The document provides an overview of mechanical ventilation essentials and strategies for different patient populations. It discusses:
1. Initial mechanical ventilation settings including tidal volume, respiratory rate, PEEP and FiO2.
2. Assessing ventilation using minute ventilation and ABG PaCO2 levels.
3. Managing patients with obstructive airway disease by monitoring PIP, flow, and intrinsic PEEP.
4. Introduction to ARDS and the low tidal volume ventilation strategy for restrictive lung disease.
1. Venovenous extracorporeal membrane oxygenation (VV ECMO) is a rescue therapy for severe acute respiratory distress syndrome (ARDS) with high mortality rates. It allows the lungs to rest and heal while providing oxygenation to the blood.
2. Modern VV ECMO circuits are safer and more effective than older models, using improved oxygenators, pumps, and often dual lumen cannulas. Patients supported with VV ECMO have survival rates around 60% according to the ELSO registry.
3. Providing effective VV ECMO requires a highly skilled multidisciplinary team and standardized protocols. Key challenges include properly selecting patients, ventilator management to rest the lungs, and coordin
Management of persistent hypoxemic respiratory failure in the icu garpestadDang Thanh Tuan
The document discusses management of persistent hypoxemic respiratory failure in ICU patients. It describes a case of a patient who developed this after abdominal surgery and peritonitis. It then discusses various ventilator strategies and their risks and benefits for improving oxygenation while minimizing lung injury, including low tidal volume ventilation, optimal levels of PEEP, recruitment maneuvers, prone positioning, and permissive hypercapnia. It summarizes several key clinical trials that have informed best practices.
HFOV uses small, rapid lung oscillations to reduce ventilator-induced lung injury compared to conventional mechanical ventilation. It works by maintaining constant mean airway pressure and small tidal volumes to avoid alveolar overdistension and collapse. Several early studies found HFOV improved oxygenation compared to CMV for ARDS, but larger trials found no significant difference in mortality. Proper patient selection, early initiation, and careful titration of pressures and settings are key to optimize outcomes with HFOV.
Oxygenation, Ventilation And Ventilator Management In The First 24 HoursDang Thanh Tuan
This document discusses oxygenation, ventilation, and ventilator management in the first 24 hours for patients requiring mechanical ventilation. It covers etiologies of respiratory failure, measures of oxygenation and ventilation, indications for mechanical ventilation and non-invasive ventilation, ventilator set up including modes, and causes and management of respiratory distress on the ventilator.
This document discusses ventilator settings for mechanical ventilation. It begins by outlining the components of ventilators including controls, monitors, alarms, and accessories. It then discusses initial ventilator settings such as setting the mode to assist control, fractional inspired oxygen to 100%, positive end-expiratory pressure starting at 5 cm H2O, respiratory rate of 12-20 breaths per minute, tidal volume of 5-12 cc/kg based on patient characteristics, inspiratory to expiratory ratio of 1:2 or 1:1.5, and sensitivity/trigger settings. Safety considerations are also outlined such as having a manual resuscitation bag available and double checking settings against pressure and volume measurements.
The document discusses mechanical ventilation settings and principles. It indicates that the goals of ventilation are to facilitate CO2 release and maintain normal PaCO2 levels. Different modes of ventilation are described, including assist-control mode, SIMV, and PSV. Key settings discussed include tidal volume, respiratory rate, I:E ratio, PEEP, and FiO2. The document notes that patients with COPD should aim for controlled hypercapnia to limit high airway pressures. For ARDS patients, a low tidal volume ventilation strategy is recommended based on clinical trial evidence showing lower mortality.
Weaning from mechanical ventilation is a process of transitioning the work of breathing from the ventilator to the patient. It involves gradually reducing ventilator support levels by decreasing settings like PIP, PEEP, and FiO2 while monitoring the patient's condition. Successful weaning depends on factors like the patient's general health, respiratory muscle strength, ventilatory need, and airway status. Clinicians consider markers like improving oxygen needs, decreasing secretions and better imaging when determining readiness. A safe wean follows a step-down process using modes like SIMV with gradual decreases in support over time.
Mechanical Ventilation Cheat Book for Internal Medicine ResidentsThe Medical Post
This short cheat book talks about basic concepts and physiology of artificial ventilation and also elaborates on point guided approach in maneuvering different modes of mechanical ventilation. Consider this as a basic overview and is intended for all internal medicine residents.
1. Venovenous extracorporeal membrane oxygenation (VV ECMO) is a rescue therapy for severe acute respiratory distress syndrome (ARDS) with high mortality rates. It allows the lungs to rest and heal while providing oxygenation to the blood.
2. Modern VV ECMO circuits are safer and more effective than older models, using improved oxygenators, pumps, and often dual lumen cannulas. Patients supported with VV ECMO have survival rates around 60% according to the ELSO registry.
3. Providing effective VV ECMO requires a highly skilled multidisciplinary team and standardized protocols. Key challenges include properly selecting patients, ventilator management to rest the lungs, and coordin
Management of persistent hypoxemic respiratory failure in the icu garpestadDang Thanh Tuan
The document discusses management of persistent hypoxemic respiratory failure in ICU patients. It describes a case of a patient who developed this after abdominal surgery and peritonitis. It then discusses various ventilator strategies and their risks and benefits for improving oxygenation while minimizing lung injury, including low tidal volume ventilation, optimal levels of PEEP, recruitment maneuvers, prone positioning, and permissive hypercapnia. It summarizes several key clinical trials that have informed best practices.
HFOV uses small, rapid lung oscillations to reduce ventilator-induced lung injury compared to conventional mechanical ventilation. It works by maintaining constant mean airway pressure and small tidal volumes to avoid alveolar overdistension and collapse. Several early studies found HFOV improved oxygenation compared to CMV for ARDS, but larger trials found no significant difference in mortality. Proper patient selection, early initiation, and careful titration of pressures and settings are key to optimize outcomes with HFOV.
Oxygenation, Ventilation And Ventilator Management In The First 24 HoursDang Thanh Tuan
This document discusses oxygenation, ventilation, and ventilator management in the first 24 hours for patients requiring mechanical ventilation. It covers etiologies of respiratory failure, measures of oxygenation and ventilation, indications for mechanical ventilation and non-invasive ventilation, ventilator set up including modes, and causes and management of respiratory distress on the ventilator.
