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Venn|atory Cr|ses

Gregory A. Schm|dt, MD
rofessor, D|v|s|on of u|monary D|seases, Cr|nca| Care,
and Cccupanona| Med|c|ne
Un|vers|ty of Iowa
No cooflcts to Jlsclose
D|sc|osure
l have no relauonshlps wlLh lndusLry Lo
dlsclose wlLh regards Lo venulaLory Crlses
Cb[ecnves
Aer Lhls course, you wlll be able Lo:
ldenufy bases for Lhe dlsLressed venulaLed pauenL
Lxplaln Lhe role of pauenL-venulaLor dyssynchrony
ropose analyzlng resplraLory mechanlcs Lo gulde
dlagnosls
ulscuss approaches Lo crlucal hypoxemla
LlsL venulaLor changes ln auLoLL
Cr|ses |n the Venn|ated anent
ulsLressed pauenL
Plgh and low pressure alarms
Crlucally lmpalred gas exchange
Plgh auLoLL
D|stressed, Venn|ated anent
venulaLor, 1ublng, LndoLracheal 1ube
venulaLor malfuncuon
ulsconnecuon
CbsLrucLed, malposluoned L11 or cu leak
lnsumclenL raLe, ow, pressure, oLher
auenL
aln, anxleLy, dellrlum, dyspnea
Cardlac lschemla, shock
Pypoxemla
8aroLrauma
wbeoevet tbe foocuoo of tbe veoulotot ot tbe posluoo ooJ poteocy of tbe
oltwoy ote lo poesuoo, tbe poueot sboolJ be temoveJ ftom tbe veoulotot ooJ
booJ-boqqeJ wltb 100X oxyqeo
Lva|uanon of the D|stressed, Venn|ated
anent
Conrm posluon and paLency of L11/Lrach
Cllnlcal exam, hand bagglng, ulLrasound
Lxamlne ow and pressure waveforms
8evlew venulaLor semngs, clrculL lnLegrlLy
CxlmeLry, Cx8, arLerlal blood gas, LCC
VENTILA GROUP
International Mechanical Ventilation Study Group
0
0.002
0.004
0.006
0.008
0.01
0.012
0.014
0.016
0.018
1 3 5 7 9 11 13 15 17 19 21 23 25 27
Days from the start the mechanical ventilation
H
a
z
a
r
d

r
a
t
e

f
o
r

b
a
r
o
t
r
a
u
m
a


Probability of Barotrauma
A. Anzueto, F. Frutos, A. Esteban et al
Intensive Care Med 2004; 30:612
Barotrauma - 2
BaroTx seen in 2.9% overall
Mean occurrence at 3.4d
neumothorax: k|sk Iactors
venulaLor semngs:
re-Lv era
plaL > 33
no clear relauon Lo LL, peak, prone posluonlng, PlCv
Lung facLors:
Compllance < 30 cc/cmP
2
C
necrosls
1rauma
no paralyuc (11.7 vs 4.0, p=0.01)
laLrogenlc
Mlllet Ml, et.ol. cbest 2008, 1J4.969 8oossotsot M, et.ol. loteoslve cote MeJ 2002, 28.406
koptetlJes l, et.ol. I ctlt cote 2009, 24.89 Amoto M8l, et.ol. N oql I MeJ 1998, JJ8.J47
weq IC, et.ol. N oql I MeJ 1998, JJ8.J41 8tlel M, et.ol. IAMA 2010, J0J.865
lopozloo l, et.ol. N oql I MeJ 2010, J6J.1107
nCUS for neumothorax
169 Lrauma pauenLs had PCuS, Cx8, and chesL C1 for
pneumoLhorax
8esulLs (uS v Cx8, C1 = gold sLd")
ueLecuon: 33 v 16 (p<0.001)
PCuS found all moderaLe" pneumo's
lor ulLrasound
v = 87
nv = 93
8took Ok, et.ol. I ulttosoooJ MeJ 28.749, 2009
AkS Case 1
A 72 yo man wlLh a CCu exacerbauon falls nlv and ls
lnLubaLed by your parLner. osL-lnLubauon hypoLenslon had
been LreaLed wlLh 1L nS and Lurnlng Lhe LL Lo 0 (ACv, v
1

400, f 14 wlLh A8C: 88/46/7.43). ?ou are called laLer when
sedauon ls lled and Lhe pauenL becomes dlsLressed. Whlch
of Lhe followlng ls Lhe mosL llkely cause for hls resplraLory
dlsLress?

