Call for help early if refractory hypoxemia persists despite troubleshooting steps. Consider prone positioning, nitric oxide, paralysis, and ECMO to improve oxygenation in severe cases.
Oxygen ( the how and why of oxygen therapy for covid-19 patients)jayalakshmi311
A huge demand for oxygen has underlined its importance in covid-19 management. The ongoing second surge in covid-19 cases has been a huge rise in the demand for supplemental oxygen. In this slide we see about why the covid patient were suffered because of oxygen consumption and reason behind the respiration problem because of corona virus. And also analyse the case study also using graph. based on the some symptoms the clinical features were various and oxygen demand were various.
THIS IS AN BRIEF INFORMATION ABOUT AN ONE OF MY FAVOURITE SUBJECT ARDS & & ITS MANAGEMENT ,ROLES OF INTENSIVE NURSES , IT WILL EXPLAINS ABOUT CATEGORIES, PF RATIO, PRONE POSITIONING & NURSING CARE .....FOR THIS I REFFERED OLD SLIDE SHARE PPTS & IN HOSPITAL ROUTINELY PRACTICING POLICIES
Ventilatory management in obstructive airway diseasesVitrag Shah
Presentation on ventilatory management in COPD & Asthma
Updated information till 26/5/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36441-ventilatory-management-obstructive-airway-diseases-presentation.html
Oxygen ( the how and why of oxygen therapy for covid-19 patients)jayalakshmi311
A huge demand for oxygen has underlined its importance in covid-19 management. The ongoing second surge in covid-19 cases has been a huge rise in the demand for supplemental oxygen. In this slide we see about why the covid patient were suffered because of oxygen consumption and reason behind the respiration problem because of corona virus. And also analyse the case study also using graph. based on the some symptoms the clinical features were various and oxygen demand were various.
THIS IS AN BRIEF INFORMATION ABOUT AN ONE OF MY FAVOURITE SUBJECT ARDS & & ITS MANAGEMENT ,ROLES OF INTENSIVE NURSES , IT WILL EXPLAINS ABOUT CATEGORIES, PF RATIO, PRONE POSITIONING & NURSING CARE .....FOR THIS I REFFERED OLD SLIDE SHARE PPTS & IN HOSPITAL ROUTINELY PRACTICING POLICIES
Ventilatory management in obstructive airway diseasesVitrag Shah
Presentation on ventilatory management in COPD & Asthma
Updated information till 26/5/16
For powerpoint format, contact dr.vitrag@gmail.com
http://www.medicalgeek.com/presentation/36441-ventilatory-management-obstructive-airway-diseases-presentation.html
Mechanical ventilator, common modes, indications,nursing responsibilities MURUGESHHJ
it is an brief summary with diagrammatic presentation for NURSES regarding Mechanical ventilator, uses, complications, types, important terms,common modes, NIV, uses, NURING ROLES & RESPONSIBILITIES for handling INTUBATED patients...
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?
THE VENTILATOR CIRCUIT AND VENTILATOR-ASSOCIATED PNEUMONIA (VAP) Bassel Ericsoussi, MD
THE VENTILATOR CIRCUIT APPEARS TO HAVE ONLY A SMALL EFFECT ON THE DEVELOPMENT OF VAP. This contradicts the widely held belief that the ventilator circuit is an important contributor to the development of VAP
An overview of adult respiratory distress syndrome with a focus on the updates in ventilatory management of this important syndrome in the intensive care
Mechanical ventilator, common modes, indications,nursing responsibilities MURUGESHHJ
it is an brief summary with diagrammatic presentation for NURSES regarding Mechanical ventilator, uses, complications, types, important terms,common modes, NIV, uses, NURING ROLES & RESPONSIBILITIES for handling INTUBATED patients...
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?
THE VENTILATOR CIRCUIT AND VENTILATOR-ASSOCIATED PNEUMONIA (VAP) Bassel Ericsoussi, MD
THE VENTILATOR CIRCUIT APPEARS TO HAVE ONLY A SMALL EFFECT ON THE DEVELOPMENT OF VAP. This contradicts the widely held belief that the ventilator circuit is an important contributor to the development of VAP
An overview of adult respiratory distress syndrome with a focus on the updates in ventilatory management of this important syndrome in the intensive care
Learning Objectives Covered1. Explain Respiratory Failure and th.docxsmile790243
Learning Objectives Covered
1. Explain Respiratory Failure and the two types of respiratory failure: hypoxemic and hypercapnic respiratory failure
2. List and describe the indications and objectives for ventilator support
3. Explain the advantages and disadvantages of volume and pressure ventilation>
Background
Mechanical Ventilation is indicated to assist the patient who cannot maintain adequate oxygenation, alveolar ventilation or lacks the ability to protect his or her own airway.The inability of a patient to maintain either the normal delivery of oxygen to the tissues or the normal removal of carbon dioxide from the tissues is referred to as acute respiratory failure. Though the three common indications for mechanical ventilation includes inability to maintain adequate oxygenation, inability to maintain adequate alveolar ventilation and/or inability to protect one’s own airway. There are more specific indications for mechanical ventilation and can be found in the table below.