This document discusses ventilator settings for mechanical ventilation. It begins by outlining the components of ventilators including controls, monitors, alarms, and accessories. It then discusses initial ventilator settings such as setting the mode to assist control, fractional inspired oxygen to 100%, positive end-expiratory pressure starting at 5 cm H2O, respiratory rate of 12-20 breaths per minute, tidal volume of 5-12 cc/kg based on patient characteristics, inspiratory to expiratory ratio of 1:2 or 1:1.5, and sensitivity/trigger settings. Safety considerations are also outlined such as having a manual resuscitation bag available and double checking settings against pressure and volume measurements.
The document discusses mechanical ventilation settings and principles. It indicates that the goals of ventilation are to facilitate CO2 release and maintain normal PaCO2 levels. Different modes of ventilation are described, including assist-control mode, SIMV, and PSV. Key settings discussed include tidal volume, respiratory rate, I:E ratio, PEEP, and FiO2. The document notes that patients with COPD should aim for controlled hypercapnia to limit high airway pressures. For ARDS patients, a low tidal volume ventilation strategy is recommended based on clinical trial evidence showing lower mortality.
Weaning from mechanical ventilation is a process of transitioning the work of breathing from the ventilator to the patient. It involves gradually reducing ventilator support levels by decreasing settings like PIP, PEEP, and FiO2 while monitoring the patient's condition. Successful weaning depends on factors like the patient's general health, respiratory muscle strength, ventilatory need, and airway status. Clinicians consider markers like improving oxygen needs, decreasing secretions and better imaging when determining readiness. A safe wean follows a step-down process using modes like SIMV with gradual decreases in support over time.
Mechanical Ventilation Cheat Book for Internal Medicine ResidentsThe Medical Post
This short cheat book talks about basic concepts and physiology of artificial ventilation and also elaborates on point guided approach in maneuvering different modes of mechanical ventilation. Consider this as a basic overview and is intended for all internal medicine residents.
This document discusses strategies for liberating patients from mechanical ventilation. It outlines key factors that indicate readiness to wean, including improved respiratory function and organ system stability. Two common approaches to weaning are described: gradual weaning using methods like pressure support ventilation or spontaneous breathing trials followed by extubation if tolerated. Protocols using objective criteria can standardize and expedite the weaning process. Factors that may cause weaning failure include respiratory issues, cardiovascular problems, or infection. Readiness is assessed through measurements of ventilatory drive, muscle strength, and breathing patterns.
This document provides information on basic mechanical ventilation. It discusses various indications for mechanical ventilation including conditions like pneumonia, ARDS, pulmonary edema, and neuromuscular disorders. It then describes the basic components and functions of a mechanical ventilator including volume change, time, gas flow, and pressure difference. Key parameters like compliance, PEEP, and I:E ratio that are important for mechanical ventilation are explained. Different ventilator modes are outlined including pressure control, volume control, SIMV, and PSV. Settings like tidal volume, pressure, and respiratory rate that should be optimized are also reviewed.
1. Pulse oximetry and capnography are important monitoring tools during procedures involving sedation. Pulse oximetry monitors oxygenation but not ventilation, while capnography directly monitors ventilation.
2. Various factors can limit the accuracy of pulse oximetry, including abnormal hemoglobins, low perfusion, and certain dyes. Capnography provides early warning of respiratory issues through waveform analysis.
3. In addition to oxygenation and ventilation, sedation monitoring should include assessment of heart rate, blood pressure and level of consciousness to rapidly identify potential complications.
This document provides information on the management of patients on mechanical ventilation. It discusses the indications for mechanical ventilation including inadequate oxygenation and ventilation. It then covers the mechanisms of oxygen transport and various causes of inadequate oxygenation and perfusion. The document outlines the purposes of ventilation and procedures for initiation and settings of mechanical ventilation including modes, parameters, and monitoring of patients. It discusses potential problems during ventilation and goals of ventilation. Finally, the document reviews weaning from mechanical ventilation.
Mechanical ventilation منتدى تمريض مستشفى غزة الاوروبegh-nsg
The document discusses the principles and history of mechanical ventilation. It covers the origins of negative pressure ventilators used during polio outbreaks and the later adoption of positive pressure ventilation. The modern standard involves positive pressure ventilation which began the era of intensive care medicine. Various ventilation modes, settings, and indications for intubation and extubation are outlined.
The document discusses various aspects of mechanical ventilation including:
1) Different ventilator settings such as mode, respiratory rate, tidal volume, and PEEP that can be adjusted for different patient types.
2) Monitoring pressures such as peak pressure and auto-PEEP is important to avoid complications.
3) Specific considerations for ventilating patients with COPD/asthma include permissive hypercapnia to reduce dynamic hyperinflation and work of breathing.
4) Ventilating ARDS patients should use low tidal volumes, as clinical trials have shown this approach reduces mortality compared to traditional higher volumes.
The document discusses pulmonary function tests (PFTs) and their use in evaluating respiratory disorders. It provides details on various PFT measurements including spirometry tests like forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Obstructive disorders like asthma decrease FEV1 relative to FVC while restrictive disorders decrease both measurements. PFTs are used to diagnose lung conditions, assess severity, and monitor treatment effectiveness. They provide standardized measurements of respiratory function but must be interpreted along with other clinical information.
The document discusses various topics related to mechanical ventilation including:
1. Ventilation strategies for acute respiratory distress syndrome (ARDS) including low tidal volumes, optimal positive end-expiratory pressure, and prone positioning.
2. Ventilation modes and settings should be tailored to the individual patient's condition and aim to prevent ventilator-induced lung injury.
3. Non-invasive ventilation can be considered for certain patients with COPD or asthma to avoid intubation if criteria are met.
Pulmonary function tests provide objective measurements of lung function through various tests. Spirometry is the most basic and widely used test that measures volumes of air inhaled and exhaled over time through a spirometer. It can detect obstructive or restrictive lung diseases patterns based on evaluations of parameters like FEV1, FVC, FEV1/FVC ratio, and flow-volume loops. Other tests measure lung volumes, diffusion capacity, and assess ventilation/perfusion ratios to further characterize lung abnormalities. Together, pulmonary function tests provide quantifiable data to support diagnoses suggested by symptoms and physical exams.
