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Lungs as a two compartment model
• First compartment: AIRWAYS.
– Do not participate in gas exchange – referred as anatomic dead space
• Second compartment: ALVEOLAR UNITS
– responsible for gas exchange
resistance = Dpressure / Dflow
transairway pressure transrespiratory pressure volume transthoracic pressure
Elastance (compliance) = Dpressure / Dvolume
Normal lung is both compliant AND elastic .Lung Compliance and Elasticity Compliance is ability of lungs to stretch Low compliance in fibrotic lungs (and other restrictive lung diseases) and when not enough surfactant Elasticity (= Elastance) is ability to return to original shape Low Elasticity in case of emphysema due to destruction of elastic fibers.
Airway Resistance • The walls of the conducting respiratory passageways have resistance to the normal flow of air into the lungs • The smaller the diameter. . Physical properties of the gas Radius of the airway. the greater the resistance • Any condition that obstructs the air passageway increases resistance. • determined by 4 factors: – – – – Flow rate Length of the airway. and more pressure is generated to force air through (increasing the PiP) • difference of pressure between mouth and alveoli.
Compliance • How volume changes as a result of pressure change (C = V/P) • Describes distensibility of the system • PPlat – Represents the static end inspiratory recoil pressure of the respiratory system. lung and chest wall respectively – Measures the static compliance or elastance 6 .
Assessment and Documentation of MV • Monitoring Airway Pressures – Peak Inspiratory Pressure (PIP or PPeak) • The highest pressure observed during inspiration • Used to calculate dynamic compliance (CD) • A constant VT with an PIP may indicate a in lung compliance (CL) or an in Raw • A declining PIP may indicate a leak or may a sign of improvement in CL or Raw .
Peak and Plateau Pressures: Pattern Recognition • PiP with a Normal Pplateau = Increased Raw • ETT trouble. Effusions. Bronchospasm • Give Bronchodilators • PiP with a Pplateau = Decreased Compliance • ARDS. P/F . … • Check synchronous expansion. Pneumothorax. IPF. BS.
Oxygenation Basics .
Gas concentration in alveoli Maximum ventilation Normal Alveolar PO2 Normal Alveolar PCO2 PO2 Normal Hyper oxygenation PCO2 Alveolar ventilation Alveolar ventilation • Determined by: – absorption or excretion of gas – level of alveolar ventilation • Opening pressures (low inflection) • Collapsing pressures • Interventions –Fi02 –Ventilation •MaP •PEEP .
Ventilation Basics .
Simple terms • Ventilatory Modes – CMV. SIMV. CPAP. PCV • Adjuncts to Mechanical Ventilation – PEEP. A/C. IMV. PSV .
the limit of the support is determined by a preset pressure OR volume.Modes • Whenever a breath is supported by the ventilator. regardless of the mode. – Volume Limited: preset tidal volume – Pressure Limited: preset PIP or PAP .
Assist Control Modes .
. with a minimum set rate and all triggered breaths above that rate fully supported.Modes • Control Mode: – Every breath is fully supported by the ventilator – In classic control modes. machines act in assist-control. patients were unable to breathe except at the controlled set rate – In newer control modes.
The Control VariableInspiratory Breath Delivery • Flow (volume) controlled – pressure may vary • Pressure controlled – flow and volume may vary • Time controlled (HFOV) – pressure. flow. volume may vary .
if pressure is set...according to the compliance….Mechanical Ventilation • If volume is set.. • COMPLIANCE = D Volume / D Pressure . • …. volume varies….. pressure varies….
cycled by time or patient effort • Indicated when full ventilatory support is needed.Assist Control • Pt. 2 cm H2O) • EVERY breath receives desired VT or PC . minimal (ie. used when pt. always receives a mechanical breath. has a stable respiratory drive (10-12 spontaneous rate) • Patient does ONLY the work necessary to “trigger” the vent – Typically.
Control Modes • Assist/Control (usually abbreviated A/C) • AC. Volume – Tidal Volume is set and remains constant – Respiratory Rate is set – Patient may initiate a ventilator breath beyond set rate – Airway Pressure varies according to lung compliance – Ventilator will deliver set volume whether patient triggers a breath or mandatory breath is being delivered .
flow profile (constant or decel) – PEEP and FIO2 • Mandatory breaths – Ventilator delivers preset volume and preset flow rate at a set back-up rate • Spontaneous breaths – Additional cycles can be triggered by the patient but otherwise are identical to the mandatory breath. TI or flow rate.Assist-control: Volume • Set variables – Volume. . frequency.
