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Which Dial Do I Turn!?

The Essence of Mechanical Ventilation
Peter DeBlieux, MD, FACEP LSUHSC Charity Hospital

Objectives
• Describe initial ventilator settings and management of different types of patients • Identify measures to optimize the mechanical ventilation while the patient is in the ED • Describe the approach toward and identify patients who may benefit from noninvasive ventilation strategies

Invasive Mechanical Ventilation
• Volume cycled

• Pressure cycled • Combined Pressure and Volume cycled

Modes of Mechanical Ventilation
• CPAP • Control • Assist Control • SIMV • Pressure Support • SIMV with Pressure Support

CPAP
• Continuous positive airway pressure • Equivalent to PEEP • May be used in conjunction with pressure support • Requires a spontaneously breathing patient

CPAP • Decreases the work of breathing by reducing inspiratory work • Increases total lung volume • Offers no back up rate • Variable tidal volume dictated by effort .

CPAP Mode Lung Volume Airway Pressure Time .

Control • Every breath is machine initiated and dictated • Fixed tidal volume with each breath • No utility outside of the operating room .

Control Mode Lung Volume Airway Pressure M M M M Time .

Assist Control • Preset rate and tidal volume • For each additional triggered attempt the ventilator will deliver a standard tidal volume breath • Initial mode of choice for respiratory failure .

Assist Control Mode Lung Volume Airway Pressure M M P P Time .

• Synchronized intermittent mandatory ventilation • Preset rate and tidal volume synchronized to the patient’s efforts • For each additional triggered attempt the ventilator will deliver a variable tidal volume breath dictated by patient effort and not ventilator supported SIMV .

SIMV Mode Lung Volume Airway Pressure M M P P Time .

chest wall.Pressure Support • Preset pressure boost on inspiration • Delivery of a variable tidal volume based on lung. ventilator system compliance and patient effort • Requires a spontaneously breathing patient .

SIMV with Pressure Support • Offers the benefits of pressure support with the security of a back-up rate • Pressure support is delivered each time the patient generates a negative inspiratory effort .

SIMV + PSV Lung Volume Airway Pressure M M P P Time .

CPAP + PSV Lung Volume Airway Pressure P P P P Time .

161:1450-1458 . and where do I set them? Am J Respir Care Med 2000.What knobs do I need to know.

Respiratory Rate • Typically set 10-20 bpm • Must be set in consideration of tidal volume as the product results in minute ventilation • Caution in reactive airways disease .

Respiratory Rate RR = 20 (resp cycle 3 seconds) I E RR = 12 (resp cycle 5 seconds I E .

Tidal Volume • 8-10 cc/kg ideal body weight • Factors together with respiratory rate to produce minute ventilation • Consider reductions in patients with reactive airways disease or multilobar infiltrates to 6-8 cc/kg .

PEEP • Positive end expiratory pressure • Increases residual volumes and total lung volumes • 5 cm H2O is considered physiologic by some and unnecessary by others • High levels may limit venous return and potentially injure the lung .

Alveolar Distention PEEP Good U g l y 6 cc/kg 10-15 cc/kg Bad •Increasing Tidal Volume and Plateau Pressure •Overdistending healthy alveoli .

FIO2 • Positive pressure ventilation alters the normal pulmonary physiology • Start with 100% FIO2 and titrate to pulse oximetry • Lung injury due to high levels of oxygen occurs at prolonged time greater than 24 hours at FIO2 greater than 70% .

Peak Flow • The speed that a tidal volume is delivered • Typically preset at 60 L/min • Increased from 80-120 L/min in those patients with reactive airways disease • May increase PIP but not plateau pressures .

the greater the work of breathing .Sensitivity • The ventilator’s ability to sense the patient’s inspiratory efforts • Measured in negative pressure cm H2 O • Typically set at -2 cm H2O • The more negative the pressure setting.

Settings Summary • Mode – Assist Control • Respiratory rate – 12-20 • Tidal volume – 8-10 cc/kg IBW • PEEP – 5 cm H2O • FIO2 – 100% • Peak flow – 60 L/min .

Lung Pressures • Peak Inspiratory Pressure (PIP)the highest inflection point reached during delivery of a breath • Dictated by system and patient compliance • No correlation with risk of lung injury .

the needle comes to rest at a point.Lung Pressures • Plateau Pressure .the plateau pressure • Reflects the pressure witnessed by the alveolus and correlates with the risk of lung injury > 30 cm H2O .if an inspiratory pause is placed at the end of inspiration.

