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
Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask or nasal mask. Learn more about NIV in this presentation by Dr Somnath Longani, consultant Anaesthesiologist & Intensivist, Midland Healthcare & Research Center, lucknow
https://midlandhealthcare.org/
Final newer modes and facts niv chandanChandan Sheet
THIS IS THE BASIC POINTS REGARDING NIV, THIS IS COMPILED AND ARRANGED FROM DIFFERENT BOOKS, JOURNALS AND PPTs.
The author is grateful to the teachers and authors of pulmonology and critical care.
It is an updated presentation(2019) which covers the basic concept of mechanical ventilation, Modes, Settings, Troubleshoots, Complications, New modes, and Preventive care. The presentation will be useful for emergency doctors
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
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
Non-invasive ventilation (NIV) is the use of breathing support administered through a face mask or nasal mask. Learn more about NIV in this presentation by Dr Somnath Longani, consultant Anaesthesiologist & Intensivist, Midland Healthcare & Research Center, lucknow
https://midlandhealthcare.org/
Final newer modes and facts niv chandanChandan Sheet
THIS IS THE BASIC POINTS REGARDING NIV, THIS IS COMPILED AND ARRANGED FROM DIFFERENT BOOKS, JOURNALS AND PPTs.
The author is grateful to the teachers and authors of pulmonology and critical care.
It is an updated presentation(2019) which covers the basic concept of mechanical ventilation, Modes, Settings, Troubleshoots, Complications, New modes, and Preventive care. The presentation will be useful for emergency doctors
Intro to Hypoxic pulmonary vasoconstriction Arun Shetty
Hypoxic pulmonary vasoconstriction, a seldom heard phenomenon but very effective physiologic property which helps lungs utilise ventilation to the maximum
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
L’abc della ventilazione meccanica non invasiva in urgenza.pdf.pdfSandro Zorzi
Condivido questo libro che la MCGraw Hill ha rilasciato gratuitamente per trattare i pazienti COVID19. Grazie agli autori, inoltre, per l'ottimo materiale didattico. Consiglio a tutti gli interessati la lettura.
La Target Controlled Infusion (TCI) è una modalità endovenosa di
somministrazione dei farmaci, che utilizza dei modelli farmacocinetici
elaborati su una popolazione campione e integrati in sistemi di infusione
dedicati.
TCI significa che la somministrazione del farmaco viene controllata da un
target o bersaglio, cioè un obiettivo di concentrazione impostato
dall’anestesista. Il sistema informatico si occuperà, tramite la pompa, di
raggiungere rapidamente il target e mantenerlo stabile, regolando la velocità
di infusione ed evitando sia il sovradosaggio che il sottodosaggio del
farmaco. All’anestesista non è richiesto di eseguire alcun tipo di calcolo.
A differenza dell’Anestesia Totalmente Endovenosa (TIVA - Total Intra Venous
Anesthesia), la TCI permette un fine controllo della somministrazione dei
farmaci ed una rapida variazione della concentrazione target, rendendo il
piano anestesiologico estremamente maneggevole. Un concetto implicito
nella modalità TCI infatti, è che la concentrazione target può venire modificata
ogni qual volta l’anestesista lo ritenga necessario, così da seguire in tempo
reale le varie fasi dell’intervento chirurgico, correggendo ipnosi ed analgesia
in modo puntuale.
L’accurata modulazione dell’analgo-sedazione rende la TCI uno strumento
ineguagliabile quando ci troviamo a dover sedare pazienti molto complessi al
di fuori della sala operatoria (NORA – Non Operating Room Anesthesia), con
la necessità di offrire un adeguato confort anestesiologico al paziente,
evitando accidentali sovradosaggi ed episodi di depressione respiratoria.