Spirometry is a test used to assess lung function by measuring airflow. It can help diagnose obstructive lung diseases like COPD and asthma by measuring airflow limitation through values like FEV1 and FEV1/FVC ratio. A spirometry report provides values for volumes of air inhaled and exhaled that are compared to predicted normal values to identify restrictive or obstructive lung abnormalities. Quality control measures ensure accurate spirometry administration and interpretation.
Respiratory failure and the acute respiratory distress syndrome (and shock) Jim Lavelle
The document provides an overview of respiratory failure and mechanical ventilation. It discusses the types and pathophysiology of respiratory failure, key ventilator settings, the definition and management of acute respiratory distress syndrome (ARDS), and some basics about shock. The goal is to help understand arterial blood gases, optimize ventilator settings, and improve survival in ARDS patients.
This document discusses pulmonary recruitment in ARDS patients and strategies for lung protection during mechanical ventilation. It describes how recruitment maneuvers using high airway pressures can reopen collapsed alveoli, preventing ventilator-induced lung injury from repeated opening and closing. The optimal settings for recruitment maneuvers and PEEP levels depend on a patient's recruitability, assessed via low-flow pressure-volume curves. PEEP levels are best guided by esophageal manometry or oxygen saturation to maintain alveolar stability and oxygenation without overdistension.
This document provides information about mechanical ventilation for pediatric patients. It discusses indications for mechanical ventilation, different ventilation modes, adjusting the ventilator, monitoring the patient, potential complications, weaning from ventilation, and nursing management of ventilated patients. Key points include classifications of ventilation modes, guidelines for adjusting settings based on blood gas results, monitoring oxygenation, ventilation and other vital signs, common complications like infections and injuries, and a process for gradually weaning patients off the ventilator.
Etco2 in non-intubated patient: a must in ednisaiims
The document discusses end-tidal carbon dioxide (EtCO2) monitoring in non-intubated patients. It defines EtCO2 and describes how it is measured using semi-quantitative capnometry, quantitative capnometry, and waveform capnography. EtCO2 monitoring provides information about a patient's ventilation and can detect hypoventilation or apnea sooner than pulse oximetry alone. Various normal and abnormal capnography waveforms are presented along with their potential causes and treatment approaches. The document advocates for increased use of EtCO2 monitoring in emergency departments given its ability to rapidly assess respiratory status in critically ill patients.
1. The document discusses various modes of mechanical ventilation including volume control, pressure control, SIMV, and PSV. It describes the settings, parameters, and considerations for each mode.
2. Initial ventilator settings should aim for adequate oxygenation and ventilation while minimizing work of breathing. Settings like tidal volume, respiratory rate, and PEEP are adjusted based on factors like patient size and condition.
3. Weaning from mechanical ventilation involves gradually reducing support through methods like spontaneous breathing trials, decreasing SIMV frequency, and lowering pressure support levels to assess the patient's ability to breathe independently. Readiness criteria and a stepwise protocol are
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.
Postoperative Ventilation in Paediatric Cardiac Surgical Patientsdr amarja nagre
In paediatric patients with congenital heart diseases,postoperative management is as important as surgical procedure.Here is discussion regarding the same.
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
This document discusses strategies for liberating patients from mechanical ventilation. It outlines key factors that indicate readiness to wean, including improved respiratory function and organ system stability. Two common approaches to weaning are described: gradual weaning using methods like pressure support ventilation or spontaneous breathing trials followed by extubation if tolerated. Protocols using objective criteria can standardize and expedite the weaning process. Factors that may cause weaning failure include respiratory issues, cardiovascular problems, or infection. Readiness is assessed through measurements of ventilatory drive, muscle strength, and breathing patterns.
This document provides information on basic mechanical ventilation. It discusses various indications for mechanical ventilation including conditions like pneumonia, ARDS, pulmonary edema, and neuromuscular disorders. It then describes the basic components and functions of a mechanical ventilator including volume change, time, gas flow, and pressure difference. Key parameters like compliance, PEEP, and I:E ratio that are important for mechanical ventilation are explained. Different ventilator modes are outlined including pressure control, volume control, SIMV, and PSV. Settings like tidal volume, pressure, and respiratory rate that should be optimized are also reviewed.
1. Pulse oximetry and capnography are important monitoring tools during procedures involving sedation. Pulse oximetry monitors oxygenation but not ventilation, while capnography directly monitors ventilation.
2. Various factors can limit the accuracy of pulse oximetry, including abnormal hemoglobins, low perfusion, and certain dyes. Capnography provides early warning of respiratory issues through waveform analysis.
3. In addition to oxygenation and ventilation, sedation monitoring should include assessment of heart rate, blood pressure and level of consciousness to rapidly identify potential complications.
This document provides information on the management of patients on mechanical ventilation. It discusses the indications for mechanical ventilation including inadequate oxygenation and ventilation. It then covers the mechanisms of oxygen transport and various causes of inadequate oxygenation and perfusion. The document outlines the purposes of ventilation and procedures for initiation and settings of mechanical ventilation including modes, parameters, and monitoring of patients. It discusses potential problems during ventilation and goals of ventilation. Finally, the document reviews weaning from mechanical ventilation.
Mechanical ventilation منتدى تمريض مستشفى غزة الاوروبegh-nsg
The document discusses the principles and history of mechanical ventilation. It covers the origins of negative pressure ventilators used during polio outbreaks and the later adoption of positive pressure ventilation. The modern standard involves positive pressure ventilation which began the era of intensive care medicine. Various ventilation modes, settings, and indications for intubation and extubation are outlined.
The document discusses various aspects of mechanical ventilation including:
1) Different ventilator settings such as mode, respiratory rate, tidal volume, and PEEP that can be adjusted for different patient types.
2) Monitoring pressures such as peak pressure and auto-PEEP is important to avoid complications.
3) Specific considerations for ventilating patients with COPD/asthma include permissive hypercapnia to reduce dynamic hyperinflation and work of breathing.
4) Ventilating ARDS patients should use low tidal volumes, as clinical trials have shown this approach reduces mortality compared to traditional higher volumes.
