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Basics of ventilation AND BEYOND SCENARIO.ppt
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- 2. Origins of mechanicalventilation Origins of mechanical ventilation •Negative-pressure ventilators (“iron lungs”) • first used in Boston Children’s Hospital in 1928 • Used extensively during polio outbreaks in 1940s – 1950s The iron lung created negative pressure in abdomen as well as the chest, decreasing cardiac output. Iron lung polio ward at Rancho Los Amigos Hospital in 1953.
- 3. Era of intensivecare begun with this Positive-pressure ventilators Invasive ventilation first used at Massachusetts General Hospital in 1955 Now the modern standard of mechanical ventilation
- 4. Outline Outline • Modes • VentilatorSettings • Indications to intubate • Indications to extubate • Trouble shooting
- 5. Pressure ventilation vs.volume ventilation Pressure ventilation vs. volume ventilation Pressure-cycled modes: -deliver a fixed pressure at variable volume Volume-cycled modes: -deliver a fixed volume at variable pressure
- 6. Ventilator settings 1. Ventilatormode 2. Respiratory rate 3. Tidal volume or pressure settings 4. Inspiratory flow 5. I:E ratio 6. PEEP 7. FiO2 8. Inspiratory trigger
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- 17. Pressure Support Ventilation(PSV) Pressure Support Ventilation (PSV) Patient determines RR, VE, inspiratory time – a purely spontaneous mode
- 18. CPAP and BiPAP CPAPand BiPAP CPAP is essentially constant PEEP; BiPAP is CPAP plus PS • Parameters CPAP – PEEP set at 5-10 cm H2O BiPAP – CPAP with Pressure Support (5-20 cm H2O) Shown to reduce need for intubation and mortality
- 19. Respiratory Rate 10-12/Min –Adult 20+_ 3 - Child 30- 40 - New born
- 20. Increase – Hypoxia Hypercapnoea /Resp.Acidosis Decrease Hypocapnoea Resp.Alkalosis Asthma / COPD Respiratory Rate
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- 23. Tidal Volume or Pressuresetting Optimum volume/pressure to achieve good ventilation and oxygenation without producing alveolar overdistention Max = 6-8 cc/kg
- 24. Inspiratory Trigger Normally setautomatically 2 modes: Airway pressure Flow triggering
- 25. I:E Ratio Normaly 1:2 Asthma/COPD1:3, 1:4, … Severe hypoxia ARDS/ALI Pul.Edema 1:1 , 2:1
- 26. FIO2 Goal – toachive PaO2 > 60mmHg or a sat >90% Start at 100% aim 40%
- 27. Vent settings toimprove <oxygenation> Vent settings to improve <oxygenation> • FIO2 • Simplest maneuver to quickly increase PaO2 • Long-term toxicity at >60% • Free radical damage • Inadequate oxygenation despite 100% FiO2 usually due to pulmonary shunting • Collapse – Atelectasis • Pus-filled alveoli – Pneumonia • Water/Protein – ARDS • Water – CHF • Blood - Hemorrhage PEEP and FiO2 are adjusted in tandem
- 28. Positive End-expiratory Pressure (PEEP) Whatis PEEP? Positive pressure measured at the end of expiration. What is the goal of PEEP? Improve oxygenation Recruit lung in ARDS Prevent collapse of alveoli Diminish the work of breathing
- 29. PEEP- Indications. If aPaO2 of 60 mmHg cannot be achieved with a FiO2 of 60% If the initial shunt estimation is greater than 25% Pulmonary edema ARDS/ALI Atelectosis
- 30. PEEP What are thesecondary effec`ts of PEEP? Barotrauma Diminish cardiac output Regional hypoperfusion Augmentation of I.C.P.? Paradoxal hypoxemia Hypercapnoea and respiratory acidosis
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- 32. Collapse/ atelectosis/ ARDS IncreasesSurface area for gas exchange Opens the collapsed lung Collapsed alveoli After PEEP PEEP
- 33. Pulmonary edema Translocation offluid to peribroncheal region – helps in oxygenation PEEP
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- 35. DOPE D- Disposition ofETT O- Obstruction / kinking P- Pneumothorax E- Equipment failure
- 36. Need for tracheostomy Needfor tracheostomy Prolonged intubation may injure airway and cause airway edema 1 - Vocal cords. 2 - Thyroid cartilage. 3 - Cricoid cartilage. 4 - Tracheal cartilage. 5 - Balloon cuff.