A. Farnia 2017
Nomenclatura per le terapie di supporto durante danno renale acutoSandro Zorzi
La gestione dei pazienti critici con danno renale acuto (AKI) che hanno bisogno di una te-
rapia di supporto renale continua (CRRT) richiede un approccio multidisciplinare. Diverse
figure professionali, quali nefrologi, rianimatori e infermieri concordano insieme quella che
è la gestione più appropriata per il paziente. L'apparente semplicità di questo processo na-
sconde un enorme grado di complessità, che richiede competenze approfondite delle di-
verse opzioni di trattamento [1]
[1].Sebbene risulti essenziale che tutti i professionisti coinvolti
utilizzino un linguaggio comune, la specifica terminologia utilizzata per descrivere le di-
verse modalità di CRRT è spesso confondente ed in continua evoluzione. Nella seguente se-
zione, verrà fornito un consensus aggiornato sulla nomenclatura da adottare riferendosi ai
diversi dispositivi delle macchine da CRRT, ai principi fondamentali alla base della tecno-
logia e dei processi di depurazione in corso di RRT, alle fasi ed ai diversi trattamenti effet-
tuabili.
C.Ronco
INVASIVE MECHANICAL VENTILATION FOR ACUTE RESPIRATORY DISTRESS SYNDROME MANAG...Sandro Zorzi
WHO Critical Care Severe Acute Respiratory Infection Training
At the end of this lecture, you will be able to:•Describe the long-term complications associated with use of sedatives in critically ill patients (firstly do no harm).•Describe the long-term benefits associated with using a protocolized management approach to pain, agitation and delirium (PAD).•Formulate a PAD protocol adapted to your hospital setting.
SEPSIS AND SEPTIC SHOCKDELIVER TARGETED RESUSCITATIONSandro Zorzi
WHO Critical Care Severe Acute Respiratory Infection Training
At the end of this lecture, you will be able to:•Describe how to deliver early, targeted resuscitation in patients (adults and children) with sepsis-induced tissue hypoperfusion and shock.•Understand the special considerations when resuscitating paediatricpatients in resource-limited settings.
SARI CRITICAL CARE TRAINING CLINICAL SYNDROMESSandro Zorzi
OPENWHO PORTAL PRESENTATION ON CORONAVIRUS
At the end of this lecture, you will be able to:•Describe the importance of early recognition of patients with SARI.•Recognize patients with severe pneumonia.•Recognize patients with ARDS.•Recognize patients with sepsis and septic shock.
PATHOPHYSIOLOGY OF SEPSIS AND ARDS / SARI PATIENTSSandro Zorzi
Presentation from the openwho elearning course on coronavirus
At the end of this lecture, you will be able to:•Describe the importance of early recognition of patients with SARI.•Recognize patients with severe pneumonia.•Recognize patients with ARDS.•Recognize patients with sepsis and septic shock.|
Overview on pain management in MSF setting. Content:
Types of pain
Assess the pain and pain scales
Treating pain according to the pain scale
All of subjected will be discussed briefly and in perspective of our work
MATERIALS:
https://emedicine.medscape.com/article/1948069-overview#a3
https://www.change-pain.com/grt-change-pain-portal/change_pain_home/chronic_pain/physician/physician_tools/picture_library/en_EN/312500026.jsp
MSF Clinical Guidelines and MSF protocols
WHO CME ANTIBIOTIC STEWARDSHIP ITALY
• Articulate the principles of antimicrobial use in surgical
prophylaxis
• Describe how key institution-specific protocols can improve
the use of antimicrobials for surgical prophylaxis
• Appreciate the importance of pre-operative dosing and limiting
prophylactic antimicrobials to the duration of the surgical
procedure
WHO CME ANTIBIOTC STEWARDSHIP ITALY
• Describe appropriate blood culture specimen collection techniques to reduce opportunities for contamination, which can lead to inappropriate antimicrobial use
• Review framework for appropriate antimicrobial prescribing for
patients with suspected blood stream infections (BSI).
• Demonstrate opportunities for collaboration between clinicians and microbiologist to achieve the dual goals of antimicrobial and
diagnostic stewardship
• Effectively use initial assessment to differentiate between viral and
bacterial respiratory tract infections determine appropriate empiric
antimicrobial therapy highlighting the importance of establishing the
correct diagnosis
• Utilize patient specific clinical and microbiologic data to reassess the
appropriateness of antimicrobial therapy
• Emphasize the role of vaccination and hand hygiene in the
prevention of lower respiratory tract infections and the role of the
clinician in educating patients about these interventions
WHO Italian CME course an antibiotic stewardship
• Understand the frequent occurrence and implications of
contaminated urine cultures and of asymptomatic bacteriuria
• Illustrate the complexity of using urinalysis and urine culture to
support the diagnosis of urinary tract infections
• Demonstrate the use of local evidence-based guidelines based
upon local antimicrobial resistance data in managing urinary tract infections
• Recognize that the majority of reported penicillin allergies are
not confirmed upon testing and expose patients to undue
harm
• Understand when diagnostic testing, including skin testing, is
indicated to confirm an antimicrobial allergy
• Employ strategies to determine if cephalosporins can be used
in patients with reported penicillin allergies.
