHE II score (28%)
CONCLUSIONS:
• Using NPV and NPPV it was possible in clinical practice to avoid
endotracheal intubation in the large majority of unselected
patients with acute respiratory failure on chronic respiratory
disorders needing ventilatory support. The sequential use of both
modalities may increase further the effectiveness of non-invasive
mechanical ventilation.
47. Similar Results With HFO2
• BCV’s ability to work synergistically with the
high flow cannula systems can make both
devices more effective.
• Improvement often more quickly than
expected
• This combination may be your most powerful
1-2 punch for respiratory support ever. This
pair can dramatically decrease intubations
• Saving the bigger guns of PPV brought in to
replace the nasal device when failure
escalates.
48. Acute respiratory distress syndrome
• Acute respiratory distress syndrome (ARDS) is
a life-threatening lung condition that prevents
enough oxygen from getting to the lungs and
into the blood. Infants can also have
respiratory distress syndrome.
https://medlineplus.gov/ency/article/000103.htm
49. Acute respiratory distress syndrome
Causes
• ARDS can be caused by any major direct or indirect
injury to the lung. Common causes include:
• Aspiration
• Chest wall impact
• Near drowning
• Chemical inhalation injury
• Lung transplant
• Pneumonia
• Septic shock
• Trauma
https://medlineplus.gov/ency/article/000103.htm
50. Acute respiratory distress syndrome
• Depending on the amount of oxygen in the blood and
during breathing, the severity of ARDS is classified as:
– Mild
– Moderate
– Severe
• ARDS leads to a buildup of fluid in the air sacs (alveoli). This
fluid prevents enough oxygen from passing into the
bloodstream.
• The fluid buildup also makes the lungs heavy and stiff. This
decreases the lungs' ability to expand. The level of oxygen
in the blood can stay dangerously low, even if the person
receives oxygen from a breathing machine (ventilator)
through a breathing tube (endotracheal tube).
• ARDS often occurs along with the failure of other organ
systems, such as the liver or kidneys. Cigarette smoking and
heavy alcohol use may be risk factors for its development.
https://medlineplus.gov/ency/article/000103.htm
51. Acute respiratory distress syndrome
Outlook (Prognosis)
• About one third of people with ARDS die of the
disease. Those who live often get back most of
their normal lung function, but many people have
permanent (usually mild) lung damage.
• Many people who survive ARDS have memory
loss or other quality-of-life problems after they
recover. This is due to brain damage that
occurred when the lungs were not working
properly and the brain was not getting enough
oxygen.
53. Acute respiratory distress syndrome
Possible Complications
• VILI mechanisms are associated with a loss of
expiratory lung volume and stability
• Problems that may result from ARDS or its
treatment include:
– Failure of organ systems
– Ventilator Induced Lung Injury (VILI) due to injury
from the ventilator needed to treat the disease
– Pulmonary fibrosis (scarring of the lung)
– Ventilator-associated pneumonia
– PTSD
– PMV
– Death
54. Acute respiratory distress syndrome
• Alveolar instability and collapse result from inflammatory changes
as well as from loss of surfactant function.
• These changes plus edema formation from increased permeability
produce right-to-left shunting of blood and ventilation-perfusion
mismatching, both producing severe hypoxemia.
• Pulmonary hypertension occurs commonly in ARDS secondary to
vasoconstriction, thrombosis, perivascular edema and
inflammation, and eventual interstitial fibrosis.
• Overt right ventricular failure may develop if pulmonary
hypertension is severe.
• Although reported ARDS mortality rates today are less than
30%, recovery is often complicated by superimposed infections,
hyperoxic injury, ventilator-induced lung injury, and barotrauma.
Even with recovery, lung fibrosis may result in irreversible lung
dysfunction.
https://www.medscape.org/viewarticle/514525
55. Acute respiratory distress syndrome
• ARDS is sometimes classified as primary or
secondary.
• Primary ARDS describes lung injury from a
direct lung insult (eg, aspiration).
• Secondary ARDS describes lung injury as part
of a systemic process (ie, the lung is one of
many organs injured by a systemic
inflammatory response such as sepsis).
https://www.medscape.org/viewarticle/514525
56. BCV Opens the Lung Naturally to
Decrease Intensity of Illness
Applied when ARF recognized through peak of
illness to resolution offers the injured lungs
the least chance of further damage and the
best chance to recover as quickly as possible
57. BCV in
Combination Therapy
BCV CAN BE USED TO EFFECTIVELY ENHANCE
RESULTS IN COMBINATION
With Continuous or Intermittent Nebulization
With HFO2/Hi-VNI
With Mask NIPPV
With Heliox
With PPV in any mode
With HFOV
With ECMO
https://www.researchgate.net/Hayek-RTX-including-power-unit-and-cuirass-attached-to-an-intubated-patient-not_fig1_320639816
59. BCV Case Studies
• 56 y.o. M with history of morbid obesity and chronic ETOH
abuse admitted with altered mental status, severe liver
disease and peritonitis with possible illeus. Chest X-ray
severe R lung atelectasis/infiltrates/effusions.
