How to initiate Mechanical ventilation in ED ?
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This document discusses mechanical ventilation in the emergency room setting. It begins with background on mechanical ventilation and its common use as a life-saving intervention in the ER. It then covers the basics of mechanical ventilation including different modes, supports, parameters to set and how to monitor patients. It discusses special clinical situations and complications that can arise. It emphasizes the ED physician's role in preventing secondary complications like ventilator-associated pneumonia through measures taken in the emergency department.
![Mechanical Ventilation
in Emergency Room
Dr.Venugopalan P P
DA,DNB,MNAMS,MEM [GWU]
Director ,Emergency Medicine
Aster DM Healthcare -India
Executive Director -Active Network Group of Emergency Life Savers](https://image.slidesharecdn.com/mechanicalventedcopy-180201132812/85/How-to-initiate-Mechanical-ventilation-in-ED-1-320.jpg)
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How to initiate Mechanical ventilation in ED ?
- 1. Mechanical Ventilation in Emergency Room Dr.Venugopalan P P DA,DNB,MNAMS,MEM [GWU] Director ,Emergency Medicine Aster DM Healthcare -India Executive Director -Active Network Group of Emergency Life Savers
- 2. Background Intubation &mechanical ventilation, is a common life-saving intervention Good understanding of techniques to optimise mechanical ventilation will minimise complications. Effects of ventilator-induced lung injury are delayed and not seen while patients are in the ED Mechanical ventilation - ED approach is different . Ventilatory strategies - different disease processes to protect pulmonary parenchyma while maintaining adequate gas exchange Noninvasive ventilation - avoid the risks and complications of tracheal intubation
- 3. Understanding of Mechanical Ventilation in ED Basics and beyond ….
- 4. Session tries to answer this Why ventilation in ED? How to initiate ? What are the problems involved ? What are the special situations to be considered? What are the trouble shoots and how it be managed ? What are the ED role in preventive care ?
- 5. Why mechanical ventilation in ED? Clinical- Airway- Breathing- Circulation- Disability Lab
- 7. Clinical Breathing Apnea Hypoventilation Respiratory distress +AMS Increased work of breathing unrelieved by noninvasive methods
- 11. “8” Sets of Indications to start mechanical ventilation in ED 1 Airway Airway protection 2 Breathing Apnea,Distress 3 Circulation Shock 4 Disability Low GCS 5 Arterial Blood Gas PaO2,PaCO2&PH 6 Volume VC<10ml/Kg 7 Pressure Neg.Insp.Pr<25cmH2O 8 Flow FEV1<10ml/Kg
- 12. Pearls No absolute contraindications exist to mechanical ventilation. The need for mechanical ventilation is best made early on clinical grounds. A good rule of thumb - if the practitioner is thinking that mechanical ventilation is needed, then it probably yes. Waiting for return of laboratory values can result in unnecessary morbidity or mortality.
- 13. How to do it? Know the modes and supports Know how to set it
- 14. Modes Volume -cycled Pressure -cycled High frequency oscillatory support
- 15. Volume cycled Inhalation till pre-set Tidal volume delivered Passive exhalation Constant inspiratory flow Peak inspiratory pressure >Plateau Pressure
- 16. Volume cycled mode Constant volume - Varied Airway pressure with Compliance[Plateau Pr] and Airway resistance [Peak Pr] Choice as initial ventilation mode in ED Ventilator pressure act a monitor for Pulm. Compliance Barotrauma