The document discusses pulmonary function tests (PFTs) and their use in evaluating respiratory disorders. It provides details on various PFT measurements including spirometry tests like forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1). Obstructive disorders like asthma decrease FEV1 relative to FVC while restrictive disorders decrease both measurements. PFTs are used to diagnose lung conditions, assess severity, and monitor treatment effectiveness. They provide standardized measurements of respiratory function but must be interpreted along with other clinical information.
The document discusses various topics related to mechanical ventilation including:
1. Ventilation strategies for acute respiratory distress syndrome (ARDS) including low tidal volumes, optimal positive end-expiratory pressure, and prone positioning.
2. Ventilation modes and settings should be tailored to the individual patient's condition and aim to prevent ventilator-induced lung injury.
3. Non-invasive ventilation can be considered for certain patients with COPD or asthma to avoid intubation if criteria are met.
Pulmonary function tests provide objective measurements of lung function through various tests. Spirometry is the most basic and widely used test that measures volumes of air inhaled and exhaled over time through a spirometer. It can detect obstructive or restrictive lung diseases patterns based on evaluations of parameters like FEV1, FVC, FEV1/FVC ratio, and flow-volume loops. Other tests measure lung volumes, diffusion capacity, and assess ventilation/perfusion ratios to further characterize lung abnormalities. Together, pulmonary function tests provide quantifiable data to support diagnoses suggested by symptoms and physical exams.
Spirometry is a test used to assess lung function by measuring airflow. It can help diagnose obstructive lung diseases like COPD and asthma by measuring airflow limitation through values like FEV1 and FEV1/FVC ratio. A spirometry report provides values for volumes of air inhaled and exhaled that are compared to predicted normal values to identify restrictive or obstructive lung abnormalities. Quality control measures ensure accurate spirometry administration and interpretation.
Respiratory failure and the acute respiratory distress syndrome (and shock) Jim Lavelle
The document provides an overview of respiratory failure and mechanical ventilation. It discusses the types and pathophysiology of respiratory failure, key ventilator settings, the definition and management of acute respiratory distress syndrome (ARDS), and some basics about shock. The goal is to help understand arterial blood gases, optimize ventilator settings, and improve survival in ARDS patients.
This document discusses pulmonary recruitment in ARDS patients and strategies for lung protection during mechanical ventilation. It describes how recruitment maneuvers using high airway pressures can reopen collapsed alveoli, preventing ventilator-induced lung injury from repeated opening and closing. The optimal settings for recruitment maneuvers and PEEP levels depend on a patient's recruitability, assessed via low-flow pressure-volume curves. PEEP levels are best guided by esophageal manometry or oxygen saturation to maintain alveolar stability and oxygenation without overdistension.
This document provides information about mechanical ventilation for pediatric patients. It discusses indications for mechanical ventilation, different ventilation modes, adjusting the ventilator, monitoring the patient, potential complications, weaning from ventilation, and nursing management of ventilated patients. Key points include classifications of ventilation modes, guidelines for adjusting settings based on blood gas results, monitoring oxygenation, ventilation and other vital signs, common complications like infections and injuries, and a process for gradually weaning patients off the ventilator.
Etco2 in non-intubated patient: a must in ednisaiims
The document discusses end-tidal carbon dioxide (EtCO2) monitoring in non-intubated patients. It defines EtCO2 and describes how it is measured using semi-quantitative capnometry, quantitative capnometry, and waveform capnography. EtCO2 monitoring provides information about a patient's ventilation and can detect hypoventilation or apnea sooner than pulse oximetry alone. Various normal and abnormal capnography waveforms are presented along with their potential causes and treatment approaches. The document advocates for increased use of EtCO2 monitoring in emergency departments given its ability to rapidly assess respiratory status in critically ill patients.
1. The document discusses various modes of mechanical ventilation including volume control, pressure control, SIMV, and PSV. It describes the settings, parameters, and considerations for each mode.
2. Initial ventilator settings should aim for adequate oxygenation and ventilation while minimizing work of breathing. Settings like tidal volume, respiratory rate, and PEEP are adjusted based on factors like patient size and condition.
3. Weaning from mechanical ventilation involves gradually reducing support through methods like spontaneous breathing trials, decreasing SIMV frequency, and lowering pressure support levels to assess the patient's ability to breathe independently. Readiness criteria and a stepwise protocol are
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.
Postoperative Ventilation in Paediatric Cardiac Surgical Patientsdr amarja nagre
In paediatric patients with congenital heart diseases,postoperative management is as important as surgical procedure.Here is discussion regarding the same.
Similar to Medmastery Mechanical Ventilation Essentials_Handbook.pdf (20)
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by...Donc Test
TEST BANK For Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler, Verified Chapters 1 - 33, Complete Newest Version Community Health Nursing A Canadian Perspective, 5th Edition by Stamler Community Health Nursing A Canadian Perspective, 5th Edition TEST BANK by Stamler Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Study Guide Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Stuvia Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Studocu Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Test Bank For Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Pdf Download Course Hero Community Health Nursing A Canadian Perspective, 5th Edition Answers Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Ebook Download Course hero Community Health Nursing A Canadian Perspective, 5th Edition Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Studocu Community Health Nursing A Canadian Perspective, 5th Edition Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Chapters Download Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Pdf Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Study Guide Questions and Answers Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Ebook Download Stuvia Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Questions Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Studocu Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Quizlet Community Health Nursing A Canadian Perspective, 5th Edition Test Bank Stuvia
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
- Video recording of this lecture in English language: https://youtu.be/kqbnxVAZs-0
- Video recording of this lecture in Arabic language: https://youtu.be/SINlygW1Mpc
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
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2. Table of contents
How to survive your first night on call
Mechanical ventilation 4
AC versus SIMV 5
Volume versus pressure 6
Parameters 7
Initial values 8
Assessing ventilation 9
Assessing oxygenation 10
PIP and plateau pressure monitoring 11
Mechanical ventilation of patients with obstructive airway disease
Airway disease versus alveolar disease 13
PIP monitoring 14
Flow monitoring 15
PEEP monitoring 16
Mechanical ventilation of patients with restrictive airway disease
Introduction to ARDS 18
Low tidal volume strategy 19
High respiratory rate strategy 20
Optimal PEEP strategy 21
Goals of lung protective modes 22
Pressure control 23
Bilevel mode 24
APRV mode 25
Assessing for extubation
Screening before weaning 27
Weaning using the SIMV strategy 28
Weaning using the SBT method 29
Weaning parameters 30
Tracheostomy 31
Weaning after prolonged mechanical ventilation 32
Managing patients with special considerations
Upper airway swelling 34
Neuromuscular weakness 35
Appendix
Reference list 37
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All
Full respiratory support
OR
What is mechanical
ventilation?