• Patient was on positive pressure ventilation with Assist
Control rate of 25, PEEP 15 and O2 at 100%. O2 saturation
was 80-82%. P/F low 60s.
• BCV was requested with goal of improving oxygenation.
BCV was set with largest size chest shell at CNEP of -20
with no initial adjustment to PPV settings
• After 14 hrs of BCV O2 had been weaned to 50% with O2
saturation of 98%. Serial ABGs obtained show patient
progressing throughout this time.
60. 14 hrs CNEP with PPV
P/F = 64 inc to 177
in 14 hrs
FiO2 PaO2
AADO2Settings
62. NPV vs PPV in ARDS
• 6 patients monitored on NPV and PPV 2 hrs each
• 6 ml/kg and controlled for equal EELV for both
• NPV resulted in better oxygenation compared to
PPV with mean P/F of 345 mmHg vs 256 mmHg
• NPV airway pressures were considerably lower at
inspiration -1.5 cmH2O vs 34.5 cmH2O
• During NPV, intraabdominal pressures decreased
from 20.5 mmHg to 1 mmHg
• Conclusions:
NPV improved gas exchange in patients with
ARDS at lower transpulmonary, airway and
intraabdominal pressures
63. Combined Negative- and Positive-PressureVentilation for the Treatment of ARDS
Case Reports in Critical Care; Volume 2015, Article ID 714902,
64. Combined Negative- and Positive-
PressureVentilation for the Treatment
of ARDS
• 75 YO M with ARDS unresponsive to high PEEP
• External negative-pressure ventilation combined
with conventional pressure support using a
PEEP of about 8 cm H2O and a pressure support
of 4–12 cm H2O
• Alveolar infiltrates disappeared rapidly
• PaO2/FiO2 values surpassed 300mmHg after the
first application and 500mmHg after the second.
• Negative-pressure ventilation was used for 6–18
hours/day over five days.Combined Negative- and Positive-PressureVentilation for the Treatment of ARDS
Case Reports in Critical Care; Volume 2015, Article ID 714902,
65. What a Difference a Day and Negative
Lung Inflation Makes
Combined Negative- and Positive-Pressure Ventilation for the Treatment of ARDS
66. New Options
The possibility of effectively applying this and similar
concepts, not only in intubated but also in
nonintubated patients with ARDS, offers new options
that may genuinely differ from the present
therapeutic approaches. Therefore, these options
may have the potential to decrease the ongoing high
mortality rate associated with ARDS.
Combined Negative- and Positive-PressureVentilation for the Treatment of ARDS
67.
68. Acute lung injury: how to stabilize a
broken lung
• The lung is designed to function optimally only
when fully inflated and thus the ideal situation
would be to cast the open lung and let it heal at
its biologically natural volume.
• Studies have shown that elevated airway
pressure with levels known to cause VILI is
relatively benign if the lung is not allowed to fall
significantly below FRC.
• Maintaining adequate FRC has also been shown
to be protective in the normal lung
• VILI mechanisms are associated with a loss of
expiratory lung volume and stability
Acute lung injury: how to stabilize a broken lung
Crit Care. 2018; 22: 136.
69. Acute lung injury: how to stabilize a
broken lung
• opening and stabilizing alveoli would prevent all
three mechanical mechanisms of VILI
• progression to ARDS is often silent with normal
blood gases in the presence of ARDS with unstable
alveoli leading clinicians to believe the lung is “fine”
• by the time this level of lung pathology is present,
there is already considerable tissue and surfactant
damage resulting in a significant loss of lung volume
predisposing the lung to VILI
• “Never give the lung a chance to collapse” and by
doing so eliminate most VILI pathophysiology
Acute lung injury: how to stabilize a broken lung
Crit Care. 2018; 22: 136.