Indications
Definition
Example
Apnea
Absence of breathing
Cardiac Arrest
Acute
Respiratory Failure (ARF)
Inability of a patient to maintain adequate: PaO2, PaCO2, and, potentially, pH.
Hypoxemic RF
Hypercapnic RF
Impending
Respiratory Failure
Respiratory failure is immi-nent in spite of therapies.
Commonly defined as: Pt is barely maintaining (or gradually deteriorating) normal blood gases but with significant WOB.
Neuromuscular
Disease (N-M)
Status Asthmaticus
Chronic
Respiratory Failure
Repeated failures after attempts to liberate from the ventilator (extubations, Trach Collar trials, etc.)
SEVERE:
Obesity Hypoventilation Syndrome
COPD
Pulmonary Fibrosis
Prophylactic
Ventilatory Support
Clinical indication = high risk of respiratory failure.
Ventilatory support is instituted to ↓ WOB,minimize O2consumption and hypoxemia, reduce cardiopulmonary stress, and/or control airway with sedation.
Brain injury
Heart muscle
Injury
Major surgery
Shock (prolonged)
Smoke injury
Trauma (some)
Hyperventilation Therapy
Ventilatory support is instituted to control and manipulate PaCO2 tor lower than normal level
Acute head injury
(↑ ICP)
(not immediately
after injury)
*respiratoryupdate.com
Respiratory failure can be acute or chronic and is classified as either hypoxemic or hypercapnic. During hypoxemic respiratory failure, the patient’s ventilatory demands exceed the lung's ability to provide blood oxygenation resulting in muscle fatigue. Hypoxemic respiratory failure is defined as a PaO2 below the predicted normal range for the patient’s age under ambient conditions. A normal PaO2 for a patient that is 60 years or younger on room air is 80-100mmHg. When a patient is hypoxemic their body naturally responds to the low PaO2by increasing respiratory rate and/or tidal volume (an increase in minute ventilation). An increase in minute ventilation leads to hyperventilation. During hyperventilation, a greater than normal amount of CO2 is exhaled resulting in a low PaCO2 (h ...
WHO Critical Care Severe Acute Respiratory Infection Training
HEALTHprogrammeEMERGENCIESLearning objectives At the end of this lecture, you will be able to:•Recognize acute hypoxaemic respiratory failure.•Know when to initiate invasive mechanical ventilation.•Deliver lung protective ventilation (LPV) to patients with ARDS.•Describe how to manage ARDS patients with conservative fluid strategy.•Discuss three potential interventions for severe ARDS
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
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Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
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3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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2. The interaction between three factors:
1) The severity of the infection, the host response, physiological reserve and
comorbidities;
2) The ventilatory responsiveness of the patient to hypoxemia;
3) The time elapsed between the onset of the disease and the observation in the
hospital.
The interaction between these factors leads to the development of a time-related
disease spectrum within two primary “phenotypes”:
Type L characterized by Low elastance (i.e., high compliance), Low ventilation-to-
perfusion ratio, Low lung weight and Low recruitability.
Type H characterized by High elastance, High right-to left shunt, High lung weight
and High recruitability.
COVID-19 Pneumonia Phenotypes
3. COVID-19 pneumonia, Type L
Low elastance.
Low ventilation-to-perfusion (VA/Q) ratio. Since the gas volume is nearly normal,
hypoxemia may be best explained by the loss of regulation of perfusion and by loss of
hypoxic vasoconstriction. Accordingly, at this stage, the pulmonary artery pressure
should be near normal.
Low lung weight. Only ground-glass densities are present on CT scan, primarily located
sub-Pleurally and along the lung fissures. Consequently, lung weight is only moderately
increased.
Low lung Recruitability.
Therefore, severe hypoxemia is primarily due to ventilation/perfusion (VA/Q)
mismatch.
