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Basics of Mechanical Ventilation in hospital.pptx
- 1.
- 2. ◗ Mechanical Ventilationis ventilation of the lungs by artificial means usually by a machine called ventilator. ◗ Aventilator delivers gas to the lungs with either negative or positive pressure. 2
- 3. ◗ Negative pressure ventilation Ironlung Chest cuirase ◗ Positive pressure ventilation Invasive Non invasive 3
- 4. 1. Relieve respiratorydistress 2. Decrease work of breathing 3. Improve pulmonary gas exchange 4. Reverse respiratory muscle fatigue 5. Permit lung healing 4
- 5. Pressur e Volume Flow Time 5
- 6. ◗ Control -themechanical breath goal, ie, a set pressure or a set volume ◗ Trigger -Variable which starts inspiration Limit - the maximum permitted value during inspiration. ◗ Cycle - Variable which ends inspiration 6
- 7.
- 8. Breath types • Mandatory breath Ventilatordoes the work Ventilator controls start and end of inspiration • Assist control breath patient triggers the breath Venti. Delivers the breath as per control variable • Spontaneously Supported breath Pt. triggers the breath Ventilator delivers pressure support • Spontaneous Patient takes on 8
- 9. ◗ Indications forventilator support present ◗ Non-invasive v/s Invasive ventilation ◗ Pressure v/s Volume ventilation ◗ Extent (Partial v/s Full) & mode of ventilation ◗ Key Ventilatory settings ◗ Appropriate Alarms and Back-up values ◗ Weaning
- 10. ◗ Patient notbreathing ◗ Patient breathing, …….but not enough ◗ Patient breathing enough, …….but hypoxemic / hypercapneic ◗ Patient breathing with normal gas exchange, ….but working hard ◗ Airway protection
- 11. ◗ Clinical deterioration ◗Hypoxia : pO2<60mm Hg ◗ Hypercarbia : pCO2 > 50mm Hg ◗ Tachypnea : RR >35 ◗ Tidal volume <3-5 ml/kg ◗ Max. inspiratory pressure <-20 cm H2O
- 12.
- 13. ◗ Patient continuouslyreceives a set air pressure, during both inspiration and expiration. ◗ Patient has full control over respiratory rate, inspiratory time , and depth of inspiration.
- 14. ◗ This providesa set inspiratory pressure and a different set of expiratory pressure ◗ Initial setting: EPAP:5cm H2O IPAP: 8cm H2O O2 @ 2-5 L/min Final IPAP pressures of 15 to 22 cm H2O are common
- 15. ◗ Patient hasfull control over the respiratory rate, inspiratory time and depth of inspiration ◗ IPAP & EPAP can be increased by increments of 2 ◗ BiPAP = CPAP + Pressure support during inspiration
- 16. 1.Cardiogenic pulmonary edema, exacerbation of COPD , Post-op respiratory failure. 2.Neuromuscular disease with respiratory muscle weakness, OSA. 3.Terminallyill patients compromised patients. 4 Weaning mode. & Immuno
- 17. Advantages: 1 Complications ofintubation –avoided 2 Allows speech ,feeding Disadvantages: 1.Respiratory drive and intact upper airway 2.Cannot protect airway and does not provide full 100% ventillatory support 3. Claustrofobia & uncomfortable for patients
- 18. ◗ Improvement in: 1.Respiratory rate and heart rate 2. Dyspnea 3. Oxygen requirement 4. Hypercarbia
- 19. Provides allthe energy for Alveolar Ventilation Every breath is fully supported by the ventilator In classic control modes, patients are unable to breathe except at the controlled set rate In newer control modes, machines may act in assist-control, with a minimum set rate and all triggered breaths above that rate are also fully supported. Ensures that patient is not required to do any Work Of Breathing
- 20. When to Consider: ◗Spontaneously breathing patient. ◗ Comfortably provide a portion of their required minute volume ◗Useful for weaning patients from MV support When not to consider: ◗ Should be avoided in case of patients with ventilatory muscle fatigue
- 21. PRESSURE VOLUME Tidal VolumeVariable Constant Peak Ins Pressure Constant Variable Dys-synchrony Less More likely Barotrauma Less More likely Flow Pattern Decreasing Preset
- 22. ◗ Balance CO2removal v/s lung protection ◗ If CO2 clearance more important than lung protection, use volume. ◗ If lung protection is more important than CO2 removal use PRESSURE ◗ If patient triggered ventilation, synchrony may be enhanced with PRESSURE
- 23. ◗ The ventilatordelivers a preset TV at a specific R/R and inspiratory flow rate. ◗ It is irrespective of patients’ respiratory efforts. ◗ In between the ventilator delivered breaths the inspiratory valve is closed so patient doesn’t take additional breaths. ◗ PIP developed depends on lung compliance and respiratory passage resistance.
