Lecture notes for medical students

1. Tips on using my ppt.
1. You can freely download, edit, modify and put your
name etc.
2. Don’t be concerned about number of slides. Half the
slides are blanks except for the title.
3. First show the blank slides (eg. Aetiology ) > Ask
students what they already know about ethology of
today's topic. > Then show next slide which enumerates
aetiologies.
4. At the end rerun the show – show blank> ask questions >
show next slide.
5. This will be an ACTIVE LEARNING SESSION x
three revisions.
6. Good for self study also.
7. See notes for bibliography.

2. • Physiological PEEP.
• PIP Peak Inspiratory Pressure at the end of
inspiration. High when airway resistance is
high.
• Plateau pressure- At the end of inspiration
before expiration begins. Rises with
pneumonia, atelactesis
• Pressure and flow are common trigerring
mechanisms.

3. Indications

4. Indications
• P0.1 –change in airway pressure ater
beginningof inspiration.
• Against an occluded air way.
• 0.1 second.
• Used ot asses ventrilatroy drive and demang
of a person.

5. • Put the larget size endotracheal trube to
have least airway resistance.
• Copliance measurement are very important.
• Always see peak and platue pressure.
• Respiratory pause .1 to .3.
• High resistance – High expiratoray pressure
• Low compliane- High inspiratory pressure

6. Initiating ventilation :modes and settings

7. Initiating ventilation :modes and settings
• invasive and non invasive
• Full venrilator support(fvs)
• Partial ventrilatory support(pvs)

8. MODES OF VENTRILATION

9. MODES OF VENTRILATION
• TYPE OF BREATH DELIVERY.
• TARGETED CONTROL VARIALBLE.
• TRYPE OF BREATH DELIVERY.

10. • MANDITAORY BREATHING
• SPONTANEOUS BREATH.
• ASSISTED BREATH.

11. TARGETED CONTRLOL
VARIABLE

12. TARGETED CONTRLOL
VARIABLE
• DETERMENENT OF GAS FLOW
• VOLUEM /PRESSURE DEPENDENT
VARIABLE
• SELECTION BASED OF WHETHER
CONSTANT VOLUEM IS IMPORTANT
OR A LIMITED PRESSURE

13. VOLUME CONTROL.

14. VOLUME CONTROL.
• DELIVER A CONSTANT VOLUME
• MAINTABUT-I A PARTICULAR PACO2
• NOT ALTERED BYVARIATIONS IN
LLUNG COMPLIANCE OR AIRWAY
PRESSURE.
• WORSENING LLUNG CONDITION
LEADS TO HIGH AIRWAY AND PLAEU
PRESSURE-OVERDISTENTIONN.
• MIGHT NORT MEENT HIGH FLOW
REQUIREMENT OF PTS AS FLOW IS

15. VOLUME CONTROL
• Use largest size ETT
• Watch for bronchospasm, oedema, mucus
plug, secretions.
• Inspiration Expiration ratio – keep
expiration 1:4 for high resistance.
– Keep 1;2 or 1;1 for low compliance

16. Which Control to Use

17. Which Control to Use
1. Volume control. Volume is fixed Flow
and pressure are varying. It’s safe
2. Pressure control best but needs expert care.
3. Dual mode.
1. PrVC- Pressure controlled Volume control
4. IRVC – Inverse Ratio VC

18. Scalars

19. Scalars
• Three graphs
1. Volume Vs time
2. Flow Vs time
3. Pressure Vs time

20. Pressures
•

21. Pressures
• PP -Peak pressure – in airway
• Plateau Pressure- In alveoli at the end of
inspiration.
• PEEP-
• PIP- Peak Inspiratorry Pressure

22. Suctioning

23. Suctioning
• Only SOS on collection of secretions -
Seasaw pattern in FLOW- VOLUME Loop.

24. Mechanical Ventilation in ARDS

25. Mechanical Ventilation in ARDS
• In 1994 renamed Acute Respiratory
Distress Syndrome.

26. ARDS
• Severe Hypoxemia + BL Patchy shadows
• Berlin definition
1. Timing- Within 1week
2. Imaging
3. Origin of oedema
4. Oxygenation PF ratio.

27. ARDS

28. ARDS
• Pathophysiology damaged oedematous
alveolar membrane leads to BABY LUNG.
• Causses
1. Sepsis
2. Trauma
3. Aspiration
4. Pneumonia
5. TRALI-Transfusion Related Lung Injury

29. Management of ARDS

30. Management of ARDS
1. ARDS is Compliance problem not
resistance problem.
2. Treat the cause- don’t wait for ARDS to
resolve.
3. Supportive care-
1. Prone position
2. Early invasive ventilatory support.
3. Low tidal volume 4 -6 ml./Kg.
4. High rate.
5. Pharmacological support.
sedatives and neuromuscular blockade,

31. Problems in Mechanical Ventilation

32. Problems in Mechanical Ventilation
VILI- Ventilator Induced Lung Injury
• Volutrauma
• Barotrauma
• Biotrauma

33. Recuitment Maneuver

34. Recuitment Maneuver
Recuitable lung CT
1. Should be Sedated , paralysed.
2. Should be Hemodynamically stable.
3. Can repeat in 15 minutes
4. High Tidal volume for 2minutes.
5. High PIP volume for 2minutes.
6. High PEEP upto 30 for 2minutes.
7. Proning.
8. ECMO

35. Strategies

36. Strategies
• Ideal is Pressure Controlled Ventilation.
• Non intensivist - Use Volume Controlled
Ventilation.
• Titrated PPEP upto 15
• CT/ USG-for recruitable alveoli > Rerecruit.
• Keep Driving pressure 12-14. DP= Plateau
Pressure – PEEP.
• Permisible Hypercapnia
• Max. Plateau pressure 30
• Max. Rate 30

37. Alarm Ringing

38. Alarm Ringing
• Never silence an alarm.
• Secretions.
• Leak
• Kinks
• Bronchospasm
• High PEEP Alarm ringing –Reset at higher
level.

39. On improvement

40. On improvement
• Reduce FiO2
• Reduce Rate
• Reduce PEEP

41. Covid

42. Covid
• Goundglssing. Peripheral demarcated.
• Pneumonia.
• No Pleural effusion fibrosis.
•

43. Covid Symptoms

44. Covid Symptoms
Asymptomatic, Mild, severe, critical
• Fever
• Cough
• Dyspnoea.
• Loss of smell.
• MODS

45. Covid Basic investigation

46. Covid Basic investigation
• CBC- Lymphonea.
• CRP biomarker for secondary infection.
• PCT
• LFT
• KFT
• Xray Chest
• CT if Covid -Ve

47. Severe Covid

48. Severe Covid
• Azithromycin 500mg od 5days.
• +- Chloroquine
• QT interval
• Antivirals
• Convalescent plasma.
• Rarely Methylprednisolone low dose.
• No nebulization.
• No broncholators.
• No Noninvasive ventilation.

49. Covid

50. Covid
• Don’t combine chloroquine and antiviral.

51. Covid: Non invasive ventilation

52. Covid: Non invasive ventilation
• NIPPV
• Non invasive ventilation is not indicated in
Covid.
• IPAP- Inspiratory Airway Pressure
• EPAP (PEEP) : In pulmonary oedema.

53. Covid

54. Covid
• CPAP
• BiPAP

55. Covid
• I Time – Inspiratory time.
• E Time- Expiratory time.

56. Weaning Mode

57. Weaning Mode
• When disease has improved.
• Hemodynamically, neurologically - Stable
• Pressure support. Don’t go above 30.
• Assist control

58. Triggers

59. Triggers
1. Biased Flow
2. Pressure
3. Time
Sensitivity we have to set.

60. • Pressure support Vs. Pressure control in
former exhalation will start automatically
(as per Cycling off % setting)

61. Get this ppt in mobile
1. Download Microsoft
PowerPoint from play
store.
2. Open Google assistant
3. Open Google lens.
4. Scan qr code from
next slide.

62. Get this ppt in mobile

63. Get my ppt collection
• https://www.slideshare.net/drpradeeppande/
edit_my_uploads
• https://www.dropbox.com/sh/x600md3cvj8
5woy/AACVMHuQtvHvl_K8ehc3ltkEa?dl
=0
• https://www.facebook.com/doctorpradeeppa
nde/?ref=pages_you_manage