& Wood LDH(eds.): Principles of Critical Care . in Hall JB.Assist-control. volume Ingento EP & Drazen J: Mechanical Ventilators. Scmidt GA.
Assist Control/Volume Control Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger .
Assist Control/Volume Control: Pressure /time relationsip Both breaths receive the set tidal volume Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger 0 1 2 3 4 5 6 7 8 .
Assist Control/Volume Control Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger .
Assist Control/Volume Control: Pressure measures Both breaths receive the set tidal volume Mandatory Ventilator Breath On time Ventilator Assist Spontaneous trigger Peak pressure depends on the flow rate. tidal volume and lung mechanics 0 1 2 3 4 5 6 7 8 PEEP is the start and finish pressure .
When to use PC. AC .
Lung Compliance and Elasticity • Compliance is ability of lungs to stretch – Low compliance in fibrotic lungs (and other restrictive lung diseases) and when not enough surfactant • Elasticity ( Elastance) is ability to return to original shape • Normal lung is both compliant AND elastic .
Measuring pressures • PIP (Peak Inspiratory Pressure) – Highest proximal airway pressure reached during inspiration • MAP (Mean Airway Pressure) – Average proximal airway pressure during the entire respiratory cycle. major determinate for oxygenation • Plateau Pressure – Airway pressure measured during an inspiratory hold. Used to determine a patient’s static lung compliance .
Inspiratory Hold: PIP and Plateau pressures (VC) Peak Pressure Plateau Proximal airway pressure Inspiratory Hold .
.Resistance vs......... Compliance Load Peak Pressure (Resistance) Proximal airway pressure Plateau (Distendability) Inspiratory Hold ..
• Pressure Control Ventilation (usually abbreviated PCV or sometimes PCIRV)
– Upper Airway Pressure Level is set and remains constant – Respiratory Rate is set – Tidal volumes will vary according to lung compliance – Ventilator will deliver gas flow to set pressure level whether patient triggers a breath or mandatory breath is being delivered – A lung protective mode
Lucangelo, Respir Care 2005; 50:55
Pressure Control Breath Types
cmH20 -20 120
Volume/Flow Control Inspiration 20 Pressure Control Inspiration 20 Expiration Expiration Paw Pressure 0 20 1 Paw 2 0 0 20 1 2 Volume 0 3 0 1 2 0 3 0 1 2 Flow 0 Time (s) 0 Time (s) -3 -3 .
however may or may not remain constant – Respiratory Rate is set – Ventilator will deliver volume according to patient’s lung compliance – A lung protective mode .Pressure Regulated VC • Pressure Regulated Volume Control (usually abbreviated PRVC) – Tidal Volume is set.
Volume vs… Pressure Control Ventilation Volume Ventilation • Volume delivery constant • Inspiratory pressure varies • Inspiratory flow constant • Inspiratory time determined by set flow and VT Pressure Ventilation • Volume delivery varies • Inspiratory pressure constant • Inspiratory flow varies • Inspiratory time set by clinician .
PAP) – Decelerating flow pattern (lower PIP for same TV) • Volume Limited – Control minute ventilation – Still can influence oxygenation somewhat (FiO2. I-time) – Square wave flow pattern .Pressure vs. PEEP. Volume • Pressure Limited – Control FiO2 and MAP (oxygenation) – Still can influence ventilation somewhat (respiratory rate.
Volume • Pressure Pitfalls – tidal volume by change suddenly as patient’s compliance changes – this can lead to hypoventilation or overexpansion of the lung – if ETT is obstructed acutely. delivered tidal volume will decrease • Volume Vitriol – no limit per se on PIP (usually vent will have upper pressure limit) – square wave(constant) flow pattern results in higher PIP for same tidal volume as compared to Pressure modes .Pressure vs.
Dealers Choice • Pressure Control – FiO2 – Rate – I-time – PEEP – PIP • Volume Control – FiO2 – Rate – Tidal Volume – PEEP – I time MV MAP .
Why PEEP? • PEEP will decrease the cardiac output more critically and will also cause an increase in mPaw • Why is this? – PEEP is always used with positive pressure ventilation – CPAP is used with spontaneously breathing patients .
5 – 1.Assessment and Documentation of MV • Monitoring Airway Pressures – Plateau Pressure (PPlateau) • Obtained by using the ventilator’s inspiratory pause of 0.5 seconds • Static pressure is read when no gas flow is occurring • Reflects the elastic recoil of the alveolar walls and thoracic cage against the volume of air in the lungs • Cannot be measured accurately if the patient makes active respiratory efforts .