Antimicrobial resistance for cliniciansSandro Zorzi
Slide from WHO CME ITALIAN COURSE
Antimicrobial resistance for clinicians
Core competencies for antimicrobial prescribing:
Understands the patient and the patient’s clinical needs
Understands treatment options and how they support the
patient’s clinical needs
Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
Monitors and reviews the patient’s response to treatment
Pharmacology of antimicrobials for clinicians: select topicsSandro Zorzi
Slides from the WHO Italian CME Antimicrobial stewardship
Introduce basic concepts of
pharmacokinetics/pharmacodynamics of antimicrobials
• Describe oral bioavailability of antimicrobials
• Illustrate the concept of time-dependent antimicrobials
and describe optimizing the use of beta-lactam
antibiotics using prolonged infusion.
Pain results from a variety of pathological processes and is considered as a vital sign.
It is expressed differently by each patient depending on cultural background, age, etc,etc.
IT IS A HIGHLY SUBJECTIVE EXPERIENCE MEANING THAT ONLY THE INDIVIDUAL IS ABLE TO ASSESS HIS/HER LEVEL OF PAIN.....
General anesthesia & obstetrics part IISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
General anesthesia & obstetrics part IIISandro Zorzi
→ Discuss indications of general anesthesia for operative delivery
→ Explain aspiration risk for general anesthesia in pregnancy and prevention strategy
Outline anaesthesia plan of care for induction, maintenance and emergency
Describe effect of volatile anaesthetics on uterine blood flow and tone
Discuss intraoperative strategies to prevent postoperative nausea and vomiting
Discuss other complications of general anaesthesia and clinical management
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of 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 leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
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. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
Prix Galien International 2024 Forum ProgramLevi Shapiro
June 20, 2024, Prix Galien International and Jerusalem Ethics Forum in ROME. Detailed agenda including panels:
- ADVANCES IN CARDIOLOGY: A NEW PARADIGM IS COMING
- WOMEN’S HEALTH: FERTILITY PRESERVATION
- WHAT’S NEW IN THE TREATMENT OF INFECTIOUS,
ONCOLOGICAL AND INFLAMMATORY SKIN DISEASES?
- ARTIFICIAL INTELLIGENCE AND ETHICS
- GENE THERAPY
- BEYOND BORDERS: GLOBAL INITIATIVES FOR DEMOCRATIZING LIFE SCIENCE TECHNOLOGIES AND PROMOTING ACCESS TO HEALTHCARE
- ETHICAL CHALLENGES IN LIFE SCIENCES
- Prix Galien International Awards Ceremony
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
The prostate is an exocrine gland of the male mammalian reproductive system
It is a walnut-sized gland that forms part of the male reproductive system and is located in front of the rectum and just below the urinary bladder
Function is to store and secrete a clear, slightly alkaline fluid that constitutes 10-30% of the volume of the seminal fluid that along with the spermatozoa, constitutes semen
A healthy human prostate measures (4cm-vertical, by 3cm-horizontal, 2cm ant-post ).
It surrounds the urethra just below the urinary bladder. It has anterior, median, posterior and two lateral lobes
It’s work is regulated by androgens which are responsible for male sex characteristics
Generalised disease of the prostate due to hormonal derangement which leads to non malignant enlargement of the gland (increase in the number of epithelial cells and stromal tissue)to cause compression of the urethra leading to symptoms (LUTS
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
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.
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Ve...kevinkariuki227
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
TEST BANK for Operations Management, 14th Edition by William J. Stevenson, Verified Chapters 1 - 19, Complete Newest Version.pdf
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
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.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
2. HEALTH
programme
EMERGENCIES
Learning 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.
|
4. HEALTH
programme
EMERGENCIES|
Five principles of ARDS management
2. Initiate ventilatory support without delay:
– high-flow oxygen versus noninvasive ventilation
(NIV)
– IMV with lung protective ventilation strategy:
– manage acidosis
– manage asynchrony
– use fluid conservative strategy if not in shock
– manage pain, agitation and delirium (next lecture)
– conduct daily SBT assessment (next lecture).