A. AcuLe pulmonary embollsm
8. 1enslon pneumoLhorax
C. 1he lnsplraLory Lhreshold load of auLoLL
u. CbsLrucuon of Lhe L11 by a plug of mucus
AutoLL
Lungs don'L empLy Lo l8C aL end-explrauon
usually assoclaLed wlLh alrow obsLrucuon
roblems:
lncreased WC8 and dlmculLy Lrlggerlng
8aroLrauma, hypoLenslon
?ou have Lo look for lL
ao
ao
a|v
a|v
!"#$$%"%& (%)(#!#*#!+
!"#$$%"%& (%)(#!#*#!+
0
0
-2
-2
x
y
z
ao
a|v
1IML
Venn|ator 1r|gger|ng
8oooet MI, et.ol. ctlt cote MeJ 21.18J, 199J
Neura||y Ad[usted Venn|atory Ass|st
nAvA lmproved vS
1rlgger delay: 178 v 69
ms
lnsplraLory ume excess:
204 v 126 ms
Asynchrony evenLs: 3.2
v 1.2 evenLs/mln
llpolllooJ l, et.ol. loteoslve cote MeJ 2011, J7.26J
Sv
nAvA
Unhappy anent
ACV: re- and ost-NM8
Adapnng Venn|ator to anent
Adapnng Venn|ator to anent
n|gh A|rway ressures
LqulpmenL malfuncuon
auenL eorL (eg, cough, bucklng")
CbsLrucuon ln Lhe Lublng (generally Lhe L11)
Change ln resplraLory mechanlcal properues (8
AW
,
C
L
, C
CW
, auLoLL)
cbeck 11 poteocy ooJ posluoo, ttocbeol Jevlouoo, 85, looq sllJloq, c\k, mecboolcs.
cooslJet mote seJouoo/potolysls.
A 19 yo woman susLalned muluple gunshoL wounds Lo Lhe
abdomen, requlrlng surglcal repalr and Lransfuslon of 23 unlLs
88Cs. 1welve hours laLer venulaLor semngs are SlMv mode aL
a raLe of 16, udal volume 900 cc, LL 13, and llC
2
of 0.6. 1he
venulaLor peak alrway pressure ls 68 cm P
2
C. 8 ls 94/68, P8
138, 88 16 (paralyzed and sedaLed). urlne ouLpuL ls nll. 1he Cv
Lraclng ls shown:
AkS uesnon 2
AkS uesnon 2
Whlch one of Lhe followlng ls mosL llkely Lo lmprove Lhls
pauenL's blood pressure and sysLemlc perfuslon?

A. uecompresslve laparoLomy
8. lncrease Lhe noreplnephrlne lnfuslon Lo 60 mcg/mln
C. 1ransfuslon of 2 unlLs of packed red blood cells
u. Change Lhe venulaLor mode from SlMv Lo pressure-
conLrol, ad[usung Lhe pressure so as Lo malnLaln a slmllar
udal volume
L|evated ao: Systemanc Approach
Lxamlne Lhe ow and pressure waveforms:
ueLermlne wheLher Lhe pauenL ls acuve
Conrm LhaL udal volume and lnsplraLory ow are
normal
SeL a brlef (0.4s) end-lnsplraLory pause
ueLermlne Lhe dlerence beLween peak and plaLeau
ueLermlne Lhe dlerence beLween plaLeau and LL
Lxclude auLoLL
Does ao Ia|| When I|ow Stops?
Does ao Ia|| When I|ow Stops?
*
plaLeau
peak
L|evated ao: Systemanc Approach
Large peak-plaLeau
narrowed L11
8ronchospasm
non-reverslble alrow
obsLrucuon
Large plaLeau-LL
ulmonary edema
ALl/A8uS
ulmonary brosls
neumoLhorax
Ma[or aLelecLasls
1ense asclLes
ACS
C
RS
C
L
C
CW
*
*
Peso
INFLATION
DEFLATION
AkS 3: Asthmanc's
AC
|s n|gh!
A 23 year old asLhmauc ls venulaLed for sLaLus asLhmaucus.
now sedaLed and muscle-relaxed, Lhe venulaLor ls seL on
vACv wlLh a v
1
300 mL, raLe 20, and consLanL lnsplraLory
ow (square wave) of 60 L/mln. 8lood gas analysls shows:
C
2
160, CC
2
62, pP 7.18. 1he peak alrway pressure ls 38,
Lhe plaLeau pressure 28, and auLoLL 9.

Whlch one of Lhe followlng should you do now?