- 37. Over view Typeofpatient TidalVolume RR PEEP FIO2 Ins. Flow I:E Note Note Normal 8cc/kg 10to 12 0to5 100%. 60l/min 1:2. ARDS 6cc/kg 10to 12 5to15 100%. 60l/min 2:10ras needed COPD 6cc/kg 10to 12 5to10 100%. 100to120 1:3to1:4 PH>7.2 PCO2<80mmhg Triggertoconsider Trauma 8cc/kg 10to 12 0. 100%. 60l/min 1:2. Pediatric 8-10cc/kg Varies age 3to5 100%. 60l/min 1:2. Triggertoconsider
Editor's Notes
- #2 In medicine, mechanical ventilation is a method to mechanically assist or replace spontaneous breathing when patients cannot do so on their own, and must be done so after invasive intubation with an endotracheal or tracheostomy tube through which air is directly delivered (in contrast to noninvasive ventilation). In many cases, mechanical ventilation is used in acute settings such as in the ICU for a short period of time during a serious illness. For some patients who have certain chronic illnesses that require long-term ventilation assistance, they are also able to do so at home or other nursing/rehabilitation institution with the help of respiratory therapists and physicians. The main form of mechanical ventilation currently is positive pressure ventilation, which works by increasing the pressure in the patient's airway and thus forcing additional air into the lungs. This is in contrast to the more historically common negative pressure ventilators (for example, the "iron-lung") that create a negative pressure environment around the patient's chest, thus sucking air into the lungs. Although often a life-saving technique, mechanical ventilation carries many potential complications including pneumothorax, airway injury, alveolar damage, and ventilator-associated pneumonia, among others. Accordingly it is generally weaned off or to minimal settings as soon as possible.
- #7 Control Mode Pt receives a set number of breaths and cannot breathe between ventilator breaths Similar to Pressure Control Assist Mode Pt initiates all breaths, but ventilator cycles in at initiation to give a preset tidal volume Pt controls rate but always receives a full machine breath Assist/Control Mode Assist mode unless pt’s respiratory rate falls below preset value Ventilator then switches to control mode Rapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation (auto-PEEP)
- #8 Control Mode Pt receives a set number of breaths and cannot breathe between ventilator breaths Similar to Pressure Control Assist Mode Pt initiates all breaths, but ventilator cycles in at initiation to give a preset tidal volume Pt controls rate but always receives a full machine breath Assist/Control Mode Assist mode unless pt’s respiratory rate falls below preset value Ventilator then switches to control mode Rapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation (auto-PEEP)
- #9 Control Mode Pt receives a set number of breaths and cannot breathe between ventilator breaths Similar to Pressure Control Assist Mode Pt initiates all breaths, but ventilator cycles in at initiation to give a preset tidal volume Pt controls rate but always receives a full machine breath Assist/Control Mode Assist mode unless pt’s respiratory rate falls below preset value Ventilator then switches to control mode Rapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation (auto-PEEP)
- #10 Control Mode Pt receives a set number of breaths and cannot breathe between ventilator breaths Similar to Pressure Control Assist Mode Pt initiates all breaths, but ventilator cycles in at initiation to give a preset tidal volume Pt controls rate but always receives a full machine breath Assist/Control Mode Assist mode unless pt’s respiratory rate falls below preset value Ventilator then switches to control mode Rapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation (auto-PEEP)
- #11 Control Mode Pt receives a set number of breaths and cannot breathe between ventilator breaths Similar to Pressure Control Assist Mode Pt initiates all breaths, but ventilator cycles in at initiation to give a preset tidal volume Pt controls rate but always receives a full machine breath Assist/Control Mode Assist mode unless pt’s respiratory rate falls below preset value Ventilator then switches to control mode Rapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation (auto-PEEP)
- #12 Control Mode Pt receives a set number of breaths and cannot breathe between ventilator breaths Similar to Pressure Control Assist Mode Pt initiates all breaths, but ventilator cycles in at initiation to give a preset tidal volume Pt controls rate but always receives a full machine breath Assist/Control Mode Assist mode unless pt’s respiratory rate falls below preset value Ventilator then switches to control mode Rapidly breathing pts can overventilate and induce severe respiratory alkalosis and hyperinflation (auto-PEEP)
- #14 The modes of ventilation can be thought of as classifications based on how to control the ventilator breath. Traditionally ventilators were classified based on how they determined when to stop giving a breath. The three traditional categories of ventilators are listed below. As microprocessor technology is incorporated into ventilator design, the distinction among these types has become less clear as ventilators may use combinations of all of these modes as well as flow-sensing, which controls the ventilator breath based on the flow-rate of gas versus a specific volume, pressure, or time. Controlled Mechanical Ventilation (CMV). In this mode the ventilator provides a mechanical breath on a preset timing. Patient respiratory efforts are ignored. This is generally uncomfortable for children and adults who are conscious and is usually only used in an unconscious patient. It may also be used in infants who often quickly adapt their breathing pattern to the ventilator timing
- #15 Assist Control (AC). In this mode the ventilator provides a mechanical breath with either a preset tidal volume or peak pressure every time the patient initiates a breath. Traditional assist-control used only a preset tidal volume--when a preset peak pressure is used this is also sometimes termed Intermittent Positive Pressure Ventilation or IPPV. However the initiation timing is the same--both provide a ventilator breath with every patient effort. In most ventilators a back-up minimum breath rate can be set in the event that the patient becomes apneic. Although a maximum rate is not usually set, an alarm can be set if the ventilator cycles too frequently. This can alert that the patient is tachypneic or that the ventilator may be auto-cycling (a problem that results when the ventilator interprets fluctuations in the circuit due to the last breath termination as a new breath initiation attempt).