Pplat and FRC • Measured by occluding the ventilator 3-5 sec at the end of inspiration • Should not exceed 30 cmH2O .
Peak and Plateau Pressures • Avoid: – Ppeak > 45 cm H2O – Pplateau > 32 cm H2O .
IPF. Effusions. Bronchospasm • Give Bronchodilators • PiP with a Pplateau = Decreased Compliance • ARDS. BS. P/F . … • Check synchronous expansion. Pneumothorax.Peak and Plateau Pressures: Pattern Recognition • PiP with a Normal Pplateau = Increased Raw • ETT trouble.
SIMV. or PCV • Referred to as CPAP when applied to spontaneous breaths . positive pressure such that at end exhalation. airway pressure does not return to a 0 baseline • Used with other mechanical ventilation modes such as A/C.PEEP • Definition – Positive end expiratory pressure – Application of a constant.
PEEP • Increases functional residual capacity (FRC) and improves oxygenation – Recruits collapsed alveoli – Splints and distends patent alveoli – Redistributes lung fluid from alveoli to perivascular space 5 cm H2O PEEP .
Problems with Auto-PEEP • Increased Pplat and over-distention – Increase work-of-breathing – Hemodynamic effects – Pneumothorax • Difficulty triggering ventilator .
PEEP • Increases the PIP and mPaw • In a study where PEEP was increased to 15cmH20 over 90 sec. the CVP and PAP had a considerable increase while the aortic pressure and CO decreased drastically. • PEEP is used with PPV • If a decrease in CO is seen due to PPV and PEEP intravascular volume expansion and positive inotropic agents can be used .
Supportive Modes of Ventilation • Synchronized Intermittent Mandatory Ventilation (SIMV) – Tidal Volume/ Pressure control is set and delivered on each mandatory breath – Respiratory Rate is set – When a patient triggers the ventilator spontaneously . the patient receives a Pressure Supported breath .
Alternatively. mandated frequency – PEEP. aided by the selected level of pressure support . FIO2. Ti). pressure support • Mandatory breaths – Ventilator delivers a fixed number of cycles with a preset volume at preset flow rate. a preset pressure is applied for a specified Ti • Spontaneous breaths – Unrestricted number.SIMV • Key set variables – Targeted volume (or pressure target). flow rate (or inspiratory time.
Synchronized Intermittent Mandatory Ventilation (SIMV) Mandatory Ventilator Breath On time Fixed volume Spontaneous breath No ventilator assist Variable volume 0 1 2 3 4 5 6 7 8 .
tidal volume and lung mechanics Peak pressure not applicable .Synchronized Intermittent Mandatory Ventilation (SIMV Peak pressure depends on the flow rate.
SIMV + Pressure Support Mandatory Ventilator Breath On time Set volume Spontaneous trigger Pressure Support Variable volume 0 1 2 3 4 5 6 7 8 .
PEEP) Initiate Terminate (cycled) Flow Pressure VT VT. RR (I:E) Pinsp. C VT I time constant (usually) decelerate rising constant fixed varies with compliance . RR (I time) (P)atient (C)ontrolled P.Basic Ventilator Modes MODE VC PC Orders (FIO2.
Types of Ventilation Volume Control Pressure Control A/C SIMV A/C PEEP SIMV Support .
When Patient requires aggressive Fi02 and/or PEEP.. . remember….
The Dangers of Overdistention • Repetitive shear stress – inflammatory response – air trapping • Phasic volume swings: volutrauma • Injury to normal alveoli .
The Dangers of Atelectasis • • • • • • compliance intrapulmonary shunt FiO2 WOB inflammatory response Give PEEP .
2000 .ARDS… Ware & Matthay NEJM.
J Clin Invest Dec 2002.Histopathology of VILI Belperio et al. 110(11):1703-1716 .
What is our Goal?? • Break the pulmonary injury sequence!!! – Lung Protection • Provide small alveolar volume swings • Provide minimal alveolar pressure swings • Provide lower peak airway pressures – Lung Recruitment • Open the lung with sustained inflation • Prevent alveolar collapse .
Lung Protective Ventilation Strategies Avoid regional over distension Avoid barotrauma Transpulmonary pressure < 35 cm H2O Avoid repeated opening/closing of airway PEEP Avoid oxygen toxicity FIO2 as low as possible Lung Recruitment Strategies: Recruitment manuevers HFOV Inverse Ratio Ventilation APRV:
• • • •
Role of Mechanical Ventilation in Lung Injury
Low or normal arterial CO2 Normal acid-base or alkalosis
Increasing tolerance for high or very high arterial CO2 Respiratory acidosis
Larger tidal volumes No PEEP
Small tidal volumes Optimal PEEP
O. – Recruits Alveoli – Improves FRC – Redistributes Pulmonary Edema Fluid – PaO2 • Bad…. – Venous Return / C.PEEP • Good…. – Risk of Barotrauma .