A. lncrease Lhe raLe from 20 Lo 32
8. Change Lhe ow Lo deceleraung
C. Change Lhe mode Lo Cv
u. no addluonal changes
50
51
52
53
54
55
56
P
P
E
A
K

(
c
m

H
2
O
)
13
15
17
19
21
23
P
P
L
A
T

(
c
m

H
2
O
)
10 16 26
0
400
800
1200
1600
V
E
(L/min)
V
E
E

(
m
L
)
nlne sub[ecLs wlLh asLhma or
CCu, paralyzed
Apnea (40s) Lo measure
hyperlnauon (v
LL
above
l8C)
normocapnla requlred v
L
=
16L/mln
7/9 hypoLenslve aL
normocapnla
v
L
musL be < 8L/mln Lo
assure accepLable v
LL
1oxeo uv, looe 5. Am kev kesplt uls 1J6. 872, 1987
ao
1IML
80
,"%((-"% ./."0
V
.
x
1| 1| 1e 1e
I|ow kate and I|ow roh|e

LAk
=
ALVLCLAk

LAk

(cm P
2
C)
o
30
100
Low-ressure A|arm
ulsconnecLed L11, Lrach
Malposluoned L11, Lrach
Leak ln venulaLor, lnsplraLory llmb, ?
8upLured L11 or Lrach cu
8ronchopleural sLula
vlgorous pauenL eorL
nooJ-boqqloq ls polckly teveolloq
AkS Case 4: nypoxem|a
A 29 year old woman develops severe A8uS followlng a
moLor vehlcle accldenL. Cn vACv wlLh vL 6 mL/kg and
88 30 Lhe aC
2
ls 80 on llC
2
0.8. LL values hlgher
Lhan 10 do noL ralse Lhe /l. She ls sedaLed and
appears comforLable. 1he Cx8 shows a dluse lung
leslon.
AkS Case 4: nypoxem|a
Whlch of Lhe followlng Lheraples ralses /l and reduces
morLallLy when applled early?
A. A8v
8. lnhaled nC
C. rone posluonlng
u. Plgh-frequency venulauon

Worsened Cxygenanon
rogresslon of Lhe underlylng lung problem (eg,
deLerloraung A8uS)
new lung problem (vA, 1x, L)
Pypovenulauon ls never an adequaLe explanauon
new clrculaLory problem
cbeck A8C, veoulotot semoqs, 5cvO
2
, c\k,
mecboolcs, olttosoooJ
1he I
I
C
2
|s 1oo n|gh
1urn Lhe l
l
C
2
down
lncrease Lhe LL
8alse SvC
2
(dobuLamlne, 88Cs, paralysls)
8educe vC
2
AccepL a lower SaC
2
8escue measures
lnC, LCMC, PlCv, A8v
8ecrulLmenL maneuver
rone posluon
lnverse rauo venulauon
Aerosollzed prosLacyclln
SurfacLanL
rone os|non|ng (kC1 n=466)
A8uS wlLh /l < 130, sLablllzed 12 - 24h before lncluslon
Suplne v rone: 16h sesslons, begln wlLhln 1h of randomlzauon,
lung-proLecuve venulaLor semngs
Average 4 sesslons/sub[ecL, 73 of venulaLed ume was prone
rone lmproved /l, morLallLy, vlus, and need for rescue
wlLhouL ralslng compllcauons
Cotlo c, et.ol. NIM 201J, epob
IkV: Usua||y AkV
l8v ralses mean alrway pressure, boosung C
2
Semngs:
Pl
= 22-30,
LCW
= 0-3, 1
Pl
= 3 sec, 88 11
A8v Lended Lo lncrease venL days, lCu LCS, and vA
(Moxwell kA, et.ol. I 1toomo 2010, 69.501)
BiPAP; BiLevel; Bivent; DuoPaP; PCV+; BiPhasic
Aeroso||zed rostacyc||n vs |NC
A8uS sub[ecLs, n = 16
Mean dose:
rosLacyclln: 7.3 ng/kg/mln
lnC: 18ppm
/l: Slmllar augmenLauon (113 Lo 140)
Amean: Slmllar reducuon (33 Lo 32)
nearly ldenucal emcacy
wolmtotb u, et.ol. Am I kesplt ctlt cote 1996, 15J.991
|NC: Meta-ana|ys|s
Adhikari NKJ, et.al: BMJ 2007; 334:757
More renal
dysfunction
with iNO
kecru|tment Maneuvers
(summary of 20 stud|es)
Cxygenauon lmproves: /
l 231 v 139 (p < 0.001)
Compllance ls ralsed
marglnally (33 v 34 cc/cm
P
2
C, p = 0.03)
PypoLenslon or
desaLurauon compllcaLe
10 of 8Ms
CannoL recommend for or
agalnsL 8Ms
loo , et.ol. AIkccM 2008, 178.1156
Surfactant
osslbly lmproved oxygenauon (Lrend only, p=0.11)
AdulL calfacLanL Lrlal sLopped enrolmenL
Davidson WJ, et.al: Crit Care 2006; 10:R41
nypercapn|a
!
"
#
$
%
&
' ( (
(
=
T
D
T
V
V
V f
k CO V
PCO
1
2
.
2
8alslng f or v
1
(or A) may noL work and could be
harmful
cbeck 11, veoulotot semoqs, cN5, 1, mecboolcs, c\k, ootoll, volome
stote, 1-cO
2
Lessons from erm|ss|ve nypercapn|a
SedaLed A8uS pauenLs - pP lowered from 7.32 Lo
7.18 (ln 60mln):
mean Ao, v8 were unchanged
mean A, P8, C
1
, CC
2
, and SvC
2
rose
Sv8 fell
changes abaLed by 36h
Slmllar ndlngs from muluple sLudles