Mechanical ventilation
Ventilate
Oxygenate
CO2
CO2
CO2
CO2 CO2
CO2
CO2
CO2
Ventilation Oxygenation
O2
It‘s not
that simple
Mode
Some
Partial respiratory support
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AC versus SIMV
AC mode
SIMV mode
Reduce the work
of breathing
Respiratory rate (RR) = 15 breaths/min
Tidal volume (VT
) = 500 mL
Tidal
volume
(mL)
Tidal
volume
(mL)
i
n
s
p
i
r
a
t
o
r
y
i
n
s
p
i
r
a
t
o
r
y
e
x
p
i
r
a
t
o
r
y
e
x
p
i
r
a
t
o
r
y
Time (sec)
Time (sec)
500
500
1
1
3
3
5
5
2
2
4
4
6
6
Ideal for muscle recovery
Ventilator does work
Patient responsible for breath
Hypoventilation
AC SIMV
Which initial mode
of ventilation
should I use?
Reference:
Esteban A, Ferguson ND, Meade MO, et al. Evolution of
mechanical ventilation in response to clinical research.
Am J Respir Crit Care Med. 2008. 177: 170–177.
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RR = 14 breaths/min
VT
= 600 mL
Minute ventilation
= 0.6 L x 14 breaths/min
= 8.4 L/min
We can calculate minute ventilation
to ensure enough CO2
is exhaled.
RR = 14 breaths/min
VT
= ?
Minute ventilation
= VT
x 14 breaths/min
= ?
We can‘t calculate minute
ventilation without VT
!
Volume versus pressure
Why volume ventilation
and not pressure
ventilation?
Pressure
Note
Some people will still benefit from pressure,
but more will benefit from volume ventilation.
Volume
Minute ventilation
VT
x RR
Key:
amount of
CO2
exhaled
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1. Tidal volume (VT
) 2. Respiratory rate (RR)
3. PEEP 4. FiO2
5. Flow
Which settings are
available for my
patient?
Parameters
Parameters
1. Tidal volume (VT
)
2. Respiratory rate (RR)
3. PEEP
4. FiO2
5. Flow
L or mL
breaths/min
cmH2
O
%
L/min
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What are the initial
values for each
parameter?
Initial values
Parameters
1. VT
2. RR
3. PEEP
4. FiO2
5. Flow
Initial values
6—8 mL/kg
10—20 breaths/min
0—5 cmH2
O
100%
40—60 L/min
1. Tidal volume (VT
)
2. Respiratory rate (RR)
5. Flow
3. PEEP
4. FiO2
Use ideal body weight based on gender
and height, not actual weight.
6–8 mL/kg
10—20 breaths/min
40—60 L/min
0—5 cmH2
O
100%
65 kg
6—8 mL/kg
10—20 breaths/min
0—5 cmH2
O
100%
40—60 L/min
x = 390 mL ≈ 400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
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Minute ventilation
= 400 mL x 15 breaths/min
= 6 L/min
How do I assess for
adequate ventilation?
Assessing ventilation
65 kg
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
VT
RR
PEEP
FiO2
Flow
VT
RR
PEEP
FiO2
Flow
Initial settings
Initial settings Ventilation = Removal of CO2
Is this adequate
removal of CO2
?
Check PaCO2
on ABG
ABG results (PaCO2
)
35–45 mmHg
<35 mmHg
>45 mmHg
Interpretation
Acceptable range
Hyperventilating
Hypoventilating
Recommendation
Maintain settings
Decrease minute ventilation (VT
or RR)
Increase minute ventilation (Vt
or RR)
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How do I assess for
adequate oxygenation?
Assessing oxygenation
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
VT
RR
PEEP
FiO2
Flow
Initial settings
ABG results (PaO2
)
80–100 mmHg
<80 mmHg
>100 mmHg
Interpretation
Acceptable range
Hypoxemia
Hyperoxemia
Recommendation
Maintain settings
Increase FiO2
? Increase PEEP
Reduce FiO2
Is this adequate
intake of O2
?
Check PaO2
on ABG
65 kg
400 mL
15 breaths/min
5 cmH2
O
100%
60 L/min
VT
RR
PEEP
FiO2
Flow
Initial settings
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PIP = Peak inspiratory pressure
Plateau pressure
How do I monitor and
measure pressure
inside the lungs?
PIP and plateau pressure monitoring
PIP
Plateau
pressure
1 sec
< 30 cmH2
O
Inspiratory pause
Monitor regularly
Monitor regularly
< 35 cmH2
O
PIP is the highest level of pressure applied
to the lungs during inhalation.
Resistance anywhere along the path from
the ventilator to the lungs can cause an
increase in PIP.
PIP should be kept below 35 cmH2
O.
Plateau pressure is the pressure in the lungs
during peak inspiratory hold.
Plateau pressure should be kept below
30 cmH2
O.
Correct by
1. Checking for causes of resistance
2. Reducing VT
3. Changing mode.
PIP
Plateau pressure
< 35 cmH2
O
< 30 cmH2
O
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Alveolar disease
A problem with oxygenation.
Airway disease
A problem with ventilation.
Airway disease
Ventilation issue
”Obstructive disease”
Airway disease versus alveolar disease
Which general lung
disease category does
the patient fall under?
airways
alveoli
alveoli
Blood
Oxygen
”Obstructive” ”Restrictive” ARDS
Air trapping
O2
Normal
airways
Normal
alveoli
Collapsed
alveoli
Inflamed
airways
Airways
blocked
by mucus
Asthmatic
bronchial
tube
CO2
Signs
Increased PaCO2
Enlarged lungs on chest x-ray
Signs
Decreased PaO2
Lung size appears smaller on chest x-ray
CO2
PaCO2
Alveolar disease
Oxygenation issue
”Restrictive disease”
O2
PaO2
Chest x-ray
Chest x-ray
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How can I identify
and manage patients
with obstructive
airway disease?