Plateau Pressure Lung Volume Peak Airway Pressure Plateau Pressure Airway Pressure Time .

Adjustments • To affect oxygenation. adjust: –FiO2 –PEEP • To affect ventilation. adjust: –Respiratory rate –Tidal volume .

158:1831-1838 .Ventilator Induced Lung Injury • High Pressures • High Volumes • High FIO2 • Rapid Alveolar Opening • Alveolar Injury Am J Respir Crit Care Med 1998.

VILI • Bronchial rupture • Pneumothorax • Pneumomediastinum • Pulmonary interstitial emphysema • Air emboli N Engl J Med 2000 May 4.2000:213-252 .342(18):1301-8 / Resp Care Clin Nor Am 6:2.

bilevel positive airway pressure Chest 1998.Noninvasive Mechanical Ventilation •CPAP •BIPAP.113:1339 .

Requirements for NIPPV • Cooperative patient • Spontaneously breathing patient • FiO2 Requirements < 50% • Availability of equipment and therapist .

Contraindications to NIPPV • Rapid deterioration • Decreased mental status • Aspiration risks • Facial instability • Excess secretions Chest 1998.113:1339 .

His presenting GCS was a 12 and during your secondary survey you note a decrease in responsiveness and a reduction in his GCS to 8.. sustaining a closed head injury. Quickly he is intubated …. .Case One A 38 yo male presents with a history of MVC. a dilated right pupil and paralysis of his left side.

What are the recommendations for initial mechanical ventilator settings in a severely brain injured patient? .

Severe Brain Injury • Mode – __________ • Respiratory rate – ______ • Tidal volume – ____cc/kg IBW • PEEP – __cm H2O • FIO2 – ____% • Peak flow – ___L/min .

.Severely Brain Injured Maintain PCO2 between 32-28 cm H2O Temporary measure only to limit blood flow to the brain in hopes of reducing ICP. renal compensation within 12 hours.

. He presented with a respiratory rate of 4 and no gag reflex.Case Two A 52 year-old male presents somnolent with a depressed mental status following the ingestion of a fifth of whiskey and a full prescription of Valium.

What are the recommendations for initial mechanical ventilator settings in an intoxicated patient with depressed respiratory drive? .

Depressed Drive • Mode – __________ • Respiratory rate – ______ • Tidal volume – ____cc/kg IBW • PEEP – __cm H2O • FIO2 – ____% • Peak flow – ___L/min .

Depressed Drive • Aspiration risks remain in intubated patients Depressed mental status Lavage and charcoal Supine positioning .

Her clinical exam and PEFR is unchanged. . steroids. She is now anxious and confused. Despite continuous aerosol therapy. and magnesium.Case Three A 23 yo female with a history of asthma presents with acute onset of shortness of breath. oxygen. Her RR is 34 and she has an initial PEFR of 100.

What are the recommendations for mechanical ventilator settings in acute asthma? .

Reactive Airways • Mode – __________ • Respiratory rate – ______ • Tidal volume – ____cc/kg IBW • PEEP – __cm H2O • FIO2 – ____% • Peak flow – ___L/min .

.Case Four A 55 yo female presents with multilobar pneumonia extensively involving both lung fields. She is not maintaining oxygen saturations on 100% NRB and she begins to tire…….

What are the choices for patients with multilobar infiltrates. edema and extensive disease patterns? .

Multilobar Disease • Mode – __________ • Respiratory rate – ______ • Tidal volume – ____cc/kg IBW • PEEP – __cm H2O • FIO2 – ____% • Peak flow – ___L/min .

He sustained multiple rib fractures that created a flail segment and awaits CT scan of his head and abdomen. The mechanical ventilator begins to alarm and the nurse informs you his BP is 60/palp!! .Case Five A 30 yo male has just been placed on mechanical ventilation following a severe MVC.

How do you trouble shoot mechanical ventilators?? .

Trouble Shooting • Disconnect the patient from the ventilator and bag the patient with 100% oxygen • Confirm ETT placement-A • Auscultate the lungs-B • Consider other causes of circulatory compromise-C • Keep needle and tube thoracostomy kit handy .

mainstem. kink • Tension pneumothorax • Dynamic hyperinflation • Agitation • Equipment failure . plug. oxygen delivery. suction.Common Problems • ETT. nebulizer .extubation.ventilator.