RESTROSPECTIVE STUDY July-September 2004

EVIDENCE BASED MEDICINE

IN
MANAGEMENT OF MECHANICAL VENTILATOR AT ICU ADAM MALIK
HOSPITAL MEDAN

by: Parhusip RS, Sitepu Sadarita

Respina, Jakarta Dec 8-11 2004

ICU / Pulmonology Department

School of Medicine University of Sumatra Utara
H. Adam Malik General Hospital
Medan
2004
 BACKGROUND
Evidence Based Medicine
Definition : Phylosophical Study of
Clinical Thinking

Problem-Based Evidence-Based
Learning Medicine
 Types : Evidence-based
(research Design)

I. Research design
II. Clinical trials
1. Bibliography III. Randomized 1. By Estimating
controled trials Probabilities
data base
2. CD-Room IV. Metanalysis 2. Applying
3. Recent article V. Cohort studies tatistical tools
VI. Case-control studies
Level of Evidence
Level 1 : Trial Multi Control Study
Single
Level 2 : Variety quash-experimental studies
Level 3 : Correlative descriptive study
Level 4 :
Level 5 :
(A, B, C, D, E: Grade)

Evaluation
Synthesis
Analysis
Application
Understanding
Knowledge-review
INTRODUCTION

Past:
Respiration inhaled O2 and exhaledCO2
(Alveolar ventilation)
 Now:

Pierson DJ. In: Foundations of Respiratory Care. 1992 Pierson DJ. In: Foundations of Respiratory Care. 1992
Mechanichal Ventilator :
1. NEGATIVE PRESSURE VENTILATION = NPV
2. POSITIVE PRESSURE :

a) Invasive
b) Non invasive
 NIVM (Non Invasif Ventilation Mecanical)
 NIPPV (Non Invasif Positive Pressure Ventilation)
Mechanical ventilation is defined as the use of a
mechanical device to assist the respiratory
muscles in the work of breathing and to improve
gas exchange.
In 1828 Leuy  Negative Pressure Ventilation.
In 1952 IBSEN  Negative Pressure Ventilation
 Poliomyelitis
In 1953 Vesalius  Positive Pressure Ventilation
(PPV).
METHOD
Retrospective study July – September 2004

TABLE 1
HOSPITALIZED PATIENT IN ICU
JULI-SEPT 2004

July August Sept Total

Amount of patient taken care of 21 20 15 56
Men 15 15 10 40 (71,4%)
Women 6 5 5 16 (28,6%)
Mean men patient age (year) 49 43 62 51
Mean woman patient age (year) 45 50 36 43
Using mechanic ventilator 11 7 4 22 (39,3%)
Amount of patient dying 15 14 9 38 (67,8%)

Evidence B
 TABLE 1A
Patient Distribution According to Previous Wards
July - September 2004

July August Sept Total

Emergency Room 9 10 13 22 (39,2%)

Neurologic Dept. 4 3 1 8 (14,2%)

Internal Med. 2 2 2 6 (10,7%)

Surgical Dept. 3 - 3 6 (10,7%)

Respiratory Dept. 2 2 1 5 (8,9%)

Obstetric Dept. 1 1 1 3 (5,3%)

Others 2 - 4 6 (10,7%)
Evidence B
 TABLE 2
Patients Distribution According to Case Presentation

July August Sept Total

Surgical Problem 10 9 4 23 (41,1%)

Respiration Problem 3 5 4 12 (21,4%)

Neurology Problem 5 2 4 11 (19,6%)

Interne Problem 2 4 6 (10,7%)

Obgyn Problem 1 2 3 (5,36%)

Evidence B
 TABLE 3
Average DATA MODE AND SETTING
VENTILATOR

Mode July August Sept Total

CMV - 3 - 3 (13.6%)

IPPV 3 1 3 7 (31.8%)
SIMV 2 8 2 12 (54.5%)

Evidence B

 Sugihartono, RS. Parhusip : Retrospective Study,

Jan – Dec. 2002, Management Mechanical
Ventilation In ICU Adam Malik Hospital Medan
DISCUSSION
A. Invasive Mechanical Ventilation
Indication to Use Mechanical Ventilation
Mechanical Approach to Respiratory Failure:
  Type I, Type II, Type III, Type IV,
Acute Ventilatory Perioperative Shock
Hypoxemia