PIP monitoring
Identify obstructive airway disease
Treat obstructive airway disease
Peak inspiratory pressure
(PIP) monitoring
Flow monitoring
Intrinsic positive end-
expiratory pressure (PEEP)
monitoring
Keep PIP < 35 cmH2
O
Decrease VT
Decrease RR
Increase flow
Bronchodilators
Steroids
Permissive hypercapnia may be necessary.
Monitoring and maintaining PIP at an acceptable level can help manage patients with obstructive airway disease.
PIP can indicate airway compromise or air trapping*
.
AND
Amount of PIP represents the severity of air trapping.
*
You should confirm with a chest x-ray.
CO2
Chest x-ray
Decrease VT
Reducing volume in, reduces volume needed to get out.
Decrease RR
Reducing RR allows more time to exhale.
Increase flow
Increasing flow shortens inspiration time and therefore
increases expiration time.
Bronchodilators
Steroids
Permissive hypercapnia
Remember, reducing VT
or RR may increase PaCO2
and you may need to tolerate hypercapnia in order
to treat these patients; just be sure to monitor pH
and PaCO2
on a case-by-case basis.
< 35 cmH2
O
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Flow-time waveform–normal Flow-time waveform—air trapping
Flow monitoring
How can I identify
and treat patients
with obstructive
airway disease?
Time
(sec)
Flow
(L/min)
inspiration
expiration
Time
(sec)
Flow
(L/min)
inspiration
expiration
Examining the flow-time waveform on the ventilator can help manage patients with obstructive airway disease.
Identify obstructive airway disease
Treat obstructive airway disease
As long as the expiratory limb reaches zero, the lung
is fully deflated and the patient is not air trapping.
A shift in the waveform, such that the expiratory limb
does not return to zero, indicates air trapping.
Decrease VT
Reducing volume, in reduces volume needed to get out.
Decrease RR
Reducing RR allows more time to exhale.
Increase flow
Increasing flow shortens inspiration time and therefore
increases expiration time.
Bronchodilators
Steroids
Permissive hypercapnia
Remember, reducing VT
or RR may increase PaCO2
and you may need to tolerate hypercapnia in order
to treat these patients; just be sure to monitor pH
and PaCO2
on case-by-case basis.
< 35 cmH2
O
Keep PIP < 35 cmH2
O
Decrease VT
Decrease RR
Increase flow
Bronchodilators
Steroids
Permissive hypercapnia may be necessary.
Peak inspiratory pressure
(PIP) monitoring
Flow monitoring
Intrinsic positive end-
expiratory pressure (PEEP)
monitoring
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PEEP monitoring
What other tools do I
have to identify and
treat air trapping?
600 mL
15 breaths/min
5 cmH2
O
40%
60 L/min
VT
RR
PEEP
FiO2
Flow
Expiratory hold
Expiratory pause
Date/Time
RR
12
breats/min
VT
600
mL
FiO2
30
%
PEEP
5
cmH2
O
PEEP (total)
Reference:
M J Tobin; R F Lodato. PEEP, auto-PEEP, and waterfalls.
Chest. 1989;96(3):449-451. doi:10.1378/chest.96.3.449
Keep PIP < 35 cmH2
O
Decrease VT
Decrease RR
Increase flow
Bronchodilators
Steroids
Increase PEEP
Permissive hypercapnia may be necessary.
Increase set PEEP
To keep work of breathing to a minimum you want
intrinsic PEEP = extrinsic PEEP. In patients with
obstructive airway disease, air trapping causes the
intrinsic PEEP > extrinsic PEEP. By performing an
expiratory hold and determining the total PEEP and
calculating the intrinsic PEEP, you can increase the set
PEEP by this amount to reduce the work of breathing.
Determining the amount of intrinsic PEEP (inadvertent PEEP or auto PEEP)—the difference between the set PEEP
and the total PEEP—can help manage patients with obstructive airway disease.
Depressing the expiratory hold or expiratory pause
button on the ventilator keeps the lungs at maximal
exhalation for about 1 second and allows you to
measure the total PEEP.
You can then calculate the intrinsic PEEP:
Total PEEP - set PEEP = intrinsic PEEP
Intrinsic PEEP > 0 air trapping
Identify obstructive airway disease
Treat obstructive airway disease
Decrease VT
Reducing volume in, reduces volume needed to get out.
Decrease RR
Reducing RR allows more time to exhale.
Increase flow
Increasing flow shortens inspiration time and therefore
increases expiration time.
Bronchodilators
Steroids
Permissive hypercapnia
Remember, reducing VT
or RR may increase PaCO2
and you may need to tolerate hypercapnia in order
to treat these patients; just be sure to monitor pH
and PaCO2
on case-by-case basis.
< 35 cmH2
O
Peak inspiratory pressure
(PIP) monitoring
Flow monitoring
Intrinsic positive end-
expiratory pressure (PEEP)
monitoring
(Tobin 1989)
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What happens in the
lungs in acute respiratory
syndrome (ARDS)?
Introduction to ARDS
alveoli
Alveolar collapse
Refractory hypoxemia
Severity of ARDS = Oxygenation status
P/F ratio =
PaO2
FiO2
Recruitment
Fluids fill airsac
Normal
Supplemental
oxygen does
not help!
ARDS
Decreased volume in
Increased recoil
Shallow and rapid
breathing
ARDS Severity
Mild
Moderate
Severe
*
on PEEP 5+; **
observed in cohort
PaO2
/ FiO2
*
200-300
100-200
< 100
Mortality **
27%
32%
45%
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What strategies can I
use to treat patients
with ARDS?
Low tidal volume strategy
You can use volume control mode with a low tidal volume strategy to manage patients with ARDS.
Add more VT
?
Increasing volume in does not help because the extra
volume just enters the normal alveoli and overextends
them, further increasing the plateau pressure above
the acceptable 30 cmH2
O. This can damage the lung.
Instead, it is better to reduce the VT
to keep plateau
pressure down and reduce the risk of barotrauma.