High PEEP and prone positioning do not improve oxygenation through recruitment of
collapsed areas.
4. COVID-19 pneumonia, Type H
High Elastance. The decrease in gas volume due to increased edema accounts for the
increased lung elastance.
High right-to-left shunt. This is due to the fraction of cardiac output perfusing the
non-aerated tissue which develops in the dependent lung regions due to the
increased edema and superimposed pressure.
High lung weight. Quantitative analysis of the CT scan shows a remarkable increase
in lung weight (> 1.5 kg), on the order of magnitude of severe ARDS.
High lung Recruitability. The increased amount of non-aerated tissue is associated, as
in severe ARDS, with increased recruitability.
The Type H pattern, 20–30% of patients in our series, fully fits the severe ARDS criteria:
hypoxemia, bilateral infiltrates, decreased the respiratory system compliance,
increased lung weight and potential for recruitment.
5.
6. Type L lung weight (1192 g), gas volume (2774 ml), percentage of non-aerated tissue (8.4%), venous admixture (56%),
P/F (68), and respiratory system compliance (80 ml/cmH2O).
Type H lung weight (1441 g), gas volume (1640 ml), percentage of non-aerated tissue (39%), venous admixture (49%),
P/F (61), and respiratory system compliance (43 ml/cmH2O).
Type L Type H
7. Type L ( Type 1) patients:
PEEP levels should be kept lower in patients with high pulmonary
compliance.
Tidal volume thresholds should not be limited at 6 ml/kg.
Respiratory rate should not exceed 20 breaths/min.
Patients should be left “quiet”; avoiding doing too much is of higher
benefit than intervening at any cost.
Type H (Type 2) patients:
Standard treatment for severe ARDS should be applied (lower tidal
volume, prone positioning, and relatively high PEEP).
8. Respiratory management
Goals of Oxygen therapy:
1. Target saturation SpO2 92%-96%.
2. Maintain stable work of breathing:
Goal respiratory rate < 24.
Target normal respiratory effort (no signs of accessory muscle use or obvious
increased respiratory work).
Supplemental oxygen support:
1. Initial oxygen delivery should be humidified nasal cannula (NC) titrated from 1 to 6 LPM
to meet goals of therapy.
2. If goals of therapy are not met at 6 LPM NC then advance to either:
Oxymizer mustache:
Initiate at 6 LPM.
Titrate to maximum of 12 LPM to meet goals of therapy.
Venturi mask
Initiate at 12 LPM and FiO2 40%.
Titrate to maximum of FiO2 60% to meet goals of therapy.
9. Respiratory management
Start by oxygen mask 5 L/min.
Escalate to face mask with bag 10-15 L/min.
Consider awake prone positioning with non-rebreathing mask.
Criteria of failure of oxygen therapy with face mask.
▪ Respiratory rate > 30 /min and SPo2 < 90% or PaO2 < 60 mmHg.
Escalate oxygen therapy to high flow nasal oxygen (if available):
Start by FIO2 100%.
Flow rate start @ 40 L/min to minimize aerosol spread and escalate to 60 L/min.
Consider prone position with HFNC.
Monitor for 1 to 2 hours.
if reached the target continue on HFNC.
if failed or HFNC is not available short trial of non-invasive ventilation.
10. Apply airborne precautions.
Pt in isolation room.
Pt wear surgical mask or N95 during HFNC.
Consider using high-flow oxygen
systems if patient is:
awake, cooperative.
with normal haemodynamics.
and without urgent need for intubation.
(PaCO2 < 45 mmHg).
Safe when compared with NIV in patients
with ARDS:
may be associated with less mortality.
nearly 40% of patients still require intubation.
If high flow tried and
unsuccessful DO NOT delay
High Flow Oxygen Systems
intubation.
11. Non-Invasive Ventilation
NIPPV: Initiation of NIPPV (bilevel positive airway pressure [BiPAP]/ continuous
positive airway pressure [CPAP]) requires attending approval; strongly
recommended to avoid NIPPV (BiPAP/CPAP) in persons under investigation and
confirmed COVID-19 cases.
Rare exceptions are
No intubation for those with acute indications for NIV or HFNC.
Patients who use NIV chronically or are currently stable or improving on NIV
or HFNC.
Exacerbations that are expected to have a rapid reversal such as congestive heart
failure.
Extubation failure or high risk for reintubation.
Equipment shortages in which milder disease could be managed to save invasive
ventilation devices.
12. Non-Invasive Ventilation
Use of non-invasive ventilation is controversial.