- 17. Pressure cycled mode Inhalation continue till pre- set peak inspiratory pressure attained Tidal volume vary with pulmonary and thoracic compliance Decelerating inspiratory flow Homogenous gas distribution
- 18. Pressure cycled mode Tidal volume changes with pulmonary dynamics Demands Close monitoring Limits its use in ED
- 19. Dual mode Volume cycled - pressure limited is ideal for Emergency departments
- 20. HFO Ultra high respiratory rates [180 to 900breaths per minute] Tiny tidal volume [1 -4ml /kg] High airway pressure [25 to 30 mmof H2O] Useful in Premature infants and ARDS Limited role in ED
- 21. Supports Control mode - Preset volume delivery regardless patient effort, Choice in Apnea , Poor respiratory drive Support mode -Provides inspiratory assistance through Pressure,Terminate with expiratory pause, Need adequate respiratory drive
- 22. “8” Methods of Support 1. CMV 2. ACV 3. IMV 4. SIMV
- 23. “8”Methods of Support 1. PSV 2. PEEP 3. CPAP 4. BiPAP
- 24. CMV Continous Mandatory Ventilation Deliver breaths in preset intervals regardless pt efforts Paralysed /Apneic pts Increase WOB if pt is having efforts
- 25. ACV Assist Control Mode Deliver preset breaths in coordination with pt efforts Useful for Pts with intact respiratory efforts Triggered inspiration
- 26. IMV Intermittent Mandatory Ventilation Deliver breaths in preset interval , Preset mandatory volume Spontaneous breaths in between cause resistance of tubings and valves Baro trauma
- 27. SIMV Synchronous Intermittent Mandatory Ventilation Deliver preset breaths and volume in coordination with pt respiratory efforts Limits barotrauma Disadvantage -increased WOB [Adding PSV will reduce it ]
- 28. PSV Pressure support Ventilation For spontaneously breathing patients Mode will support every inspiration at preset pressure levels Airway pressure will maintain till the cut off level reaches Limits barotrauma Decrease WOB Pt decide RR,VT and Flow rate
- 29. Pearls ACV/SIMV with full support is the choice in patients require high MV Reduces Oxygen consumption and carbon dioxide production ACV in Obstructive airway diseases causes air trapping and Breath staking Full support ventilation with paralysis ACV=SIMV PSV is the choice in Pts with adequate respiratory drive PSV- better pt outcome ,reduced CVS effects ,Less Barotrauma and better gas distribution
- 30. Non Invasive ventilation Most commonly used in Ed Most useful Less complications
- 31. NIV Biphasic Positive Airway Pressure [BiPAP] Ventilatory support though mask in place of ETT Very useful in mild to moderate respiratory failure Pt must be mentally alert BiPAP is not pressure support. Form of CPAP-alternates high and low positive airway pressures
- 32. NIV 4-Indications Acute exacerbations -COPD Acute exacerbations - Asthma Decompensated CHF with mild to moderate pulmonary oedema Hypervolemic pulmonary oedema
- 33. NIV Recommended as an adjunct to Standard medical therapy [4 clinical scenarios ] Severe COPD exacerbations[PH, 7.35,Relative hypercarbia] Cariogenic Pulmonary oedema Respiratory failure with out shock ACS for urgent PCTA
- 34. How do I set ventilator in Ed? Guideline for initial setting and Special clinical situations
- 35. Set “8”parameters Mode of ventilation Tidal volume -TV Respiratory rate -RR Fractional inspiratory concentration of Oxygen- FiO2
- 36. Set “8” parameters Inspiration/Expiration Ratio Inspiratory flow rate Positive End Expiratory Pressure-PEEP Sensitivity
- 37. Mode Based on the need of the patients Need to order quickly in ED SIMV and ACV are best modes for initial setting PSV - for pts with good respiratory drive