6. HEALTH
programme
EMERGENCIES
Recognize non-hypercapneic,
hypoxaemic respiratory failure
• Rapid progression of severe respiratory distress and
hypoxaemia (SpO2 < 90%, PaO2 <60 mmHg or <8.0 kPa)
that persists despite escalating oxygen therapy.
• SpO2/FiO2 < 300 while on at least 10 L/min oxygen therapy
(and PaCO2 < 45 mmHg).
• Cardiogenic pulmonary oedema not primary cause.
Hypoxaemic respiratory failure is an indication for ventilatory support.
7. HEALTH
programme
EMERGENCIES
• 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.
• Apply airborne precautions.
If high flow tried and
unsuccessful DO NOT delay
intubation.
High flow oxygen systems
8. HEALTH
programme
EMERGENCIES|
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.
9. HEALTH
programme
EMERGENCIES|
• 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
10. HEALTH
programme
EMERGENCIES|
In most patients with ARDS, IMV with LPV is
preferred treatment.
NIV can be used in select patients with mild
ARDS.
Clinical trial evidence has shown that
implementation of LPV saves lives when
compared with usual care.
There are no trials comparing LPV with high
flow or NIV.
11. HEALTH
programme
EMERGENCIES
INVASIVE VENTILATION
Methods of delivery:
• Endotracheal tube (preferred)
• Nasotracheal tube
• Laryngeal mask (short-term, emergency)
• Tracheostomy (emergency airway, or long-term ventilation)
Requires sedation, appropriate equipment and trained staff
14. HEALTH
programme
EMERGENCIES|
Endotracheal intubation
• Inform the patient and family.
● Use airborne precautions.
• Anticipation and preparation are key:
– but do not delay procedure
– patients with ARDS can desaturate quickly when oxygen is removed
– monitor-respond to haemodynamic instability
– properly titrate induction anaesthetics
– have a plan if difficulties encountered.
• Ensure experienced clinician performs procedure.
• Checklist for rapid sequence induction.
Pre-oxygenate with 100% FiO2 for 5 minutes, via a bag valve mask, NIV or high-
flow system.
15. HEALTH
programme
EMERGENCIES|
LPV targets
• Target tidal volume 6 mL/kg in adult and children
– ideal body weight
• Target plateau airway pressure (Pplat) ≤ 30 cmH2O
• Target SpO2 88–93%
• Reaching LPV targets reduces mortality in patients with ARDS.
• Lung Safe (JAMA 2016) study observed only < 2/3 patients with
ARDS received TV < 8 mL/kg, Pplat measured in just 40% patients
and PEEP < 12 cm H2O in 82%. Finding indicate potential for
improvement.
• Implementation remains a challenge worldwide.
16. HEALTH
programme
EMERGENCIES
Pplat: target ≤ 30 cm H2O
Measure the plateau airway pressure at the end of passive inflation, during an inspiratory pause
(> 0.5 sec). PEEP is the pressure at the end of expiration.
17. HEALTH
programme
EMERGENCIES
Initiation of LPV
• Set TV 6–8/kg predicted body weight.
• Set RR to approximate minute ventilation (MV):
– do not set > 35/min
– remember MV = VT × RR.
• Set I:E ratio so inspiration time less than expiration:
– requires higher flow rates
– monitor for intrinsic PEEP.
• Set inspiratory flow rate above patient demand:
– commonly > 60 L/min.
• Set FiO2 at 1.00, titrate down.
• Set PEEP 5–10 cm H20 or higher for severe ARDS.
|
18. HEALTH
programme
EMERGENCIES|
Monitor ventilator and gas exchange
parameters frequently to reach targets
• Monitor SpO2 continuously.
• Monitor pH, PaO2, PaCO2 as needed using blood
gas analyser:
– should be available in all ICUs.
• Monitor ventilator parameters regularly:
– Pplat and compliance at least every 4 hours, and after changes in PEEP
or TV
– intrinsic PEEP and I:E ratio after changes in respiratory rate
– ventilator waveforms for asynchrony.