- 25. ◗ Ventilator givespressure limited, time cycled breaths thus preset inspiratory pressure is maintained. ◗ Decelerating flow pattern. ◗ Peak airway/alveolar pressure is controlled but TV, minute volume & alveolar volume depends on lung compliance, airway resistance, R/R & I:E ratio.
- 27. ◗ Ventilator assistspatient’s initiated breath, but if not triggered, it will deliver preset TV at a preset respiratory rate (control). patient (control) ◗ If R/R triggered (assist) or time triggered > preset rate, ventilator will assist, otherwise it will control the ventilation.
- 29. ◗ Ventilator deliverseither assisted breaths at the beginning of a spontaneous breath or time triggered mandatory breaths. ◗ Synchronization window- time interval just prior to time triggering. ◗ Breath stacking is avoided as mandatory breaths are synchronized with spontaneous breaths. ◗ In between mandatory breaths patient is allowed to take spontaneous breath at any TV.
- 31. ◗ Patient isspontaneously breathing ◗ The vent augments the patient’s respiratory effort with a “pressure support” ◗ Tidal Volume is determined by patient’s effort and respiratory system compliance ◗ Can set a FiO2 PEEP and PS above PEEP ◦ Can not set respiratory rate except back-up apnea rate.
- 32. ◗ FiO2 ◗ TidalVolume /Pressure ◗ Respiratory Rate ◗ PEEP ◗ Flow Rate ◗ I:E Ratio ◗ Trigger
- 33. Start with FiO2=1.0 and titrate to SpO2 >=94% ABG after 20-30min Goal –PaO2 between 60 –100 mmHg If FiO2 requirement is>0.5 , increase PEEP FiO2 =1.0, before & after suction, during bronchoscopy, & any other risky procedure
- 34. ◗ The tidalvolume is the amount of air delivered with each breath. ◗ Initial tidal volumes should be 8-10ml/kg, depending on patient’s body habitus. ◗ If patient is in ARDS consider tidal volumes between 4 – 6 ml/kg with increase in PEEP ◗ In Pressure-Targeted modes you’ll set the Pressure High (PH) according to the delivered tidal volume
- 35. ◗ Males: IBW= 50 kg + 2.3 kg for each inch over 5 feet. ◗ Females: IBW = 45.5 kg + 2.3 kg for each inch over 5 feet.
- 36. An optimalmethod for setting the respiratory rate has not been established. ◗ 12 - 15/Min – Adult 20+_ 3 - Child 30- 40 - New born On somemachines you set the Inspiratory Time (Ti) and Expiratory Time (Te)
- 37. ◗ Increase RR– Hypoxia Hypercapnoea / Resp. Acidosis ◗ Decrease RR- Hypocapnoea Resp. Alkalosis Asthma / COPD
- 38. •Minute Ventilation (L/min)= RR (b/min) x Tidal Volume (liters) •If you decrease one or both the MV will decrease resulting inHypercapnia •Tolerated in status asthmaticus and ARDS/ALI – Called “permissive hypercapnea”
- 39. ◗ A typicalinitial PEEP applied is 5 cmH2O. ◗ Adjust up by increments of 2 for marked hypoxia ◗ However, up to 20 cm H2O used in ARDS ◗ PEEP increases intra thoracic pressure and can thus decrease venous return and thus Blood Pressure
- 40. Improves oxygenation RecruitsLung in ARDS Prevents collapse of alveoli Diminishes the work of breathing
- 41. ◗ Peak flowrates of 60 L per minute ◗ Higher rates are frequently necessary in Asthma or those with air hunger ◗ An insufficient peak flow rate is characterized by dysnoea, spuriously low peak inspiratory pressures, and scalloping of the inspiratory pressure tracing ◗ Pressure-Targeted modes allow patient to dictate the flow rate that they want
- 42. ◗ During spontaneousbreathing, the normal I:E ratio is 1:2. ◗ If exhalation time is too short “breath stacking” occurs resulting in an increase in end-expiratory pressure also called auto-PEEP. ◗ Asthma/COPD 1:3, 1:4, … ◗ Severe hypoxia ARDS 1:1, 2:1,
- 43. ◗ Most frequentlyused to obtain an estimate of Plateau pressure and static compliance ◗ Patient should not be actively breathing ◗ When used with each breath, improves distribution of air, V/Q ratio.
