management of patient requiring breathing assistance topic 2 (q and a session) dr. s. nishan silva...

Management of Patient Management of Patient Requiring Breathing AssistanceRequiring Breathing Assistance

Topic 2Topic 2

(Q and A session)(Q and A session)

Dr. S. Nishan Silva(MBBS)

Q : Parts of the Q : Parts of the Respiratory System?Respiratory System?

Q : Explain the different Q : Explain the different “Lung volumes”“Lung volumes”

Q : Indications for Q : Indications for Ventilation?Ventilation?

Initiation of Mechanical VentilationInitiation of Mechanical Ventilation

IndicationsIndications– Indications for Ventilatory SupportIndications for Ventilatory Support

– Acute Respiratory FailureAcute Respiratory Failure– Prophylactic Ventilatory SupportProphylactic Ventilatory Support– Hyperventilation TherapyHyperventilation Therapy


IndicationsIndications– Acute Respiratory Failure (ARF)Acute Respiratory Failure (ARF)

Respiratory activity is inadequate or is insufficient to Respiratory activity is inadequate or is insufficient to maintain adequate oxygen uptake and carbon maintain adequate oxygen uptake and carbon dioxide clearance.dioxide clearance.

Inability of a patient to maintain arterial PaO2, Inability of a patient to maintain arterial PaO2, PaCO2, and pH acceptable levels PaCO2, and pH acceptable levels

PaO2 < 70 on on O2 PaO2 < 70 on on O2 PaCO2 > 55 mm Hg and risingPaCO2 > 55 mm Hg and rising pH 7.25 and lowerpH 7.25 and lower



Hypoxic lung failure (Type I)Hypoxic lung failure (Type I)– Ventilation/perfusion mismatchVentilation/perfusion mismatch– Diffusion defectDiffusion defect– Right-to-left shuntRight-to-left shunt– Alveolar hypoventilationAlveolar hypoventilation– Decreased inspired oxygenDecreased inspired oxygen

– Acute life-threatening or vital Acute life-threatening or vital organ-threatening tissue hypoxiaorgan-threatening tissue hypoxia



Clinical Presentation of Severe HypoxemiaClinical Presentation of Severe Hypoxemia– TachypneaTachypnea– DyspneaDyspnea– Central cyanosisCentral cyanosis– TachycardiaTachycardia– HypertensionHypertension– Irritability, confusionIrritability, confusion– Loss of consciousnessLoss of consciousness– ComaComa



Acute Hypercapnic Respiratory Failure Acute Hypercapnic Respiratory Failure (Type II)(Type II)– CNS DisordersCNS Disorders

Reduced Drive To Breathe:Reduced Drive To Breathe: depressant depressant drugs, brain or brainstem lesions (stroke, drugs, brain or brainstem lesions (stroke, trauma, tumors), hypothyroidismtrauma, tumors), hypothyroidism

Increased Drive to Breathe:Increased Drive to Breathe: increased increased metabolic rate (metabolic rate (CO2 production), metabolic CO2 production), metabolic acidosis, anxiety associated with dyspneaacidosis, anxiety associated with dyspnea



Acute Hypercapnic Respiratory Failure Acute Hypercapnic Respiratory Failure (Type II)(Type II)– Neuromuscular DisordersNeuromuscular Disorders

Paralytic Disorders:Paralytic Disorders: Myasthenia Gravis, Myasthenia Gravis, Guillain-Barre´, ALS, poliomyelitis, etc.Guillain-Barre´, ALS, poliomyelitis, etc.

Paralytic Drugs:Paralytic Drugs: Curare, Curare, nerve gas, nerve gas, succinylcholine, insecticidessuccinylcholine, insecticides

Drugs that affect neuromuscular Drugs that affect neuromuscular transmission;transmission; calcium channel blockers, long- calcium channel blockers, long-term adenocorticosteroids, etc. term adenocorticosteroids, etc.

Impaired Muscle Function:Impaired Muscle Function: electrolyte electrolyte imbalance, malnutrition, chronic pulmonary imbalance, malnutrition, chronic pulmonary disease, etc.disease, etc.