70. Extra-thoracic Lung Casting
• Open lung with BCV
• Use of Continuous Negative or highly negative Control
Mode settings to set a guard against loss of FRC
• Use of Extrathoracic Lung Casting (ELC) initiated at
early signs of respiratory distress to prevent lung
contracture and prevent illness escalation that would
be resultant from loss of FRC/atelectasis
• ELC can be maintained through mask to intubation and
PPV potentiall shortening duration and lessening
intensity of illness and PPV settings
• Goal: Earlier extubation and more rapid recovery for
larger number of survivors
71. The effectiveness of continuous negative
abdominal pressure management in a patient
with severe obesity experiencing respiratory failure
The effectiveness of continuous negative abdominal pressure management
in a patient with severe obesity experiencing respiratory failure
J Jpn Soc Intensive Care Med 2018;25:26-30
72. The effectiveness of continuous negative
abdominal pressure management in a patient
with severe obesity experiencing respiratory
failure
The effectiveness of continuous negative abdominal pressure management in a patient with severe obesity experiencing respiratory
failure
J Jpn Soc Intensive Care Med 2018;25:26-30
73. Continuous Negative Abdominal Pressure Recruits
Lungs at Lower Distending Pressures
• Ventilator-induced lung injury in acute respiratory distress
syndrome (ARDS) occurs mostly in ventilated, nondependent lung
regions, termed the baby lung
• Recruitment of dependent atelectasis involves transient elevations
of airway pressure to increase the size of the baby lung and reduce
its susceptibility to injury from inspiratory stretch. Clinical studies of
these techniques, however, have resulted in only marginal benefit
possibly because increased airway pressure first overinflates (and
potentially injures) already aerated regions before recruiting
atelectatic lung.
• Abdominal pressure is a key factor that increases the propensity to
dependent atelectasis. Negative pressure applied outside the
abdomen can lower the intra-abdominal pressure in patients and
could potentially decrease dorsal atelectasis by caudal shift of the
diaphragm.
American Journal of Respiratory and Critical Care Medicine Volume 197 Number 4 | February 15 2018
74. Continuous Negative Abdominal
Pressure Recruits
Lungs at Lower Distending Pressures
American Journal of Respiratory and Critical Care Medicine Volume 197 Number 4 | February 15 2018
75. Continuous Negative Abdominal
Pressure Recruits
Lungs at Lower Distending Pressures
American Journal of Respiratory and Critical Care Medicine Volume 197 Number 4 | February 15 2018
76. Continuous negative abdominal pressure:
mechanism of action and comparison
with prone position
We recently reported that continuous negative
abdominal pressure (CNAP) could recruit
dorsal atelectasis in experimental lung injury
and that oxygenation improved at different
transpulmonary pressure values compared
with increases in airway pressure
Continuous negative abdominal pressure: mechanism of action and comparison with prone position.
J Appl Physiol (1985). 2018 Jul 1;125(1):107-116.
77. Continuous negative abdominal pressure:
mechanism of action and comparison
with prone position
• The mechanism of recruitment with CNAP is
uncertain, and its impact compared with a
commonly proposed alternative approach to
recruitment, prone positioning, is not known.
• We hypothesized that CNAP recruits lung by
decreasing the vertical pleural pressure (P )
gradient (i.e., difference between dependent
and nondependent P ), thought to be one
mechanism of action of prone positioning.
Continuous negative abdominal pressure: mechanism of action and comparison with prone position.
J Appl Physiol (1985). 2018 Jul 1;125(1):107-116.
78. Continuous negative abdominal pressure:
mechanism of action and comparison
with prone position
• CNAP lowered the P in dependent but not in
nondependent lung, and therefore, in contrast
to PEEP, it narrowed the vertical P gradient.
CNAP increased respiratory system
compliance and oxygenation and appeared to
selectively displace the posterior diaphragm
caudad (computerized tomography images).
Continuous negative abdominal pressure: mechanism of action and comparison with prone position.
J Appl Physiol (1985). 2018 Jul 1;125(1):107-116.
79. Continuous negative abdominal pressure:
mechanism of action and comparison
with prone position
• Compared with prone position without CNAP, CNAP in the
supine position was associated with higher arterial partial
pressure of oxygen and compliance, as well as greater
homogeneity of ventilation.
• The mechanism of action of CNAP appears to be via
selective narrowing of the vertical gradient of P . CNAP
appears to offer physiological advantages over prone
positioning.
• NEW & NOTEWORTHY Continuous negative abdominal
pressure reduces the vertical gradient in (dependent vs.
nondependent) pleural pressure and increases oxygenation
and lung compliance; it is more effective than prone
positioning at comparable levels of positive end-expiratory
pressure
Continuous negative abdominal pressure: mechanism of action and comparison with prone position.
J Appl Physiol (1985). 2018 Jul 1;125(1):107-116.
80. Lung recruitment: The combined effect
of pressures North and South of the
Diaphragm
• PEEP alone did not result in lung recruitment,
whereas PEEP+CNAP did open a significant
volume of lung, especially in the
diaphragmatic lung regions
• They concluded that CNAP might be a
potential adjunct to PEEP in the recruitment
of diaphragmatic atelectasis
Lung recruitment: the combined effect of pressures "North" and "South" of the diaphragm
Crit Care Med. 2012 Jun;40(6)
81. BCV for ARDS
• Few improvements in mortality since
ARDSNET
• Oxygenation and compliance benefit from
successful restoratin/maintenance of FRC
• BCV works well with HFO2, NIPPV, and PPV for
better result in ARDS
• BCV improves P/F
• BCV increases FRC