20. HEALTH
programme
EMERGENCIES|
Target TV 6 mL/kg and Pplat ≤ 30 cm H2O
• Reduce TV to reach target of 6 mL/kg over couple of
hours.
• If TV is at 6 mL/kg and Pplat remains > 30 cm H2O
then reduce TV by 1 mL/kg each hour, to a minimum 4 mL/kg:
– at the same time, increase RR to maintain MV
– allow for permissive hypercapnea
– monitor and treat asynchrony.
21. HEALTH
programme
EMERGENCIES|
Considerations when interpreting Pplat measurement
• Pplat is most accurate when measured during passive
inflation.
• Patients who are actively breathing have higher
transpulmonary pressures for given Pplat.
• Patients with stiff chest wall or abdominal compartment
may have lower transpulmonary pressures for given Pplat.
• Goal is to avoid high Pplat and high TV in ARDS patients.
22. HEALTH
programme
EMERGENCIES|
Allow permissive hypercapnea
• Mortality benefits of LPV outweigh risk of moderate
respiratory acidosis:
– no benefit to normalizing pH and PaCO2
– contraindications to hypercapnea are high intracranial pressure and
sickle cell crisis.
• If pH 7.15–7.30:
– increase RR until pH > 7.30 or PaCO2 < 25 (maximum 35)
– decrease dead space by:
– decreasing I:E ratio to limit gas-trapping
– changing heat and moisture exchanger to a heated humidifier
– remove the dead space (flex tube) from the ventilator circuit.
• If pH < 7.15 after above:
– give buffer therapy intravenously (e.g. sodium bicarbonate)
– TV may be increased in 1 mL/kg steps until pH > 7.15
– if necessary, Pplat target of 30 may be temporarily exceeded.
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EMERGENCIES
Benefits of PEEP
• PEEP is the airway pressure at the end of expiration:
– recruits atelectatic lung to prevent atelectrauma.
• Challenge is in determining “how much PEEP” for the heterogenous ARDS
lung.
• Zone B are open units
(“baby lung”)
• Zone C are at risk units
that can participate in gas
exchange
• Zone A are lung units
that are collapsed
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Use the ARDS-net PEEP-FiO2 grid to guide PEEP
• Set PEEP corresponding to severity of oxygen impairment:
– titrate the FiO2 to the lowest value that maintains target SpO2 88–93%.
– set corresponding PEEP, based on individual:
• higher PEEP for moderate-severe ARDS.
See website: www.ardsnet.org
Table used
for adults
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Risks of high PEEP
• When high PEEP levels are used, be cautious:
– earlier application of low tidal volume and the appropriate level of PEEP
will minimize risk.
– hypotension due to decreased venous return to right heart.
– over-distension of normal alveoli and possible ventilator-induced lung
injury and increase in dead space ventilation.
– maximal PEEP levels:
• maximal levels to be determined on individual basis, range between 10–15
cm H20
• use caution with higher PEEP levels in young children.
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EMERGENCIES|
Driving pressure and PEEP
• An observational study found that ventilator changes
associated with reduction of driving pressure (ΔP)
was associated with improved outcome:
– ΔP= TV/Compliance = Pplat - PEEP
• Consider to also target ΔP= 12–15 cm H2O:
– can be achieved if an increase in PEEP leads to improved compliance
from opening of lung units
– helpful in patients with severely reduced chest wall compliance (i.e. severe
ARDS) and high-PEEP requirements when ideal Pplat targets are not
achieved.
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EMERGENCIES
Optimal PEEP for severe ARDS:
maximal compliance vs tidal overdistension
• 1. TV = 6 mL/kg, PEEP titration trial
assessing compliance
• 2. Second trial to determine whether
optimal PEEP shifts when a smaller TV is
used
C
PEE
P
C
PEEP
6 mL/kg
5 mL/kg
• Optimal PEEP is TV dependent. Measure compliance after PEEP and TV changes.
• It is the PEEP that provides the best oxygenation and compliance (TV/Pplat-PEEP).
• Consider to use as adjunct to PEEP/FiO2 grid.
• Useful in situations when very high levels of PEEP are required, or when there is little
recruitable lung tissue due to extensive consolidation/fibrosis.