Acute Hypercapnic Respiratory FailureAcute Hypercapnic Respiratory Failure– Increased Work of BreathingIncreased Work of Breathing

Pleural Occupying Lesions: Pleural Occupying Lesions: pleural pleural effusions, hemothorax, empyema, effusions, hemothorax, empyema, pneumothoraxpneumothorax

Chest Wall Deformities:Chest Wall Deformities: flail chest, flail chest, kyphoscoliosis, obesitykyphoscoliosis, obesity

Increased Airway Resistance:Increased Airway Resistance: secretions, secretions, mucosal edema, bronchoconstriction, mucosal edema, bronchoconstriction, foreign bodyforeign body

Lung Tissue Involvement:Lung Tissue Involvement: interstitial interstitial pulmonary fibrotic diseasespulmonary fibrotic diseases



Acute Hypercapnic Respiratory FailureAcute Hypercapnic Respiratory Failure– Increased Work of Breathing (cont.)Increased Work of Breathing (cont.)

Lung Tissue Involvement:Lung Tissue Involvement: interstitial interstitial pulmonary fibrotic diseases, aspiration, pulmonary fibrotic diseases, aspiration, ARDS, cardiogenic PE, drug induced PEARDS, cardiogenic PE, drug induced PE

Pulmonary Vascular Problems:Pulmonary Vascular Problems: pulmonary thromboembolism, pulmonary thromboembolism, pulmonary vascular damagepulmonary vascular damage

Dynamic HyperinflationDynamic Hyperinflation (air trapping) (air trapping) Postoperative Pulmonary Postoperative Pulmonary

ComplicationsComplications



Clinical Presentation of HypercapniaClinical Presentation of Hypercapnia– TachypneaTachypnea– DyspneaDyspnea– TachycardiaTachycardia– HypertensionHypertension– Headache (hallucinations when severe)Headache (hallucinations when severe)– Confusion (loss of consciousness, even Confusion (loss of consciousness, even

coma when severe)coma when severe)– SweatingSweating


Prophylactic Ventilatory SupportProphylactic Ventilatory Support– Clinical conditions in which there is a high Clinical conditions in which there is a high

risk of future respiratory failurerisk of future respiratory failure

Examples: Examples: Brain injury, heart muscle injury, Brain injury, heart muscle injury, major surgery, prolonged shock, smoke injurymajor surgery, prolonged shock, smoke injury

Ventilatory support is instituted to:Ventilatory support is instituted to:– Decrease the WOBDecrease the WOB– Minimize O2 consumption and hypoxemiaMinimize O2 consumption and hypoxemia– Reduce cardiopulmonary stressReduce cardiopulmonary stress– Control airway with sedationControl airway with sedation


Hyperventilation TherapyHyperventilation Therapy– Ventilatory support is instituted to control Ventilatory support is instituted to control

and manipulate PaCO2 to lower than normal and manipulate PaCO2 to lower than normal levelslevels

Acute head injuryAcute head injury


ContraindicationsContraindications– Untreated pneumothoraxUntreated pneumothorax

Relative ContraindicationsRelative Contraindications– Patient’s informed consentPatient’s informed consent– Medical futilityMedical futility– Reduction or termination of patient pain and Reduction or termination of patient pain and

sufferingsuffering

NomenclatureNomenclature

NomenclatureNomenclature

Airway PressuresAirway Pressures– Peak Inspiratory Pressure (PIP)Peak Inspiratory Pressure (PIP)– Positive End Expiratory Pressure (PEEP)Positive End Expiratory Pressure (PEEP)– Pressure above PEEP (PAP or ΔP)Pressure above PEEP (PAP or ΔP)– Mean airway pressure (MAP)Mean airway pressure (MAP)– Continuous Positive Airway Pressure (CPAP)Continuous Positive Airway Pressure (CPAP)

Inspiratory Time or I:E ratioInspiratory Time or I:E ratio Tidal Volume: amount of gas delivered Tidal Volume: amount of gas delivered

with each breathwith each breath

ModesModes Control ModesControl Modes::

– every breath is fully supported by the every breath is fully supported by the ventilatorventilator

– in classic control modes, patients were in classic control modes, patients were unableunable to breathe except at the to breathe except at the controlled set ratecontrolled set rate

– in newer control modes, machines may in newer control modes, machines may act in assist-control, with a minimum set act in assist-control, with a minimum set rate and all triggered breaths above that rate and all triggered breaths above that rate also fully supported.rate also fully supported.