6–8 mL/kg 4–6m L/kg
VT
by 1 mL/kg
Volume control mode
Low tidal
volume strategy
High respiratory
rate strategy
Optimal PEEP strategy
Note
Reducing VT
may cause an increase in PaCO2
and
a decrease in pH.
According to the ARDSnet protocol,
compared to barotrauma, respiratory
acidosis is the lesser of the evils.
1. Reduce VT
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Air trapping in restrictive lung disease is bad, but air
trapping may help your ARDS patient!!!
Air trapping can act like PEEP and help recruit and
stabilize the collapsed alveoli.
What strategies can I
use to treat patients
with ARDS?
High respiratory rate strategy
High respiratory rate
Low tidal volume
Plateau pressure ≤ 30 cmH2
O
pH as low as 7.30
Alveolar
recruitment
PaCO2
pH
35
7.35
45
7.45
<7.30
Treating ARDS patients with a high RR strategy is
like walking a fine line... and you may need to adjust,
and readjust, RR as necessary to balance PaCO2
and
plateau pressure.
Volume control mode
Low tidal
volume strategy
High respiratory
rate strategy
Optimal PEEP strategy
You can use volume control mode with a high respiratory rate (RR) strategy to manage patients with ARDS.
Increase RR PaCO2
Air trapping
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PEEP
PEEP
What strategies can I
use to treat patients
with ARDS?
Optimal PEEP strategy
PaO2
Static compliance
ABG
PEEP that produces the highest PaO2
=
Optimal PEEP
PEEP that produces the highest static compliance =
Optimal PEEP
*
Use inspiratory hold.
Static compliance =
Tidal
volume
Plateau
pressure
Volume control mode
Low tidal
volume strategy
High respiratory
rate strategy
Optimal PEEP strategy
You can use volume control mode with an optimal PEEP strategy to manage patients with ARDS.
Alveolar
recruitment
Lots of needle sticks (ABG)
Highest PaO2
= best oxygenation
(not necessarily best lung compliance)
Easier to ensure no negative
hemodynamic effects of a high PEEP.
Still a debated topic... and so you
might want to switch modes!
Volume control ???
In this strategy, you adjust PEEP up and down to find the PEEP at which
the lung is the most compliant. To determine when the lung is most
compliant you can monitor PaO2
or calculate the static compliance.
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Goals of lung protective modes
What is lung
protection?
Switch
mode + PEEP Inhalation
”Sweet spot”
Pressure
Volume
VT
Lung protective modes:
Pressure control
Bilevel
APRV
When treating patients with ARDS it is common to switch from AC volume control to a mode that is more
lung protective.
We are trying to protect the lungs from two things:
1. alveolar collapse
2. overdistension barotrauma!
1. alveolar collapse 2. overdistension
When using AC volume control you need to constantly
adjust and readjust tidal volume and PEEP to keep the
lungs in the sweet spot.
Other lung protective modes have been developed that
are less frustrating and make it easier to keep the lung
in the sweet spot.
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CON
Asynchrony
Set i-time may not match the patient‘s desired
i-time, causing patient to be out-of-sync with
venilator anxiety!
1. Adjust and readjust i-time
2. Sedate patient
3. Switch to another mode
Pressure control
Which lung protective
modes can I use to treat
patients with ARDS?
Bilevel?
APRV?
PRO
VT
= Lung compliance
In pressure control mode, the VT
changes with
lung compliance so you can easily monitor
improvement in lung function.
1
10
20
Pressure
(PIP)
(cmH2
O)
Time (sec)
i-time
0.8-1.2 sec
20 cmH2
O
PEEP > 5 cmH2
O
30 cmH2
O
30
3
2 4 5 6
Pressure control mode is a lung protective mode that can be used to treat patients with ARDS.
Pressure
control
Pressure control
Bilevel mode
APRV mode
Initial settings
PIP 20–30 cmH2
O
i-time 0.8–1.2 sec
PEEP >5 cmH2
O
Monitor PaCO2
(ABG)
Adjust RR as necessary
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Bilevel mode
Which lung protective
modes can I use to treat
patients with ARDS?
Pressure
(cmH2
O)
Time (sec)
T high
spontaneous breaths
P high
T low
P low
30 cmH2
O
Pressure
(cmH2
O)
Time (sec)
i-time
PIP
e-time
PEEP
30 cmH2
O
triggered breath
Bilevel
Pressure
control
Pressure control
Bilevel mode
APRV mode
Bilevel mode is a lung protective mode that can be used to treat patients with ARDS.
Bilevel
1. Max/min pressure support
(P high/P low).
2. Set RR. But, breaths are
spontaneous and can be
taken any time.
3. Set T high (T low*
).
Pressure support
1. Max/min total pressure
(PIP/PEEP).
2. Set RR. Breaths are controlled
(or triggered at set times).
PRO
Protect lung from
exceeding high
pressure.
Lessen anxiety
because patient
can breathe freely.
Initial settings
P high 20–30 cmH2
O
T high 0.8–1.2 sec
RR 20-30 breaths/min
PEEP (P low) >10 cmH2
O
Pressure support 0–10 cmH2
O
*
This method closely resembles
the pressure control method.
NOTE
Physicians may choose to closely
resemble the APRV initial settings.
*
T low is automatically set based on T high and RR.
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APRV mode
Which lung protective
modes can I use to treat
patients with ARDS?
APRV
Bilevel
+ Pressure
support
APRV mode is a lung protective mode that can be used to treat patients with ARDS.
Time (sec)
P high
P low
T high
T low
RR
Pressure
(cmH2
O)
Time (sec)
P high
PEEP
T high
T low
RR = 30
Pressure
(cmH2
O)
APRV
1. Set P high/P low. (No pressure support.)
2. Set T high (traditionally set longer).
3. Set T low (traditionally set shorter to prevent lung deflation).
Bilevel
1. Set P high/P low (PEEP).
2. Set T high (T low*
).
3. Set RR.
Pressure control
Bilevel mode
APRV mode
Initial settings
P high 20–30 cmH2
O
T high 4–6 sec
P low 0–5 cmH2
O
T low 0.2–0.8 sec
*
T low is automatically determined
based on T high and RR.