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EMERGENCIES
Severe ARDS: PaO2/FiO2 ≤ 100 mmHg
• Patients with severe ARDS may be difficult to
manage with just LPV strategy alone:
– may develop refractory hypoxaemia, severe acidosis
and unable to achieve LPV targets successfully.
• Recognize these patients early, using the Berlin
definition, PaO2/FiO2 ≤ 100 mmHg:
– earlier interventions with additional therapeutic options reduces
mortality from ARDS
– key point is to avoid harmful ventilation.
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EMERGENCIES|
Severe ARDS:
PaO2/FiO2 ≤ 100 mmHg
ARDS
Mild/Moderate
LPV +
Fluid restriction
Severe
LPV, fluid
restriction
+ Prone position
Higher PEEP
If asynchrony,
add NMB ≤ 48
hours
Recruitment
manoeuvre
ECMO
If LPV targets
not met,
consider:
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EMERGENCIES
Prone position and lung recruitment
a)Supine, prior to proning
b)Prone - note aeration of posterior
lung
c) Return to supine - posterior lung
remains aerated
d)Repeat proning - further aeration of
posterior lung
a) c)
b) d)
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EMERGENCIES
Intervention Advantages Disadvantages
Prone position Recruits collapsed alveoli and improve
VQ matching without high airway
pressures. Reduces mortality in
patients with PaO2/FiO2 < 150 mmHg.
Start early and use > 16hrs/day.
Requires experienced team, risks of
dislodgement of invasive catheters and ETT,
ETT obstruction, pressure ulcers and brachial
plexus injuries.
High PEEP Easy, may recruit collapsed alveoli.
Reduces mortality in mod-severe
ARDS (P/F ≤ 200).
Slower onset, risks of êBP, êSpO2,
barotrauma, édead space.
Recruitment
manoeuvres + high
PEEP
Faster onset, may recruit collapsed
alveoli. Recommended for refractory
hypoxaemia.
Risks of êBP, êSpO2, barotrauma, édead
space.
Neuromuscular
blockade*
Easy, fast acting, êasychrony, êVO2.
Use for 48 hours maximum. Conflicting
evidence on benefit when compared to
usual care.
Weakness during prolonged infusion. Though
when used early for short course (< 48 hours)
no increase in weakness.
*Early neuromuscular blockade in the ARDS. N Engl J
Med 2019;380:1997-2008
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EMERGENCIES
LPV in young children and infants
• Principles are similar for children with following
considerations:
– Most paediatric patients now have micro-cuffed or cuffed endotracheal tubes.
– VC mode is preferred in children with cuffed endotracheal tube:
• ensures primary control over TV.
– PC mode is preferred if using uncuffed endotracheal tube in younger children:
• ensures that adequate TV is delivered despite the leak of gas around the tube.
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EMERGENCIES
LPV in young children and infants
• For severe pARDS:
– maximal PEEP levels:
• maximal levels to be determined on individual basis, range between 10–15 cm H20
• use caution with higher PEEP levels in your children.
– prone position can be considered, though trial data are lacking.
– NMB can also be considered, though trial data are lacking.
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EMERGENCIES|
Tip #1 (1/2)
Avoid patient ventilator asynchrony
• Identify and treat patient-ventilator asynchrony:
– Double-triggering is the most common form of asynchrony:
• patient takes two breaths without exhaling
• usually because patient ventilatory demand higher than set TV.
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Tip #1 (2/2)
Avoid patient ventilator asynchrony
• Potential harmful effects:
– increased respiratory load, ventilator induced lung injury, worse gas
exchange, worse lung mechanics, prolong days of IMV.
• Treatment:
– increase flow (VC mode), prolong inspiratory time (PC mode)
– suction trachea, eliminate water from ventilator tubing, eliminate circuit
leaks
– increase sedation if severe ARDS and unable to control TV.
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EMERGENCIES|
Tip #2
Targeted sedation
• For patients with severe ARDS:
– Target deep sedation if ventilatory asynchrony and unable to control TV
and use NMB early.
• As the patient’s ARDS improves:
– Target lighter sedation targets to facilitate early mobility and SBT.
• Respiratory alkalosis may be a sign of untreated
pain.
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Tip #3
Reducing PEEP levels at the right time
• Patients may have prolonged course of IMV.