ModesModes IMV ModesIMV Modes: intermittent mandatory : intermittent mandatory

ventilation modes - breaths “above” set ventilation modes - breaths “above” set rate not supportedrate not supported

SIMVSIMV: vent synchronizes IMV “breath” : vent synchronizes IMV “breath” with patient’s effortwith patient’s effort

Pressure SupportPressure Support: vent supplies pressure : vent supplies pressure support but no set rate; pressure support but no set rate; pressure support can be fixed or variable support can be fixed or variable (volume (volume support, volume assured support, etc)support, volume assured support, etc)

Ventilator Settings Ventilator Settings Terminology (con’t)Terminology (con’t)

PRVCPRVC: Pressure Regulated Volume : Pressure Regulated Volume Control Control PEEPPEEP: Positive End Expiratory : Positive End Expiratory PressurePressureCPAPCPAP: Continuous Positive Airway : Continuous Positive Airway

PressurePressurePSVPSV: Pressure Support Ventilation: Pressure Support VentilationNIPPVNIPPV: Non-Invasive Positive : Non-Invasive Positive Pressure VentilationPressure Ventilation

ModesModes

Whenever a breath is supported by the Whenever a breath is supported by the

ventilator, regardless of the mode, ventilator, regardless of the mode,

the limit of the support is determined the limit of the support is determined

by a preset pressure by a preset pressure OROR volume. volume.

– Volume LimitedVolume Limited: preset tidal volume: preset tidal volume

– Pressure LimitedPressure Limited: preset PIP or PAP: preset PIP or PAP

Modes of Ventilation: The BasicsModes of Ventilation: The BasicsAssist-Control Ventilation Volume Assist-Control Ventilation Volume

ControlControlAssist-Control Ventilation Pressure Assist-Control Ventilation Pressure

ControlControlPressure Support VentilationPressure Support VentilationSynchronized Intermittent Mandatory Synchronized Intermittent Mandatory

Ventilation Volume ControlVentilation Volume ControlSynchronized Intermittent Mandatory Synchronized Intermittent Mandatory

Ventilation Pressure ControlVentilation Pressure Control

CMVCMV

Control ModeControl Mode

Assist Control VentilationAssist Control VentilationA set tidal volume (if set to volume A set tidal volume (if set to volume

control) or a set pressure and time (if control) or a set pressure and time (if set to pressure control) is delivered set to pressure control) is delivered at a minimum rate at a minimum rate

Additional ventilator breaths are Additional ventilator breaths are given if triggered by the patientgiven if triggered by the patient

A/CVA/CV

A/C cont.

Negative deflection, Negative deflection, triggering assisted triggering assisted breathbreath

Synchronized Intermittent Mandatory Synchronized Intermittent Mandatory VentilationVentilation

Breaths are given are given at a set minimal Breaths are given are given at a set minimal rate, however if the patient chooses to breath rate, however if the patient chooses to breath over the set rate no additional support is givenover the set rate no additional support is given

One advantage of SIMV is that it allows patients One advantage of SIMV is that it allows patients to assume a portion of their ventilatory driveto assume a portion of their ventilatory drive

SIMV is usually associated with greater work of SIMV is usually associated with greater work of breathing than AC ventilation and therefore is breathing than AC ventilation and therefore is less frequently used as the initial ventilator less frequently used as the initial ventilator modemode

Like AC, SIMV can deliver set tidal volumes Like AC, SIMV can deliver set tidal volumes (volume control) or a set pressure and time (volume control) or a set pressure and time (pressure control)(pressure control)

SIMVSIMV

SIMV cont.

Machine BreathsMachine BreathsSpontaneous BreathsSpontaneous Breaths

PSV(pressure support PSV(pressure support ventilation)ventilation)

Spontaneous inspiratory efforts Spontaneous inspiratory efforts trigger the ventilator to provide a trigger the ventilator to provide a variable flow of gas in order to attain variable flow of gas in order to attain a preset airway pressure.a preset airway pressure.