Downloaded from www.org .ardsnet.
Ventilation with lower tidal volumes as compared with traditional tidal volumes The Acute Respiratory Distress Syndrome Network 2000. • • • • • 861 patients randomly assigned to 6ml/kg or 12 ml/kg group 9 % decrease in mortality in low tidal volume group Targeted at 6 ml/kg PBW Range of 4-8 ml/kg depending on plateau pressures & pH Plateau pressures measured after 0.5 sec end-inspiration pause ≤ 30 cmH20 RESULTS • Lower tidal volumes (6ml/kg) decreased mortality in patients with acute lung injury and acute respiratory distress syndrome • Increased the number of days without ventilator use • Increased organ failure–free days • Decrease levels of IL-6 in low tidal volume group .
revised Jan. Mechanical Ventilator Summary.Guidelines from ARDS Network NIH NHLBI ARDS Clinical Network. 2005 .
Tidal Volume Strategies in ARDS Traditional Approach • High priority to traditional goals of acid-base balance and patient comfort • Lower priority to lung protection Low Stretch Approach • High priority to lung protection • Lower priority to traditional goals of acidbase balance and comfort .
Why aren’t all patients on PLV Compliance with LPV Before publication After publication Day 0 3% 1% Day 3 6% 3% Day 7 9% 7% • Changing Medical Practice is the Most Difficult Task – 6 ml/kg tidal volume ventilation for ARDS – Reasons for Non-Compliance • • • • Reluctance to give up control to a protocol Patient comfort Acidosis Oxygenation – Therefore: • Most patients with ARDS are not managed with LPV .
% of recruitable lung close to zero because normal function surfactant maintains alveolar units in a noncollapse status • The goal of OLC ↓collapse atelectasis and ↑optimal gas exchange .The open lung concept • ARDS multiple atelectasis. % of recruitable lung varied widely. the open lung concept (OLC) • In healthy lungs. from negligible to >50% • The treatment for alveolar collapse is lung recuitment.
then minimal pressure prevent lung from collapsing • Intrapulmonary suction renewed collapse of alveoli PaO2↓. must balance secretion management with alveolar recruitment • Early OLC ( < 72hrs ) higher response rate.The open lung concept • ↑initial inspiratory pressure recruit collapsed alveoli. related to the change from exudate to a fibroproliferative process .
PEEP • protection – Decreases atelectasis – PaO2 • recruitment – Recruits Alveoli – Improves FRC – PaO2 How Much PEEP? .
Always pursue the sweet spot! Overdistention 20 “Sweet Spot” 10 Atelectasis Airway Pressure (cmH20) 0 13 33 38 .
Conflicting Actions of Higher Airway Pressure • Lung Unit Recruitment and Maintenance of Aerated Volume – Gas exchange • Improved Oxygenation • Distribution of Ventilation – Lung protection • Parenchymal Damage • Airway trauma • Increased Lung Distention – Impaired Hemodynamics – Increased Dead Space – Potential to Increase Tissue Stress • …Only If Plateau Pressure Rises .
over an increment of time. . to recruit. open and keep open closed alveoli. to an injured lung.What is a Recruitment Maneuver? • A Recruitment Maneuver is a procedure where a sustained positive pressure is applied.
• *It is also done to re-recruit the lungs once there has been a break in the ventilation circuit.* . • To try and determine the “Optimal PEEP” to keep the lung from dynamic collapse and alveolar de-recruitment. help improve distribution of ventilation. and improve shunts.Why is Recruitment done? • Recruitment maneuvers are performed to help improve oxygenation.
but once open.Opening and Closing Pressures in ARDS High pressures may be needed to open some lung units. 50 40 Opening pressure Closing pressure From Crotti et al AJRCCM 2001. 30 % 20 10 0 0 5 10 15 20 25 30 35 40 45 50 Paw [cmH2O] . many units stay open at lower pressure.
Recruitment Maneuver • Purpose: Prolonged high alveolar pressure to recruit collapsed lung units • Procedure: PEEP 30 – 40 cm H2O for 2040 sec. (subsequent high PEEP to maintain recruitment • Repeat maneuver after a ventilator disconnect • Specific approach and safety to be determined .
