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Presentation
Different settings to consider Monitoring of the patient Different type of patient
COPD, Asthma ARDS
Trouble shooting
Ventilator settings
Ventilator settings
1.
2. 3.
4.
5. 6.
7.
8.
Ventilator mode Respiratory rate Tidal volume or pressure settings Inspiratory flow I:E ratio PEEP FiO2 Inspiratory trigger
CMV
A/CV
SIMV
Respiratory Rate
1. What is the pt actual rate demand?
Inspiratory flow
Varies with the Vt, I:E and RR
Normally about 60 l/min Can be majored to 100- 120 l/min
I:E Ratio
1:2 Prolonged at 1:3, 1:4,
Inverse ratio
FIO2
The usual goal is to use the minimum Fio2 required to have a PaO2 > 60mmhg or a sat >90%
Start at 100%
Inspiratory Trigger
Normally set automatically
2 modes:
Airway pressure Flow triggering
Improve oxygenation
PEEP
What are the secondary effects of PEEP?
Barotrauma Diminish cardiac output Regional hypoperfusion NaCl retention Augmentation of I.C.P.? Paradoxal hypoxemia
PEEP
Contraindication:
No absolute CI
PEEP
What PEEP do you want?
Pressures
Pplat
Measured by occluding the ventilator 3-5 sec at the end of inspiration Should not exceed 30 cmH2O
Ppeak
Pressure measured at the end of inspiration Should not exceed 50cmH2O?
Normally, at end expiration, the lung volume is equal to the FRC When PEEPi occurs, the lung volume at end expiration is greater then the FRC
Predisposes to barotrauma Predisposes hemodynamic compromises Diminishes the efficiency of the force generated by respiratory muscles Augments the work of breathing Augments the effort to trigger the ventilator
Diminish DHI
Why?
Diminish DHI
How?
Controlled hypercapnia
Why?
Limit high airway pressures and thus diminish the risk of complications
Controlled hypercapnia
How?
Control the ventilation to keep adequate pressures up to a PH > 7.20 and/or a PaCO2 of 80 mmHg
Controlled hypercapnia
CI:
Head pathologies Severe HTN Severe metabolic acidosis Hypovolemia Severe refractory hypoxia Severe pulmonary HTN Coronary disease
A.R.D.S.
Ventilation with lower tidal volume as compared with traditional volumes for acute lung injury and the ARDS
The Acute Respiratory Distress Syndrome Network N Engl J Med 2000;342:1301-08
Methods
March 96 March 99 10 university centers Inclusion:
Diminish PaO2 Bilateral infiltrate Wedge < 18
Exclusion Randomized
Methods
A/C 28d or weaning 2 groups:
End point:
Results
The trails were stopped after 861 pt because of lower mortality in low Vt group
Trouble Shooting
Trouble Shooting
Doctor, doctor, his pressures are going up!!!
What is your next step?
Trouble Shooting
1. Call the I.T., he will take care of it!
2. Where is the staff? 3. I dont know this pt, and run! 4. Ask which pressure is going up
Trouble Shooting
Ppeak is up
Trouble Shooting
If your Pplat is high, you are faced with a COMPLIANCE problem
If your Pplat is N, you are faced with a RESISTIVE problem DD?
Trouble Shooting
Trouble Shooting
Doctor, doctor, my patient is very agitated!
Trouble Shooting
1. Give an ativan to the nurse!
2. Give haldol 10mg to the patient! 3. Take 5mg of morphine for yourself! 4. Look at your pt!
Trouble Shooting
At the time of intubation, fighting is largely due to anxiety
But what do you do if pt is stable and then becomes agitated?
Trouble Shooting
1.
2. 3.
4.
5.
6.
Remove pt from ventilator Initiate manual ventilation Perform P/E and assess monitoring indices Check patency of airway If death is imminent, consider and treat most likely causes Once pt is stabilized, undertake more detailed assessement and management
Trouble Shooting
Conclusion
Type of patient Normal ARDS COPD Tidal Volume 10 cc/kg 6 cc/kg 6 cc/kg RR 10 to 12 10 to 12 10 to 12 PEEP 0 to 5 5 to 15 5 to 10 FIO2 100%. 100%. 100%. Ins. Flow 60 l/min 60 l/min 1:2. 1:2. PH>7.2 PCO2 <80 mmhg Trigger to consider I:E Note Note
Trauma Pediatric
10 cc/kg
10 to 12
0.
100%. 100%.
60 l/min 60 l/min