Can be used in adjunct with SIMV.Can be used in adjunct with SIMV.

Pressure Support VentilationPressure Support VentilationThe patient controls the respiratory rate The patient controls the respiratory rate

and exerts a major influence on the and exerts a major influence on the duration of inspiration, inspiratory flow rate duration of inspiration, inspiratory flow rate and tidal volumeand tidal volume

The model provides pressure support to The model provides pressure support to overcome the increased work of breathing overcome the increased work of breathing imposed by the disease process, the imposed by the disease process, the endotracheal tube, the inspiratory valves endotracheal tube, the inspiratory valves and other mechanical aspects of and other mechanical aspects of ventilatory support. ventilatory support.

Tidal Volume or Pressure Tidal Volume or Pressure setting setting

Maximum volume/pressure to Maximum volume/pressure to achieve good ventilation and achieve good ventilation and oxygenation without producing oxygenation without producing alveolar overdistentionalveolar overdistention

Max cc/kg? = 10 cc/kgMax cc/kg? = 10 cc/kg

Some clinical exceptionsSome clinical exceptions

Flow RateFlow RateThe peak flow rate is the maximum flow The peak flow rate is the maximum flow

delivered by the ventilator during delivered by the ventilator during inspiration. Peak flow rates of 60 L per inspiration. Peak flow rates of 60 L per minute may be sufficient, although minute may be sufficient, although higher rates are frequently necessary. higher rates are frequently necessary. An insufficient peak flow rate is An insufficient peak flow rate is characterized by dyspnea, spuriously characterized by dyspnea, spuriously low peak inspiratory pressures, and low peak inspiratory pressures, and scalloping of the inspiratory pressure scalloping of the inspiratory pressure tracingtracing

Inspiratory flowInspiratory flow

Varies with the Vt, I:E and RRVaries with the Vt, I:E and RR

Normally about 60 l/minNormally about 60 l/min

Can be majored to 100- 120 l/minCan be majored to 100- 120 l/min

Inspiratory Time: Expiratory Time Inspiratory Time: Expiratory Time Relationship (I:E Ratio)Relationship (I:E Ratio)

During spontaneous breathing, the normal I:E During spontaneous breathing, the normal I:E ratio is 1:2, indicating that for normal patients ratio is 1:2, indicating that for normal patients the exhalation time is about twice as long as the exhalation time is about twice as long as inhalation time. inhalation time.

If exhalation time is too short “breath If exhalation time is too short “breath stacking” occurs resulting in an increase in stacking” occurs resulting in an increase in end-expiratory pressure also called auto-end-expiratory pressure also called auto-PEEP.PEEP.

Depending on the disease process, such as in Depending on the disease process, such as in ARDS, the I:E ratio can be changed to ARDS, the I:E ratio can be changed to improve ventilationimprove ventilation

I:E RatioI:E Ratio

1:21:2

Prolonged at 1:3, 1:4, …Prolonged at 1:3, 1:4, …

Inverse ratioInverse ratio

Fraction of Inspired OxygenFraction of Inspired OxygenThe lowest possible fraction of The lowest possible fraction of

inspired oxygen (FiO2) necessary to inspired oxygen (FiO2) necessary to meet oxygenation goals should be meet oxygenation goals should be used. This will decrease the likelihood used. This will decrease the likelihood that adverse consequences of that adverse consequences of supplemental oxygen will develop, supplemental oxygen will develop, such as absorption atelectasis, such as absorption atelectasis, accentuation of hypercapnia, airway accentuation of hypercapnia, airway injury, and parenchymal injuryinjury, and parenchymal injury

FIO2FIO2

The usual goal is to use the minimum The usual goal is to use the minimum Fio2 required to have a PaO2 > Fio2 required to have a PaO2 > 60mmhg or a sat >90%60mmhg or a sat >90%

Start at 100%Start at 100%

Oxygen toxicity normally with Fio2 Oxygen toxicity normally with Fio2 >40%>40%

Inspiratory TriggerInspiratory Trigger

Normally set automaticallyNormally set automatically

2 modes:2 modes:

– Airway pressureAirway pressure– Flow triggeringFlow triggering

Positive End-expiratory Positive End-expiratory Pressure (PEEP) Pressure (PEEP)

What is PEEP?What is PEEP?