Mechanism Qs/Qr VA Atelectasis Hypoperfusion

Etiology Airspace 1. CNS drive 1.FRC 1. Cardiogenic
  flooding 2. N-M 2. CV 2.Hypovolemic
    coupling   3. Septic
3. Work/dead-
Clinical Pulmonary space 1.Supine/obese,ascites/ 1. Myocardial
Description edema peritonitis,upper infarct,
Cardiogenic 1. abdominal incision, pulmonary
ARDS Overdose/CNS anesthesia hypertension
Pneumonia injury 2. Age/smoking, fluid 2. Hemorrhage,
Lung 2. Myasthenia overload, dehydration,
hemorrhage gravis, bronchospasm, airway temponade
polyradiculitis/ALS secretions 3Endotoxemia,
botulism/curare bacteremia
3.
Asthma/COPD,
pulmonary
Indication Absolute for Mechanical Ventilation:
• Cardiocirculatory arrest following cardiopulmonary
resuscitation.
• Stage III or IV coma.
• Poisoning by organic phosphates.
• Peripheral or central neurogenic respiratory paralysis.
• Intoxication by respiratory poisons.
• PaO2 < 45 mmHg despite 6 L O2 / min via oxygen prongs,
regard less of age.
• PaCO2 > 80 mmHg, regardless of patient’s age.
• Therapy-resistant tachypnea >35/min.
 Indications for Intubations and Invasive
Mechanical Ventilation:
• Apnea
• Impaired alveolar ventilation (as assessed by PaCO2) when
accompanied by one or more of the following:
- Depressed mental status
- Increasing fatigue
- reduced PaO2 that cannot other wise be corrected
- Compromise of upper airways (e.g. by secretion)
• Low PaO2 (e.g. less than 60 mmHg): a that cannot be
improved with an FIO2 less than 0.50 and b. that is causing
symptoms or seriously impairing bodily function.
SETTING
 Respiratory Rate
 Tidal Volume
 Inspiratory Pressure
 Fraction of Inspired Oxygen
 Flow Rate
 I:E
MODES
 VC
 AC
 SIMV
 PC
 PS
MODES

1. Controlled Mechanical Ventilation (CMV):

- CMV is included only for purpose of
instruction.
- The physician sets RR, TV, IFR.
- This mode works well for patients who are
unresponsive or heavily sedated.
- Not for conscious patients.
2. Assist-Control Mode:
Ventilator sens respiratory efforts by the patient.
Breaths are delivered automatically, regardless
of patient.
The patients receives a minimum number of
ventilator breaths synchronized to spontaneous
effort can increase that number ventilation
support.
3. Intermittent Mandatory Ventilation:

 The practitioner also sets FIO2, PEEP, and flow

rate.
 The patients can make inspiratory efforts between
the mandatory breaths.
 This mode of ventilatory support may be
comfortable for patients.
4. Pressure-Support Ventilation:
o The practitioner sets pressure-support level,
FIO2, and PEEP.
o PSV is often combined with SIMV.
o Pressure support ventilation provides a preset
level of inspiratory pressure assist with each
breath.
SETTING VENTILATOR
Respiratory Rate:
 Range for respiratory rate is between 4/min and
20/min.
 ARDS, the use of low tidal volumes sometimes
necessitates respiratory rates up to 35/min to maintain
adequate minute ventilation.

Tidal Volume:
 Setting tidal volume in volume-targed modes is 5 to 8
mL/kg of ideal body weight.
 In patients normal lungs who are intubated for other
reasons, slightly higher tidal volumes can be
considered: up to 12 mL/kg of ideal body weight.
Inspiratory Pressure:
 Generally set to keep the plateau pressure at or below
35 cm H2O.

Fraction of Inspired Oxygen:

 FIO2 should be 100% when the patients is first
intubated and placed on mechanical ventilation.
 Once proper tube placement is assured and the patients
has stabilized, FIO2 should be progresively reduced to
the lowest concentration that maintains adequate
oxygen saturation of hemoglobin.
 Maintaining oxygen saturation of 90% or more is the
usual goal.
B. NIPPV (Non Invasif Positive Pressure Ventilation)

Indication
Acute Respiratory Acidosis
Respiratory Distress
Patient Cooperative
Abdominal Paradox
Modes
Facial Mask
Nasal Mask
Discontinuation of Mechanical Ventilation
(Weaning Criteria):
1. Evidence for some reversal of the underlying cause
for respiratory failure.
2. Adequate oxygenation (eg. PaO2/HFiO2 ratio > 150 to
200: requiring positive end expiratory pressure
[PEEP]  5 to 8 cm H2O: FiO2 0.4 to 0.5): and pH
(e.g  7.25).
3. Hemodynamic stabil.
4. Cavability to initiate inspiratory efford.
Protocol Weaning of Mechanical Ventilation
Conclusion
RF  most common in ICU
EBM  Invasive Mechanical Ventilation
 Indication
 Setting
 Mode
 Weaning
 Non Invasive Mechanical Ventilation
 Indication
 Setting
 Mode
 Weaning
TYPE OF VENTILATOR
Type SC 9000XL SIEMENS:
Type SC 8000 SIEMENS:
Type 7200:
Galileo:
Non Invasive Ventilation Mechanical: