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Tutorial: Pulmonary Function--Dr. Bhutani Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support @ 18 hours age: Settings:  18 / 5 cm H 2 0 x 45 breaths / min; FiO 2  = 0.65 Driving Pressure:  18-5 = 13   cm H 2 0 Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaC O 2  = 55 mmHg Is this baby a candidate for  permissive hypercapnia?
Normocapnia varies? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Strategies to Prevent  Non-Permissive Hypercapnia ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Alveolar Algebra: Ventilation ,[object Object],[object Object],[object Object],Based on Pulmonary Gas Law: in a steady state, when inspired CO2 is negligible, then  PACO2  =  863 (VCO2 / VA);  where,  VCO2  is CO2 production;  PACO2  is partial pressure of carbon dioxide;  863  is body temp. x std. pressure / standard temperature ( 310 X 760/273 = 863 )
Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support and is now about 18 hours age and has stable vital signs, normotensive and is normoglycemic: Settings:  PIP:18 cm H 2 0; PEEP: 5 cm H 2 0; SIMV: 45 br / min;  Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaCO 2  = 55 mmHg Is the Alveolar Ventilation compromised? If so, by how much?
Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support and is now about 18 hours age and has stable vital signs, normotensive and is normoglycemic: Settings:  PIP:18 cm H 2 0; PEEP: 5 cm H 2 0; SIMV: 45 br / min;  Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaCO 2  = 55 mmHg PaCO 2  = 55 mmHg  is 35% higher  than 40 mmHg Alveolar Ventilation is decreased by 35%
Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support and is now about 18 hours age and has stable vital signs, normotensive and is normoglycemic: Settings:  PIP:18 cm H 2 0; PEEP: 5 cm H 2 0; SIMV: 45 br / min;  Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaCO 2  = 55 mmHg PaCO 2  = 54 mmHg  is 35% higher  than 40 mmHg Questions: Do we wean? Which option?
Clinical Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Clinical Case: Use of Tidal Volume 695 g male neonate with RDS, treated with surfactant and on ventilatory support: Settings:  18 / 5 cm H 2 0 x 35 breaths / min Driving Pressure:  18-5 = 13   cm H 2 0 Tidal Volume (measured):   =  4 ml  (5.7ml/kg) Effective Compliance:  =   V /    P ;  5.7 / 13  ml/cm H 2 0/kg Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaC O 2  = 55 mmHg
Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support: Settings:  18 / 5 cm H 2 0 x 35 breaths / min Driving Pressure:  18-5 = 13   cm H 2 0 Tidal Volume (measured):   =  4.0 ml  (5.7 ml/kg) Effective Compliance:  =   V /    P ; 5.7 /13  = 0.44 ml / cm H 2 0/kg Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaC O 2  = 55 mmHg
Relationship to FRC
Least Intervention or Barotrauma ,[object Object],[object Object],[object Object],[object Object],Ventilate  at  Optimal  FRC
Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support: Settings:  18 / 5 cm H 2 0 x 45 breaths / min Driving Pressure:  18-5 = 13   cm H 2 0 Tidal Volume (measured):   =  4.0 ml  (5.7 ml/kg) Effective Compliance:  =   V /    P ; 5.7 /13  = 0.44 ml / cm H 2 0 Arterial Gas:  pH = 7.3;  Pa O 2  = 74 ;  PaC O 2  = 55 mmHg
(PEEP) 5 18 (PIP)    P = 13 cm H 2 0    V = 5.7   ml/kg Graphic Representation of Ventilator Settings
(PEEP) 5 18 (PIP)    P = 13 cm H 2 0    V = 5.7   ml/kg    V /    P = 5.7   / 13 = 0.44  ml/cm H 2 0 /kg Graphic Representation of Ventilator Settings
5 TLC RV 19    P = Driving pressure    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 18 17 Linear Change  in    V/    P    V /    P = 5.7   / 13  = 0.44  ml/cm H 2 0
5 TLC RV 19    P = Driving pressure    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 18 17 Imaginary P-V relationship
Clinical Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
5 17 18 TLC RV 19 16    P = 12    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP Wean Peak Inflating Pressure Tidal Volume decreases with weaning Driving pressure decreased
Clinical Case ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
5 18 TLC RV 19 17    P = 14    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 4 Wean PEEP Tidal Volume increases with weaning Driving pressure increased
Circuit Airflow ,[object Object],[object Object],[object Object],[object Object],[object Object]
 
 
Clinical Case ,[object Object],[object Object],[object Object],[object Object],[object Object]
5 17 18 TLC RV 19 16    P = 13    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 4 DUAL WEAN: concurrent wean of both PIP and PEEP Tidal Volume increases with weaning Tidal Volume increases with weaning Driving pressure unchanged
5 18 TLC RV 14    P = 10    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 4 DUAL WEAN that allows for  permissive hypercapnia Tidal Volume unchanged with weaning Driving pressure decreased
Clinical Case  ,[object Object],[object Object],[object Object],[object Object],[object Object]
4 5 17 18 TLC RV 19 16    P    V PRESSURE  (cmH 2 0) VOLUME Peak Inflating Pressure PEEP Iatrogenic hypercapnia with  inappropriate Dual Wean Tidal Volume decreases with weaning

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Pulmonary Function Tutorial,Bhutani

  • 1. Tutorial: Pulmonary Function--Dr. Bhutani Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support @ 18 hours age: Settings: 18 / 5 cm H 2 0 x 45 breaths / min; FiO 2 = 0.65 Driving Pressure: 18-5 = 13 cm H 2 0 Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaC O 2 = 55 mmHg Is this baby a candidate for permissive hypercapnia?
  • 2.
  • 3.
  • 4.
  • 5. Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support and is now about 18 hours age and has stable vital signs, normotensive and is normoglycemic: Settings: PIP:18 cm H 2 0; PEEP: 5 cm H 2 0; SIMV: 45 br / min; Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaCO 2 = 55 mmHg Is the Alveolar Ventilation compromised? If so, by how much?
  • 6. Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support and is now about 18 hours age and has stable vital signs, normotensive and is normoglycemic: Settings: PIP:18 cm H 2 0; PEEP: 5 cm H 2 0; SIMV: 45 br / min; Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaCO 2 = 55 mmHg PaCO 2 = 55 mmHg is 35% higher than 40 mmHg Alveolar Ventilation is decreased by 35%
  • 7. Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support and is now about 18 hours age and has stable vital signs, normotensive and is normoglycemic: Settings: PIP:18 cm H 2 0; PEEP: 5 cm H 2 0; SIMV: 45 br / min; Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaCO 2 = 55 mmHg PaCO 2 = 54 mmHg is 35% higher than 40 mmHg Questions: Do we wean? Which option?
  • 8.
  • 9. Clinical Case: Use of Tidal Volume 695 g male neonate with RDS, treated with surfactant and on ventilatory support: Settings: 18 / 5 cm H 2 0 x 35 breaths / min Driving Pressure: 18-5 = 13 cm H 2 0 Tidal Volume (measured): = 4 ml (5.7ml/kg) Effective Compliance: =  V /  P ; 5.7 / 13 ml/cm H 2 0/kg Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaC O 2 = 55 mmHg
  • 10. Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support: Settings: 18 / 5 cm H 2 0 x 35 breaths / min Driving Pressure: 18-5 = 13 cm H 2 0 Tidal Volume (measured): = 4.0 ml (5.7 ml/kg) Effective Compliance: =  V /  P ; 5.7 /13 = 0.44 ml / cm H 2 0/kg Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaC O 2 = 55 mmHg
  • 12.
  • 13. Clinical Case 695 g male neonate with RDS, treated with surfactant and on ventilatory support: Settings: 18 / 5 cm H 2 0 x 45 breaths / min Driving Pressure: 18-5 = 13 cm H 2 0 Tidal Volume (measured): = 4.0 ml (5.7 ml/kg) Effective Compliance: =  V /  P ; 5.7 /13 = 0.44 ml / cm H 2 0 Arterial Gas: pH = 7.3; Pa O 2 = 74 ; PaC O 2 = 55 mmHg
  • 14. (PEEP) 5 18 (PIP)  P = 13 cm H 2 0  V = 5.7 ml/kg Graphic Representation of Ventilator Settings
  • 15. (PEEP) 5 18 (PIP)  P = 13 cm H 2 0  V = 5.7 ml/kg  V /  P = 5.7 / 13 = 0.44 ml/cm H 2 0 /kg Graphic Representation of Ventilator Settings
  • 16. 5 TLC RV 19  P = Driving pressure  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 18 17 Linear Change in  V/  P  V /  P = 5.7 / 13 = 0.44 ml/cm H 2 0
  • 17. 5 TLC RV 19  P = Driving pressure  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 18 17 Imaginary P-V relationship
  • 18.
  • 19. 5 17 18 TLC RV 19 16  P = 12  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP Wean Peak Inflating Pressure Tidal Volume decreases with weaning Driving pressure decreased
  • 20.
  • 21. 5 18 TLC RV 19 17  P = 14  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 4 Wean PEEP Tidal Volume increases with weaning Driving pressure increased
  • 22.
  • 23.  
  • 24.  
  • 25.
  • 26. 5 17 18 TLC RV 19 16  P = 13  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 4 DUAL WEAN: concurrent wean of both PIP and PEEP Tidal Volume increases with weaning Tidal Volume increases with weaning Driving pressure unchanged
  • 27. 5 18 TLC RV 14  P = 10  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP 4 DUAL WEAN that allows for permissive hypercapnia Tidal Volume unchanged with weaning Driving pressure decreased
  • 28.
  • 29. 4 5 17 18 TLC RV 19 16  P  V PRESSURE (cmH 2 0) VOLUME Peak Inflating Pressure PEEP Iatrogenic hypercapnia with inappropriate Dual Wean Tidal Volume decreases with weaning

Editor's Notes

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