What is the goal of PEEP?What is the goal of PEEP?

– Improve oxygenationImprove oxygenation

– Diminish the work of breathingDiminish the work of breathing

– Different potential effectsDifferent potential effects

Positive End-Expiratory Pressure Positive End-Expiratory Pressure (PEEP)(PEEP)

Applied PEEP is generally added to Applied PEEP is generally added to mitigate end-expiratory alveolar mitigate end-expiratory alveolar collapse. A typical initial applied PEEP collapse. A typical initial applied PEEP is 5 cmH2O. However, up to 20 is 5 cmH2O. However, up to 20 cmH2O may be used in patients cmH2O may be used in patients undergoing low tidal volume undergoing low tidal volume ventilation for acute respiratory ventilation for acute respiratory distress syndrome (ARDS)distress syndrome (ARDS)

PEEPPEEP

What are the secondary effects of PEEP?What are the secondary effects of PEEP?– BarotraumaBarotrauma– Diminish cardiac outputDiminish cardiac output

– Regional hypoperfusionRegional hypoperfusion– NaCl retentionNaCl retention– Augmentation of I.C.P.?Augmentation of I.C.P.?– Paradoxal hypoxemiaParadoxal hypoxemia

PEEPPEEP

Contraindication:Contraindication:– No absolute CINo absolute CI

– BarotraumaBarotrauma– Airway traumaAirway trauma– Hemodynamic instabilityHemodynamic instability– I.C.P.?I.C.P.?– Bronchospasm?Bronchospasm?

PEEPPEEP

What PEEP do you want?What PEEP do you want?

– Usually, 5-10 cmH2OUsually, 5-10 cmH2O

PEEP cont.

PEEP is the amount of pressure remaining in the lung at the END of the expiratory phase.

Pressure above zero

Continuous Positive Airway Pressure (CPAP):

• This IS a mode and simply means that a pre-set pressure is present in the circuit and lungs throughout both the inspiratory and expiratory phases of the breath.

• CPAP serves to keep alveoli from collapsing, resulting in better oxygenation and less WOB.

• The CPAP mode is very commonly used as a mode to evaluate the patients readiness for extubation.

Advantages of Each ModeAdvantages of Each Mode

ModeMode AdvantagesAdvantages

Assist Control Ventilation (AC)Assist Control Ventilation (AC) Reduced work of breathing Reduced work of breathing compared to spontaneous compared to spontaneous breathingbreathing

AC Volume VentilationAC Volume Ventilation Guarantees delivery of set Guarantees delivery of set tidal volumetidal volume

AC Pressure Control AC Pressure Control VentilationVentilation

Allows limitation of peak Allows limitation of peak inspiratory pressuresinspiratory pressures

Pressure Support Ventilation Pressure Support Ventilation (PSV)(PSV)

Patient comfort, improved Patient comfort, improved patient ventilator interactionpatient ventilator interaction

Synchronized Intermittent Synchronized Intermittent Mandatory Ventilation (SIMV)Mandatory Ventilation (SIMV)

Less interference with normal Less interference with normal cardiovascular functioncardiovascular function

Disadvantages of Each ModeDisadvantages of Each ModeModeMode DisadvantagesDisadvantages

Assist Control Ventilation (AC)Assist Control Ventilation (AC) Potential adverse Potential adverse hemodynamic effects, may hemodynamic effects, may lead to inappropriate lead to inappropriate hyperventilationhyperventilation

AC Volume VentilationAC Volume Ventilation May lead to excessive May lead to excessive inspiratory pressuresinspiratory pressures

AC Pressure Control AC Pressure Control VentilationVentilation

Potential hyper- or Potential hyper- or hypoventilation with lung hypoventilation with lung resistance/compliance resistance/compliance changeschanges