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3. Hemodynamic status
No active myocardial infarction
No (or low) vasopressor infusion
4. Sedation status
No neuromuscular
blocking agents
2. Ventilation status
< 35 breaths / minute
1. Oxygenation status
SpO2
≥ 90% on FiO2
≤ 40%
PEEP ≤ 5 cmH2
O
What should I screen
before weaning my
patient?
Screening before weaning
O2
CO2
O2
CO2
Before weaning you need to screen your patient to make sure they meet the following criteria.
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Tidal
volume
(mL)
i
n
s
p
i
r
a
t
o
r
y
e
x
p
i
r
a
t
o
r
y
Time
(sec)
500
1 3 5
2 4 6 7
Spontaneous
breaths
Pressure support < 20 cmH2
O
What strategies can
I use to wean my
intubated patients?
Weaning using the SIMV strategy
You can use the SIMV strategy to wean your patient off the ventilator.
1. Check patient meets screening criteria.
2. Switch patient from AC SIMV
(with same settings).
3. Reduce RR—gradually.
Reducing the RR allows for more opportunity for
spontaneous breathing.
SIMV strategy
SBT
(CPAP or T-piece)
Reduce RR to as
low as possible.
Reference:
Hess Dean, RRT, PhD, FCCP. Ventilator modes
used in weaning. Chest 2001. 120: 474S-476S.
PRO
Patient assessment
You are often more successful with
something you are familiar with.
CON
Poor outcomes
4. Observe patient‘s spontaneous ability.
5. Add pressure support as needed.
Added pressure support can assist low volume
spontaneous breaths; but be careful not to add
more than 20 cmH2
O support this probably
means patient isn‘t ready.
(Hess 2011)
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What strategies can
I use to wean my
intubated patients?
Weaning using the SBT method
CPAP T-piece
CPAP
5 cmH2
O
Pressure support
6-8 cmH2
O
CPAP
0 cmH2
O
Pressure support
0 cmH2
O
SIMV
SBT
SIMV strategy
SBT
(CPAP or T-piece)
You can use the SBT method to wean your patient off the ventilator.
1. Check patient meets screening criteria.
2. Switch patient from AC T-piece.
3. Remove all pressure support (but leave connected
to ventilator).
Keeping patient connected to ventilator
allows you to monitor spontaneous breaths and VT
.
4. Cycle between no support and support, with
increasing duration of no support.
No support for 2 hours.
1. Check patient meets screening criteria.
2. Switch patient from AC CPAP
3. CPAP of 5cmH2
O helps distend alveoli.
4. Add pressure support of 6–8 cmH2
O.
Sink or swim method
Even though the SBT method can be considered a
sink or swim method, it appears to be better than
SIMV because the patient breaths spontaneously
with little support.
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1. Respiratory 2. Cardiovascular
3. Neurologic 4. Psychologic
Which weaning
parameters do I
monitor to help
guide my decision
to extubate?
Weaning parameters
RSBI = RR/VT
RSBI < 105
RSBI < 80
Stable with
minimum
pressors
FiO2
< 40%
PEEP < 5-8
No seizures
p/f > 150
Follow
instructions
WOB O2
No dyspnea
Awake
RR < 35
breaths/min
Alert Anxiety
Stress
Fear
Before extubating, you need to monitor your patient and make sure they meet the following weaning parameters.
And... you should always evaluate to ensure there has been
a reversal of the primary cause for mechanical ventilation.
Key
Reversal of the primary cause
for mechanical ventilation.
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How do I know
if a patient requires
a tracheostomy?
Tracheostomy
Ventilatory
capability
Ventilatory
demand
Multiple failed weaning attempts
Secrection clearance
Neuromuscular impairment
After prolonged mechanical ventilation, some patients will require a tracheostomy.
The length of time mechanical ventilation is needed
is often dependent on the severity of the disease.
And, once a patient has been on ventilation for two
weeks, a tracheostomy is commonly considered.
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TIPS protocol
How do I wean my
patients with a
tracheostomy?
Weaning after prolonged
mechanical ventilation
You can still
wean after
tracheostomy
Go slow!
Barlow hospital
TIPS protocol
Step 1: AC to SIMV of 10/min and PS of 20
Step 2: SIMV of 8/min and PS of 20
Step 3: SIMV of 6/min and PS of 20
Step 4: SIMV of 4/min and PS of 20
Step 5: SIMV of 4/min and PS of 18
Step 6: SIMV of 4/min and PS of 16
Step 7: SIMV of 4/min and PS of 14
Step 8: SIMV of 4/min and PS of 12
Step 9: SIMV of 4/min and PS of 10
Step 10: 1 hour
Step 11: 2 hours
Step 12: 4 hours
Step 13: 6 hours
Step 14: 8 hours
Step 15: 10 hours
Step 16: 12 hours
Step 17: 16 hours
Step 18: 20 hours
Step 19: 24 hours
4 breaths/min (SIMV)
Pressure support (PS)
to 10 cmH2
O
CPAP and PS to 0
Patient can be extubated
Up to 3 steps per day at 4-
hour intervals.
Up to 2 steps per day.
If patient is breathing comfortably
at the 9th step, a slow-paced,
spontaneous breathing trial can
be started.
After completion of daily steps,
put back on step 9 for rest of day.
If patient is breathing comfortably
after 19th step, they can be
removed from ventilator.
SBT: Reduce to CPAP of 0
and PS of 0 and monitor for:
Reduce the pressure support (PS):
Reduce to SIMV:
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How do I know if my
patient‘s upper airway
swelling is reduced
enough to extubate?
Upper airway swelling
Leak No leak
Deflate cuff
How do we know
when the swelling
has decreased
enough in order to
extubate the patient?
Leak No leak
Deflate cuff and listen for a leak.
Swelling
reduced
OK to
extubate
Swelling
still present
Check
daily
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How do I know if my
patient‘s neuromuscular
weakness has improved
enough to extubate?
Neuromuscular weakness
better than
-20 cmH2
O
worse than
-20 cmH2
O
check
daily
Remember a lower
pressure (more
negative) is better!
NIF
Negative inspiratory force
NIF/MIP
OK to
extubate
Check
daily
OR MIP
Maximum inspiratory pressure
The amount of force that is generated
by the patient in an inspiration.
37. 37
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