- 38. Tidal Volume IPPV -10ml/ Kg Spontaneous breaths 7ml/ kg Obstructive airway diseases and ARDS- 5 -8 ml/kg [ Target to maintain plateau pressure <35cm of water
- 39. Respiratory rate 8-12 per minute for Pts not requiring hyperventilation 5-6 per minute is enough for Asthma Pts Permissive hypercapnia in Asthma is acceptable
- 40. “4”Reasons not to set high RR in obstructive airway diseases Less time for exhalation increase mean airway pressure Air trapping Hypotension
- 41. FiO2 Lowest FiO2 to get SaO2<90% and PaO2>60 mm of Hg A FiO2 of 0.4 is acceptable
- 42. Inspiration/Expiration ratio [I/E] I/E to start with 1:2 Obstructive airway disease 1:4 or 1:5[To avoid air trapping and auto PEEP] ARDS - 2:1[Inverse ratio]
- 43. Inspiratory Flow rate IFR is a function of TV,I/E and RR Controlled by these parameters Typical setting 60L/mt Obstructive airway disease up to 100L/mt
- 44. PEEP Positive End Expiratory Pressure Beneficial if used optimally with low tidal volume Decreases ventilator induced lung injury Reduce atelectasis trauma Minimise trauma due to cyclical collapse and reopening
- 45. PEEP Positive End Expiratory Pressure Shift lung water from alveolar space to perivascular interstitial space Provide acceptable O2 level & Reduce FiO2 to non toxic level [0.5] PEEP must be balanced with excessive intra thoracic pressures
- 46. PEEP Positive End Expiratory Pressure “4” indications ARDS Cariogenic Pulmonary oedema Non cariogenic Pulmonary Oedema Congestive heart failure
- 47. PEEP Positive End Expiratory Pressure “8” adverse effects Increased intra thoracic pressure Decreased Preload Decreased cardiac out put Hypotension Dead space ventilation Barotrauma Increased ICP Tension Pneumothorax
- 48. PEEP Positive End Expiratory Pressure Setting start with 3-5 cm of H2O Titrate against FiO2 FiO2 target less than 0.5 and PaO2 >60mm of Hg
- 49. Sensitivity Assist ventilation [ -1 to -2cm of H2O iPEEP increases the difficulty to generate a negative inspiratory force New Gen ventilators senses flow instead of negative pressure - Flow by Mode Flow sensing decreases WOB
- 51. How do I monitor a patient on ventilator Titrate parameters setting against clinical outcome and safe target values
- 52. Monitor “8” parameters in pts on ventilator Heart rate Blood pressure Oximetry ETCO2 ABG/VBG Peak inspiratory pressure Plateau Pressure Exhaled tidal volume
- 53. Monitoring pt on Ventilator Stable patient - Titrate FiO2 to Minimum using SpO2 or SaO2 as guide ABG A baseline value and repeat 30 mts after a major change in the setting PaCO2 is the indicator of ventilatory function. PIP &PP reflects Ventilatory dysfunction and lung compliance Exhaled volume to detect leaks and disconnect
- 54. SpO2 and ETCO2 SpO2 reflect beat to beat oxygenation status ETCO2 reflect breath to breath ventilation status
- 55. ETCO2 detects Ventilation status Detects ventilator dysfunction ETT obstruction Tube dislodgement Fight with ventilator
- 56. What are the consequences ? Cautions and Precautions
- 57. Adverse consequences of Mechanical ventilation Systemic inflammatory effects and biochemical pulmonary injury Barotrauma and volutrauma High FiO2 related free radical lung injury - Atelectasis and shunt Dead space ventilation
- 58. Adverse consequences of Mechanical ventilation Bacterial translocation and Bacteremia Increased Intra thoracic pressure ,decreased venous return and COP, RV and LV dysfunction Hypotension
- 59. Adverse consequences of Mechanical ventilation Decline in renal function Increased hepatic vascular resistance and bile duct pressure Gastric mucosal ischemia and GI bleed
- 60. Trouble shooting in ventilation How do I manage complications in the ED ?