Pressure Support Ventilation Pressure Support Ventilation (PSV)(PSV)

Apnea alarm is only back-up, Apnea alarm is only back-up, variable patient tolerancevariable patient tolerance

Synchronized Intermittent Synchronized Intermittent Mandatory Ventilation (SIMV)Mandatory Ventilation (SIMV)

Increased work of breathing Increased work of breathing compared to ACcompared to AC

IntubationIntubation

Intubation Intubation ProcedureProcedure

Check and Assemble EquipmentCheck and Assemble Equipment::

Oxygen flowmeter and OOxygen flowmeter and O22 tubing tubingSuction apparatus and tubingSuction apparatus and tubingSuction catheter or yankauerSuction catheter or yankauerAmbu bag and maskAmbu bag and maskLaryngoscope with assorted bladesLaryngoscope with assorted blades3 sizes of ET tubes3 sizes of ET tubesStyletStyletStethoscopeStethoscopeTapeTapeSyringeSyringeMagill forcepsMagill forcepsTowels for positioningTowels for positioning


Position your patient into the Position your patient into the sniffing positionsniffing position

Intubation ProcedureIntubation ProcedurePreoxygenate with 100% oxygen Preoxygenate with 100% oxygen

to provide apneic or distressed to provide apneic or distressed patient with reserve while patient with reserve while

attempting to intubate.attempting to intubate.

Do not allow more than 30 seconds to Do not allow more than 30 seconds to any intubation attempt.any intubation attempt.

If intubation is unsuccessful, ventilate If intubation is unsuccessful, ventilate with 100% oxygen for 3-5 minutes with 100% oxygen for 3-5 minutes

before a reattempt.before a reattempt.

Intubation ProcedureIntubation Procedure Insert LaryngoscopeInsert Laryngoscope


After displacing the After displacing the epiglottis insert the ETT. epiglottis insert the ETT.

The depth of the tube for a The depth of the tube for a male male patient on average is patient on average is 21-23 cm at teeth21-23 cm at teeth

The depth of the tube on average The depth of the tube on average for a female patient is 19-21 at for a female patient is 19-21 at teeth.teeth.


Confirm tube position:Confirm tube position:

By auscultation of the chestBy auscultation of the chestBilateral chest riseBilateral chest riseTube location at teethTube location at teethCOCO2 2 detector – (esophageal detector – (esophageal

detection device)detection device)

Intubation ProcedureIntubation Procedure Stabilize the ETT

Q: Describe suction Q: Describe suction procedure for ventilated procedure for ventilated

patients. patients.

TROUBLESHOOTINGTROUBLESHOOTING

TroubleshootingTroubleshooting Is it working ?Is it working ?

–Look at the patient !!Look at the patient !!–Listen to the patient !!Listen to the patient !!– Pulse Ox, ABG, EtCOPulse Ox, ABG, EtCO22

– Chest X rayChest X ray– Look at the vent (PIP; expired TV; Look at the vent (PIP; expired TV;

alarms)alarms)

TROUBLESHOOTINGTROUBLESHOOTING

Anxious Patient Anxious Patient

– Can be due to a malfunction of the ventilatorCan be due to a malfunction of the ventilator– Patient may need to be suctionedPatient may need to be suctioned– Frequently the patient needs medication for Frequently the patient needs medication for

anxiety or sedation to help them relaxanxiety or sedation to help them relax

Attempt to fix the problemAttempt to fix the problem

Call your doctorCall your doctor

Low Pressure AlarmLow Pressure Alarm

Usually due to a leak in the circuit.Usually due to a leak in the circuit.