Because the atelectasis is the main cause of hypoxemia in these
patients, CPAP is preferred over BiPAP.
Initial settings for high level of CPAP 13-15 cmH2O.
Titrate FIO2 against oxygen saturation.
Falling FIO2 indicate successful therapy.
Predictors of failure (the patient should be evaluated within 30-60min after
starting NIV)
High Tidal volume exceeding 9.5 ml/kg predicts excess work of breathing
Progressive worsening of blood gases.
Increase work of breathing.
13. Non-Invasive Ventilation
NIV is continuous positive airway pressure
(CPAP) or bi-level positive airway pressure
delivered via a tight- fitting mask.
Not generally recommended for
treatment of patients with ARDS:
may preclude achieving low tidal volumes and
adequate PEEP level.
complications: facial skin breakdown, poor
nutrition, failure to rest respiratory muscles.
If used, apply airborne
precautions.It can be difficult to achieve a tight-fit
with face masks in children and infants.
EMERGENCIES|
14. Some experts use NIV in carefully selected
patients with mild ARDS:
cooperative, stable haemodynamics, few
secretions, without urgent need for intubation.
Can be used as a temporizing measure
until IMV is initiated.
If NIV tried and unsuccessful, do not delay
intubation:
i.e. inability to reverse gas exchange
dysfunction within 2–4 hours.
Non-Invasive Ventilation
|
15. GAP: Escalation to invasive ventilation
G: Gas exchange abnormality:
COVID-19 respiratory failure is usually hypoxemic, not hypercarbic.
Worsening oxygenation: PaO2/FIO2 or SpO2/FiO2 <150.
NIV with FIO2 >0.6 and can’t maintain SpO2 >90%.
Oxygenation unresponsive to HFNC therapy.
Hypercapnia with acidosis, pH <7.3.
Increased work of breathing suggests deterioration of respiratory function.
A: Airway protection:
Altered mental status attributed to respiratory failure.
Neurological dysfunction.
P: Pulmonary toilet:
Increased airway secretions.
16. Indication of intubation:
Worsening hypercarbia.
Acidemia.
Altered mental status.
Fatigue.
Hemodynamic instability.
Indications of mechanical ventilation:
Respiratory exhaustion.
Refractory severe hypoxemia (PaO2
<50-60 mmHg) on maximal oxygen
therapy.
Progressive CO2 retention with
academia.
Failure of NIV.
Non-respiratory indications
especially refractory hemodynamic
compromise and Deep coma.
17. Intubation protocol
Apply disposable mask, goggles, footwear,
gown and gloves. Consider adopting the
double glove technique.
Designate the most experienced anesthesia
professional available to perform
intubation.
Avoid awake fiberoptic intubation unless
specifically indicated.
Use filters between the bag valve & ET
tube, and on the ventilator circuit. Ensure
the absence of leaks on patient circuit.
Having vasopressor for bolus or infusion
immediately available for managing
hypotension.
Ensure the placement of a high quality
HMEF.
Place nasogastric tube after tracheal
intubation.
Re-sheath the laryngoscope immediately
post intubation (double glove technique).
18.
19.
20. Ventilatory management protocol:
1. Calculate Ideal Body Weight
Set Initial respiratory rate
Typical starting rates will be 16-24
titrated to goal minute ventilation of
5-8 L/min.
Consider starting rates of 24-28
titrated to goal minute ventilation of
8-12 L/min in setting of acidosis (pH <
7.25) pre-intubation.
21. Initial settings
Ventilator settings: Lung protective ventilation
Initial mode of ventilation: Assist control/ PRVC
Tidal volume: 6 mL/kg PBW (calculate this from height and gender)
Male patients: 50 + 2.3 [height (inches) – 60]
Female patients: 45.5 + 2.3 [height (inches) – 60]
PEEP 10 cm H2O: Monitor hemodynamics with increasing PEEP.
Respiratory rate: 20-25
Consider patients’ preintubation respiratory rate.
Goal: Limit overdistention of alveoli and ensure adequate oxygenation and
ventilation. Overdistention causes inflammation, organ dysfunction,
decreased venous return, and worsens ARDS.
22. Maintenance: Goals of therapy
Oxygenation
PaO2 > 60 / SpO2 88-98%
FIO2 to maintain a SpO2 of 88-98%
FIO2 <0.6
Try to avoid 100% oxygen, which favors de-nitrogen atelectasis.
Lower FIO2 of 0.7-0.9 may not drastically change
oxygenation due to high levels of shunt.