• The initial reduction of high levels of PEEP should
be done gradually:
– 2 cm H2O, once or twice a day
– too rapid reduction of PEEP may precipitate significant deterioration
– increase in dead space (Vd/Vt) will rise before compliance or
oxygenation decreases.
• Give lung protective ventilation strategy time to
work (lungs need time to heal).
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EMERGENCIES|
Tip #4 (1/2)
LPV using PCV
• PC ventilation may be used for LPV, when
appropriate:
– if patient ventilator asynchrony is difficult to manage on VC mode
– preferred in young children when using uncuffed ETT (next slide).
• Set Pinsp (inspiratory pressure) to target desired TV:
– because TV is variable, MV not controlled.
– Pinsp needs to be changed as compliance of respiratory system changes
– control I:E ratio with the i-time setting.
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EMERGENCIES|
Tip #4 (2/2)
LPV using PCV
• Caution:
– if patient has high ventilatory demand and is triggering vent the VT
goal may be exceeded
– when PC level is reduced to control VT the patient may experience
increased work of breathing
– PCV does not always improve asynchrony and WOB in ARDS.
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Tips #5 & 6
• Avoid (or minimize) disconnecting the patient from
the ventilator to prevent lung collapse and worse
hypoxaemia:
– use in-line catheters for airway suctioning
– clamp tube when disconnection required
– minimize unnecessary transport.
• Be systematic in your approach to troubleshooting
problems encountered when delivering IMV:
– see toolkit for checklists to guide troubleshooting.
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EMERGENCIES|
Use a restrictive fluid strategy (1/2)
• Safe to use in patients with ARDS that are not in
shock or with acute kidney injury:
– at least 12 hours after vasopressor use.
• Leads to fewer days of IMV (quicker to extubate).
• Monitor urine output and CVP (when available), see Toolkit for
details.
CVP Urine output < 0.5 mL/kg/hr Urine output ≥ 0.5 mL/kg/hr
> 8 Furosemide and reassess in 1 hr Furosemide and reassess in 4hr
4–8 Fluid bolus and reassess in 1 hr Furosemide and reassess in 4hr
< 4 Fluid bolus and reassess in 1hr No intervention and reassess in 4hr
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Use a restrictive fluid strategy (2/2)
• Minimize fluid infusions.
• Minimize positive fluid balance.
● Infants commonly present with elevated levels of
antidiuretic hormone and hyponatraemia:
- avoids hypotonic fluids
- treat with fluid restriction.
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EMERGENCIES|
Treat the underlying cause
• Identify and treat the cause of ARDS to control the
inflammatory process:
– e.g. patients with severe pneumonia or sepsis must be treated with
antimicrobials as soon as possible
• If there is no obvious cause of ARDS, you must
consider alternate aetiologies:
– need objective assessment (e.g. echocardiogram) to exclude hydrostatic
pulmonary oedema
– see Diagnosis of pneumonia, ARDS and sepsis slideshow
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EMERGENCIES|
Summary
• Intubation and invasive mechanical ventilation are indicated in
most patients with ARDS and hypoxaemic respiratory failure.
• Lung protective ventilation (LPV) saves lives in patients with
ARDS. LPV means:
– delivering low tidal volumes (target 6 mL/kg ideal body weight or less)
– achieving low plateau airway pressure (target Pplat ≤ 30 cm H2O)
– use of moderate-high PEEP levels to recruit lung.
• Restrictive fluid management when no shock or acute kidney
injury
• For patients with severe ARDS, also consider early use of prone
position and moderate-high PEEP levels; patients with
asynchrony may benefit from NMB.
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EMERGENCIES
• Contributors
Dr Neill Adhikari, Sunnybrook Health Sciences Centre, Toronto, Canada
Dr Janet V Diaz, WHO, Emergency Programme
Dr Edgar Bautista, Instituto Nacional de Enfermedades Respiratorias, México City, Mexico
Dr Steven Webb, Royal Perth Hospital, Perth, Australia
Dr Niranjan Bhat, Johns Hopkins University, Baltimore, USA
Dr Timothy Uyeki, Centers for Disease Control and Prevention, Atlanta, USA
Dr Paula Lister, Great Ormond Hospital, London, UK
Dr Michael Matthay, University of California, San Francisco, USA
Dr Markus Schultz, Academic Medical Center, Amsterdam
Acknowledgements