cotvolbo ckk. AIkccM 156.1458, 1997
1boteos I-8. loteoslve cote MeJ 22.182, 1996
kooletl vM. Aoestbesloloqy 8J.710, 1995
loybosset l. Aoestbesloloqy 80.1254, 1994
Mclotyte kc. I 1toomo J7.4JJ, 1994
1he AutoLL Won't Come Down
8ronchodllaLe
use hellox
venulaLor semngs:
*8educe v
1
, 88 (< 10L/mln)
ShorL 1
l
, approprlaLe lnsp ow (60L/mln), generally noL
pressure-preseL mode
8alse LL
AccepL (and monlLor) lL
Max|m|z|ng 1
L
Dur|ng Mechan|ca|
Venn|anon
Dramanca||y ra|s|ng V
I

(to 120L]m|n) ra|ses
1
L
on|y to 3.7Ss

keduc|ng rate to
14 extends 1
L
to
3.8s
V
1
S00, kk 1S, V
I
60L]m|n
1
L
= 3.Ss
8ouom L|ne
ln a crlsls, separaLe Lhe complex venulaLor from Lhe
complex pauenL
Assure LhaL venulaLor semngs meeL Lhe pauenL's
demand (raLe, ow, Lrlgger)
Seek abnormallues ln mechanlcs (waveforms, check
auLoLL)
ln asLhma, avold Loo much venulauon
Lxclude common problems: 1x, malposluoned L11
Abbrev|anons
L11: LndoLracheal Lube
A8C: ArLerlal blood gas
LCC: LlecLrocardlogram
Cx8: ChesL radlograph
Lv: Lung proLecuve venulauon
peak: eak alrway pressure
plaL: laLeau alrway pressure
PlCv: Plgh frequency osclllaLory venulauon
PCuS: Pand-carrled ulLrasound
uS: ulLrasound
C1: CompuLed Lomography
nlv: nonlnvaslve venulauon
CCu: Chronlc obsLrucuve pulmonary dlsease
ACS: Abdomlnal comparLmenL syndrome
ALl: AcuLe lung ln[ury
A8uS: AcuLe resplraLory dlsLress syndrome
v
L
: MlnuLe venulauon
v
LL
: Lnd-explred lung volume
SvC2: Mlxed venous oxygen saLurauon
vC2: Cxygen consumpuon
88Cs: acked red blood cells
CC2: Cxygen dellvery
/l: 8auo of C2 Lo llC2
Ll: LxLracuon fracuon
v
u
: uead space
ACv: AsslsL conLrol mode
l8C: luncuonal resldual capaclLy
alv: Alveolar pressure
ao: Alrway openlng pressure
nAvA: neurally ad[usLed venulaLor asslsL
vS: auenL-venulaLor synchrony
Sv: ressure supporL venulauon
nM8: neuromuscular blockers
8aw: Alrways reslsLance
C
L
: Lung compllance
C
CW
: ChesL wall compllance
eso: Lsophageal pressure
C
8S
: Compllance of Lhe resplraLory sysLem
vACv: volume aslsL-conLrol mode
Cv: ressure conLrol mode
vA: venulaLor assoclaLed pneumonla
1x: neumoLhorax
L: ulmonary embollsm
ScvC2: CenLral venous oxygen saLurauon
lnC: lnhaled nlLrlc oxlde
A8v: Alrway pressure release venulauon
LCMC: LxLracorporeal membrane oxygenauon
l8v: lnverse rauo venulauon
8C1: 8andomlzed conLrolled Lrlal
1L: LxplraLory ume