Ventilation
Tidal volumes of 4-8 mL/kg of PBW
pH 7.25-7.42
PaCO2 40-65 / end-tidal carbon dioxide (ETCO2) 35-60 mm Hg
Pulmonary Mechanics
FIO2
PEEP
FIO2
PEEP
ARDSNet low PEEP/ FIO2 Chart
Plateau pressures of ≤30 cm H2O (reflects respiratory system compliance)
Peak inspiratory pressure <35 cm H2O
0.3 0.4 0.4 0.5 0.5 0.6 0.7
6 6 8 8 10 10 10
0.7 0.7 0.8 0.9 0.9 0.9 1
12 14 14 14 16 18 18-24
23. Modes of ventilation
Primary ventilator modes
Assist/control (A/C) mode: The ventilator delivers a set minimum number of
mandatory breaths each minute. A/C mode can be used with either pressure
control or volume control.
Synchronous intermittent mandatory ventilation (SIMV) mode: The ventilator
delivers a set minimum number of mandatory breaths each minute but also allows
the patient to breathe spontaneously in between the mandatory breaths. SIMV
can be used with either pressure control or volume control.
24. Modes of ventilation (cont.)
Secondary ventilator modes
Airway pressure release ventilation (APRV): APRV is an applied continuous
positive airway pressure that at a set timed interval releases the applied pressure.
Occasionally used in those with severe acute respiratory distress syndrome
(ARDS).
Pressure regulated volume control (PRVC): This is a pressure- controlled mode
but adds a targeted tidal volume, so the
inspiratory pressure changes breath-to-breath to achieve the targeted tidal
volume.
25. When to troubleshoot
Peak airway pressure greater than 35 cm H2O
Evaluate the need for suctioning.
Check plateau pressure.
Check placement of ETT (deep?) and cuff pressure (do you hear a leak?).
Evaluate for pneumothorax: Chest x-ray, ultrasound.
Plateau pressure >30 cm H2O
Requires an inspiratory hold maneuver.
Reduce the tidal volume 1 mL/kg (minimum of 4 mL/kg).
Consider diuresis.
Consider paralysis.
Adjust respiratory rate lower (usually 2-6/min per change) to increase CO2.
26. When to troubleshoot (cont.)
FIO2 >0.6 with SpO2 <88%
Increase PEEP to level indicated on chart: Monitor blood pressure with each
PEEP increase.
Consider positioning of patient (ie, proning).
Consider diuresis.
PH <7.25
Assess whether acidosis is respiratory or metabolic.
Adjust respiratory rate higher (usually 2-6/min per change) to lower CO2 (max 35/min)
If you go higher than a respiratory rate of 30, you will need to decrease the
inspiratory time to 0.8 to avoid an inverse inspiratory-to-expiratory ratio.
Monitor for auto-PEEP.
Evaluate and treat metabolic abnormalities (check anion gap, lactate).
PH >7.42
Adjust respiratory rate lower (usually 2-6/min per change) to increase CO2.
27. Refractory hypoxemia
Call for help early
Consider proning to improve V/Q ratio mismatch
Assess cardiac function (myocarditis and cardiomyopathy
are reported)
Consider nitric oxide to improve V/Q ratio mismatch
Consider paralysis
Patient must be sedated with a benzodiazepine or propofol;
analgesics do not provide amnesia for paralysis.
Consider extracorporeal membrane oxygenation (ECMO)
28. Call for help
SpO2 less than 88% on an FIO2 of 1.0 for more than 15 minutes
despite troubleshooting.
pH less than 7.25 for more than 2 blood gases.
pH less than 7.10.
PaO2 less than 40.
SpO2/FIO2 or PaO2/FIO2 ratio of less than 150 for 2 hours.
SpO2/FIO2 or PaO2/FIO2 ratio of less than 80.
High-priority alarms (red) you cannot resolve within 2 minute
Manually ventilate until help arrives.
Low-priority alarms (yellow) you cannot resolve within 15 minutes
29. Clinical Pearls
Ventilator kills your patient unless you prevent it from doing so!
The best mode is the most suitable and comfortable mode for patients (not for you).
Patient fight with your mistakes not with the ventilator!
Calm your patient with opioids & Hypnotics, not relaxants.
Nebulizers & Humidifiers are your guardian angels.
Use lab. tests to confirm diagnosis not to diagnose.
Plan and order nutrition professionally.
Plan for and manage the stress of ETT & IPPV.