- #16 Synchronized Intermittent Mandatory Ventilation (SIMV). In this mode the ventilator provides a preset mechanical breath (pressure or volume limited) every specified number of seconds (determined by dividing the respiratory rate into 60 - thus a respiratory rate of 12 results in a 5 second cycle time). Within that cycle time the ventilator waits for the patient to initiate a breath using either a pressure or flow sensor. When the ventilator senses the first patient breathing attempt within the cycle, it delivers the preset ventilator breath. If the patient fails to initiate a breath, the ventilator delivers a mechanical breath at the end of the breath cycle. Additional spontaneous breaths after the first one within the breath cycle do not trigger another SIMV breath. However, SIMV may be combined with pressure support (see below). SIMV is frequently employed as a method of decreasing ventilatory support (weaning) by turning down the rate, which requires the patient to take additional breaths beyond the SIMV triggered breath
- #18 Continuous Positive Airway Pressure (CPAP). A continuous level of elevated pressure is provided through the patient circuit to maintain adequate oxygenation, decrease the work of breathing, and decrease the work of the heart (such as in left-sided heart failure - CHF). Note that no cycling of ventilator pressures occurs and the patient must initiate all breaths. In addition, no additional pressure above the CPAP pressure is provided during those breaths. CPAP may be used invasively through an endotracheal tube or tracheostomy or non-invasively with a face mask or nasal prongs.
- #28 Positive End Expiratory Pressure (PEEP) is functionally the same as CPAP, but refers to the use of an elevated pressure during the expiratory phase of the ventilatory cycle. After delivery of the set amount of breath by the ventilator, the patient then exhales passively. The volume of gas remaining in the lung after a normal expiration is termed the functional residual capacity (FRC). The FRC is primarily determined by the elastic qualities of the lung and the chest wall. In many lung diseases, the FRC is reduced due to collapse of the unstable alveoli, leading to a decreased surface area for gas exchange and intrapulmonary shunting (see above), with wasted oxygen inspired. Adding PEEP can reduce the work of breathing (at low levels) and help preserve FRC.
- #29 Indications. PEEP is a cardiodepressant and can cause severe hemodynamic consequences through decreasing venous return to the right heart and decreasing right ventricular. As such, it should be judiciously used and is indicated in two circumstances. If a PaO2 of 60 mmHg cannot be achieved with a FiO2 of 60% If the initial shunt estimation is greater than 25% If used, PEEP is usually set with the minimal positive pressure to maintain an adequate PaO2 with a safe FiO2. As PEEP increase intrathoracic pressure, there can be a resulting decrease in venous return and decrease in cardiac output. A PEEP of less than 10 cmH2O is usually safe if intravascular volume depletion is absent. Older literature recommended routine placement of a Swan-Ganz catheter if the amount of PEEP used is > 10 cmH2 for hemodynamic monitoring. More recent literature has failed to find outcome benefits with routine PA catheterization when compaired to simple central venous pressure monitoring.[2] If cardiac output measurement is required, minimally invasive techniques, such as esophageal doppler monitoring or arterial waveform contour monitoring may be sufficient alternatives.[3][4] PEEP should be withdrawn from a patient until adequate PaO2 can be maintained with a FiO2 < 40%. When withdrawing, it is decreased through 1-2 cmH2O decrements while monitoring hemoglobin-oxygen saturations. Any unacceptable hemoglobin-oxygen saturation should prompt reinstitution of the last PEEP level that maintained good saturation.