- 44. ◗ Pressure triggering -1to-2cm H2O Ventilator-delivered breath is initiated if the demand valve senses a negative airway pressuredeflection greater than thetrigger sensitivity. ◗ Flow triggering 1 to 3 L/ min (preferred) Continuous flow of gas through the ventilator circuit is monitored. A ventilator delivered breath is initiated when the return flow is less than the delivered flow
- 45. •different medications forsedation. •Opiates (morphine, fentanyl) Benzodiazepines (Midazolam) • Propofol • Less is sometime more
- 46. • Paralysis withoutsedation = Torture Atracurium,Vecuronium can be used •All one needs in this situation is chemical weakening…
- 47. • Low pressure, •High pressure limit and alarm • Volume alarm(low TV, high and low minute ventilation) • High respiratory rate alarm • Apnea alarm and apnea values • High/low temperature alarm • I:E ratio limit and alarm
- 48. Complications of positive pressureventilation Increase in positive airway pressure ● High intrathorasic pressure ● this pressure transmitted to airway,alveoli,as as mediastinum and great vessels ● Compression of great vessels ●Decreased venous return Decreased strock volume and D c ease oxy n elivecrayrdiac oHuytppoutetnsion ec eased r na lood fl decreased GFR 29 decreased urine output51
- 49. Weaning The process ofwithdrawing mechanical ventilatory support and transferring the work of breathing from the ventilator to patient. 5 2
- 50. Improvement of thecause of respiratory failure Absence of major system dysfunction Appropriate level of oxygenation Adequate ventilatory status Intact airway protective mechanism (needed for extubation) 53
- 51. Rapid Shallow BreathingIndex • Failure of weaning may be related to the development of a spontaneous breathing pattern that is rapid (high frequency) and shallow (low tidal volume). • The rapid shallow breathing index (RSBI) or f/VT index has been used to evaluate the effectively of the spontaneous breathing pattern. • Favourable RSBI is < 105 54
- 52. ◗ No one ormethod of weaning has been definitely found to be superior; ◗ Spontaneous Breathing Trial ◗ Pressure Support Ventilation ◗ Other Modes of Partial Ventilatory Support SIMV Volume support (VS) and volume-assured pressure support (VAPS) Mandatory minute ventilation (MMV) Airway pressure-release ventilation (APRV) 55
- 53. PROCEDU Steps RE PSV 1.PSVmay be used in conjunction with spontaneous breathing or SIMV mode; 2.Start PSV at a level of 5 to 15 cm H2O (up to 40 cm H2O) to augment spontaneous VT until a desired VT (10 to 15 mL/kg) or spontaneous frequency (<25/min) is reached; 3.Decrease pressure support (PS) level by 3 to 6 cm H2O intervals until a level of close to 5 cm H2O is reached; 4.If patient tolerates step (3), consider extubation when blood gases and vital signs are satisfactory. 56
- 54. What after weaning • Oxygentherapy • Close monitoring: ABGs evaluation, Pulse oximetry • Bronchodilator therapy • Chest physiotherapy • Adequate nutrition, hydration, and humidification • Incentive spirometry 57
- 55.
- 56. 59 • The ETTmust be repositioned and re-secured at least once a shift to prevent tissue breakdown • Mouth care needs to be performed routinely • Cuff pressure needs to be assessed once a shift • Sometimes a higher pressure is needed to seal (ETT is too small, anatomical differences) • Check for proper inflation, determine the location of the leak, assess the integrity of the pilot line • Suctioning Management of the tube
- 57. Evaluating for Leaks •Every ventilator check must include assessing the circuit integrity • PIP and Vt measurements are lower than previous measurements • Start at the patient connection and work back to the ventilator • May need to disconnect the patient and provide manual ventilation while testing the circuit 60
- 58. ◗ Check plateaupressures by allowing an inspiratory pause (this gives you the pressure in the lung itself without the addition of resistance) pressures are low then you have an obstruction ◗ If both peak pressures and plateau pressures are high then you have a lung compliance issue
- 60. ◗ High peakpressure differential: High Peak Pressures Low Plateau Pressures High Peak Pressures High Plateau Pressures Mucus Plug Bronchospasm ET tube blockage Biting ARDS Pulmonary Edema Pneumothorax ET tube migration to a single bronchus Effusion
- 61. ◗ Increase inpatient agitation and dis- synchrony on the ventilator: ◦ Could be secondary to overall discomfort • Increase sedation ◦ Could be secondary to feelings of air hunger • Options include increasing tidal volume, increasing flow rate, adjusting I:E ratio, increasing sedation
- 62. • Early useof NPPV •Prepare and expect hypotension during intubation – IVF bolus •Mechanical Ventilation Strategy – Permissive Hypercapnia • Ventilator maneuvers that prolong I:E – Low tidal volumes, low respiratory rates, square wave forms, high flow rates.
- 63. • Tidal Volumes:6-7 ml/kg (IBW) • Respiratory Rate: 8-10 bpm • Flow Rate: 80-100 L/min • Square Wave forms • SEDATION: propofol,fentanyl • Last resort: chemical weakening • Expect high peak pressures
- 64. ◗ Lung ProtectiveStrategy ◗ Low-Tidal Volumes ◗ Start at 6 mL/kg IBW ◗ Goal of 4-6 mL/kg IBW ◗ Low Plateau Pressures – Less than 30 ◗ High PEEP ◗ Permissive hypercapnia