– Attempt to quickly find the problemAttempt to quickly find the problem– Bag the patient and call your doctorBag the patient and call your doctor

High Pressure AlarmHigh Pressure Alarm

Usually caused by:Usually caused by:– A blockage in the circuit (water A blockage in the circuit (water

condensation)condensation)– Patient biting his ETTPatient biting his ETT– Mucus plug in the ETTMucus plug in the ETT

– You can attempt to quickly fix the You can attempt to quickly fix the problem problem

– Bag the patient and call for your Bag the patient and call for your doctordoctor

Low Minute Volume AlarmLow Minute Volume Alarm

Usually caused by:Usually caused by:– Apnea of your patient (CPAP)Apnea of your patient (CPAP)– Disconnection of the patient Disconnection of the patient

from the ventilatorfrom the ventilator

– You can attempt to quickly fix You can attempt to quickly fix the problem the problem

– Bag the patient and call for Bag the patient and call for your doctoryour doctor

Accidental ExtubationAccidental Extubation

Role of the NurseRole of the Nurse::

– Ensure the Ambu bag is attached to Ensure the Ambu bag is attached to the oxygen flowmeter and the oxygen flowmeter and it is on!it is on!

– Attach the face mask to the Ambu Attach the face mask to the Ambu bag and after ensuring a good seal bag and after ensuring a good seal on the patient’s face; supply the on the patient’s face; supply the patient with ventilation.patient with ventilation.

– Bag the patient and call for Bag the patient and call for your your doctordoctor

OTHEROTHER

Anytime you have concerns, Anytime you have concerns, alarms, ventilator changes or alarms, ventilator changes or any other problem with your any other problem with your ventilated patient.ventilated patient.

– Call for your Call for your doctordoctor

– NEVER hit the silence NEVER hit the silence button!button!

Trouble ShootingTrouble Shooting

ABGABG

• Goal:

• Keep patient’s acid/base balance within normal range:

• pH 7.35 – 7.45• PCO2 35-45 mmHg• PO2 80-100 mmHg

ComplicationsComplicationsVentilator Induced Lung InjuryVentilator Induced Lung Injury

– Oxygen toxicityOxygen toxicity– Barotrauma / VolutraumaBarotrauma / Volutrauma

Peak PressurePeak PressurePlateau PressurePlateau PressureShear Injury (tidal volume)Shear Injury (tidal volume)PEEPPEEP


Cardiovascular ComplicationsCardiovascular Complications– Impaired venous return to RHImpaired venous return to RH– Bowing of the Interventricular SeptumBowing of the Interventricular Septum– Decreased left sided afterload (good)Decreased left sided afterload (good)– Altered right sided afterloadAltered right sided afterload

Sum Effect…..decreased cardiac output Sum Effect…..decreased cardiac output (usually, not always and often we don’t (usually, not always and often we don’t even notice)even notice)


Other ComplicationsOther Complications– Ventilator Associated PneumoniaVentilator Associated Pneumonia– SinusitisSinusitis– SedationSedation– Risks from associated devices Risks from associated devices

(CVLs, A-lines)(CVLs, A-lines)– Unplanned ExtubationUnplanned Extubation

ExtubationExtubationWeaningWeaning

– Is the cause of respiratory failure Is the cause of respiratory failure gone or getting better ? gone or getting better ?

– Is the patient well oxygenated and Is the patient well oxygenated and ventilated ?ventilated ?

– Can the heart tolerate the Can the heart tolerate the increased work of breathing ?increased work of breathing ?

ExtubationExtubationWeaning (cont.)Weaning (cont.)

– decrease the PEEP (4-5)decrease the PEEP (4-5)– decrease the ratedecrease the rate– decrease the PIP (as needed)decrease the PIP (as needed)

What you want to do is decrease What you want to do is decrease what the vent does and see if the what the vent does and see if the patient can make up the patient can make up the difference….difference….

ExtubationExtubationExtubationExtubation

– Control of airway reflexesControl of airway reflexes

– Patent upper airway (air leak around Patent upper airway (air leak around tube?)tube?)

– Minimal oxygen requirementMinimal oxygen requirement

– Minimal rate Minimal rate

– Minimize pressure support (0-10)Minimize pressure support (0-10)

– ““Awake ” patientAwake ” patient

Mechanical Mechanical VentilatorsVentilators

Different Types of Ventilators Different Types of Ventilators Available:Available:

Will depend on you place of Will depend on you place of employmentemployment

Mechanical VentilatorsMechanical Ventilators

High Frequency Mechanical High Frequency Mechanical VentilatorVentilator

management of patient requiring breathing assistance topic 2 (q and a session) dr. s. nishan silva...

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