- 61. Clinically deteriorating Mechanically ventilated Pt EET/Ventilator dysfunction Improper Ventilator settings Pain Anxiety Pulmonary or Extra Pulmonary disease process
- 62. “4” most common presentations of ventilator trouble shoots in the ED 1. Hypoxia 2. Hypotension 3. High pressure alarms 4. Low exhaled volume alarms
- 63. Intubated and ventilator patient with Heamodynamic and respiratory instability … Disconnect from ventilator Initiate manual ventilation Set 100% oxygen Look for DOPE Displacement -Obstruction- Pneumothorax-Equipment failure
- 64. Displacement -ETT Obstruction - ET Tube and Tubings Pneumothorax -Tension Equipment failure DOPE
- 65. “4” reasons for Cardio-Respiratory instability in Pts on ventilators 1. Tension Pneumothorax 2. Intrinsic PEEP 3. Obstructed Tube 4. ETT cuff leak
- 66. Tension Pneumothorax Needle decompression Tube thoracotomy Clinical diagnosis Should not wait for Chest radiograph NOT
- 67. Intrinsic PEEP Asthma & COPD patients Incomplete exhalation and hyper inflation Confirmation - Perform an End expiratory Hold or Non zero End expiratory flow on ventilator
- 68. Intrinsic PEEP Allow lung deflation Change setting by longer expiratory timings Decrease RR ,Decrease TV or Change I/E Ratio
- 69. Obstructed tube Significant airway resistance High pressure alarms Extrinsic compression,Tube plugs and Mucus,Blood ,FB, Kinks and Bites Suction and Sedation
- 70. PIP and Pplat helps to locate resistance PIP = resistance to air flow [measured by ventilator ] Plato = pulmonary compliance [measured by a brief inspiratory pause ]
- 71. PIP and Pplat locate resistance High PIP +Normal Pplat= Increased resistance to flow [ETT obstruction or Bronchospasm] High PIP +High Pplat= Decreased lung compliance [Pneumonia,ARDS,Pulmona ry Oedema,Abdominal distension]
- 72. “8” causes for High pressure PIP and Pplat
- 73. High pressure alarm? “8”Causes 1. Worsening ARDS 2. Pneumothorax 3. Endobrochial Intubation 4. Tube Bite and Block 5. Pulmonary oedema 6. Chest wall rigidity 7. Increased Intra abdominal pressure 8. Psychomotor agitation
- 74. Low exhaled volume Alarm Air leak Ventilatory Tube disconnection Balloon deflation Tracheal tube dislodgement Treat- Tube placement ,Ballon inflation& Reconnect to ventilator
- 75. “8” causes for Hypoxia following intubation and Mechanical ventilation 1. Secondary to hypoventilation 2. Worsening cardiac shunting 3. Inadequate FiO2 4. Main stem intubation 5. Aspiration 6. Tube dislodgement 7. Pulmonary Oedema 8. Wrong gas- compressed air or Nitrous oxide
- 76. Hypoxia following intubation and Mechanical ventilation Increase Oxygen -FiO2 Change ventilator setting Increase PEEP ,RR Exclude DOPE
- 77. Hypotension following intubation and Mechanical ventilation Decreased venous return and Increased Intrathorvacic pressure Vasovagal reaction to intubation RSI Sedation Tension pneumothorax
- 78. Hypoxia following intubation and Mechanical ventilation IV fluids Change Ventilatory setting Reduce PEEP Reduce VT and RR
- 79. Supportive care Anticipatory … how to reduce morbidity and mortality
- 80. How does ED physician responsible for secondary complication Traditionally limited to Intubation and Initiation of ventilation Long ED stay is due to non availability of ICU beds EP should initiate preventive measures to decrease secondary complications
- 81. Secondary complications Ventilator associated pneumonia -VAP Venous thromboembolism - VTE Stress Related Mucosal injury
- 82. VAP Most common infectious complication Prolonged ICU & Hospital stay Prolonged Ventilator days Increases cost of care
- 83. VAP ED related independent risk factors Pre-hospital intubation ED intubation ED length of stay
- 84. ED level measures to decrease VAP Due to Aspiration and bacterial colonisation Semi upright position -3o to 45 degree head end elevation NG Tube Oral care with soft tooth brush Chlorhexidine rinses Cuff pressure monitoring 4 hourly [20 to 30cm of H2O
- 85. VTE VTE prophylaxis from ED Unfractionated Heparin Low molecular weight Heparin
- 86. Stress related GI mucosal injury 75% ICU patients develops SRGIM injury within 24 hours Proton pump inhibitors Sucralfate Histamine receptor antagonist Identify high risk patients to develop Stress induced GI injuries
- 87. High risk patients Coagulopathy GI bleeds Gastritis Peptic ulcer Mechanical ventilation more than 48 hours
- 88. Summary EP has to initiate mechanical ventilation in critical scenarios EP should know basics and beyond ED based mechanical ventilation strategy is different Close monitoring and targeted titration is essential to bring successful outcome EP has pivotal role in preventive care in ICU complications
- 90. Thank you so much critically yours dr.venu www .drvenu .blog .in www.drvenu.me