• Improvements in lung mechanics. • Greater Tidal Volume for same pressure in (PC). – A 20% change or greater in PaO2/FIO2 • Improvements in intrapulmonary shunting. • Same Tidal Volume at less pressure in (VC). .How do you know it worked? • Improvements in oxygenation.
• *Rapidly counters the prolonged drop in PaO2 post suction.How do you know it worked? • Lower Plateau Pressure for the same Vt after a RM has been applied. • *Best after disconnection from ventilator or post suctioning. .
Conventional and Recruitment .
0. rate 20 • Recruitment maneuver: PEEP 40. PC34 (VT 300). FIO2 1. PaO2 21. pH 7. rate 10. Old woman transferred with sevr ARDS secondary to streptococcal sepsis: • BP 50/30. • Dramatic improvement in PaO2 and tidal volume PEEP 25 cm H2O needed to sustain recruitment • Extubated 6 days after.00. PaCO2 78. PC 20. I:E 1:1 for 2 minutes. PEEP 15.Recruitment Maneuver Case Study • 32 yr. . Discharged 2 wks after.
Finding the sweet spot… .
BiLevel is not APRV but Both are protective .
What is BiLevel Ventilation? • spontaneous breathing mode in which two levels of pressure hi/low are set • Substantial improvements for spontaneous breathing – better synchronization. and potential for improved monitoring . more options for supporting spontaneous breathing.
BiLevel Ventilation Spontaneous Breaths 60 Synchronized Transitions Spontaneous Breaths Paw cmH20 -20 1 2 3 4 5 6 7 .
PS supports spontaneous breath at upper pressure .What is BiLevel Ventilation? • At either pressure level the patient can breathe spontaneously – spontaneous breaths may be supported by PS – if PS is set higher than PEEPH.
BiLevel Ventilation PressHigh + PS 60 Press H Pressure Support Paw cmH20 -20 Press L 1 2 3 4 5 6 7 .
Then What Is APRV? • breathing mode in which two levels of pressure hi/low are set: • sudden short releases in pressure to rapidly reduce continuous opening and allow for ventilation (Ex. C02) • Can work in spontaneous or apneic patients • Difference between the two: APRV very short expiratory time for PRESSURE RELEASE • APRV looks like inverse I:E ratio • BUT spontaneous breathing is allowed ONLY at upper pressure level – TH 5-8 secs – TL 0.3 secs .
Airway Pressure Release Ventilation Waveform Pressure 50 Pressure hi Release time (Tlo) 25 Time high (Thi) 0 Pressure lo Time .
APRV (Airway Pressure Release Ventilation) • Indications • Partial to full ventilatory support • Patients with ALI/ARDS • Patients with refractory hypoxemia due to collapsed alveoli • Patients with massive atelectasis • May use with mild or no lung disease .
APRV (Airway Pressure Release Ventilation) • Advantages – Allows inverse ratio pressures (IRV) with or without spontaneous breathing (less need for sedation or paralysis) – Improves patient-ventilator synchrony if spontaneous breathing is present – Improves mean airway pressure – Improves oxygenation by stabilizing collapsed alveoli – Allows patients to breath spontaneously while continuing lung recruitment – Lowers PIP – May decrease physiologic deadspace .
COPD or asthma) – Auto-PEEP is usually present (and desired) – Caution should be used with hemodynamically unstable patients – Asynchrony can occur if spontaneous breaths are out of sync with release time – Requires the presence of an “active exhalation valve” .e..APRV (Airway Pressure Release Ventilation) • Disadvantages and Risks – Variable VT – Could be harmful to patients with high expiratory resistance (i.
T low.Maintaining Opening APRV .Principle of Operation • BiLevel (BIPAP.PCV+) – Preset RR. . • APRV – Preset T high. P high & P low – Switches between P high & P low – based on set time intervals. PEEP & Pip – Switches between press. IT. based on pt insp and exp.
OI = FiO2 x Paw PaO2
• Predictor of mortality • High value = bad outcome
Principles of Ventilation
Theoretical advantages of HFOV
• Smaller VT
– Limit alveolar overdistension
• Higher mean airway pressure (mPaw/Pmaw)
– More alveolar recruitment
• Constant mPaw during inspiration and expiration
– Preventing end-expiratory alveolar collapse
• Rapid rates (up to 900 baby breaths/min) • “lung protective” due to decreased volutrauma • more efficient conventional ventilation methods
the entire cycle operates in the “safe window” and avoids the injury zones INJURY HFOV INJURY .Pressure and Volume Swings During HFOV.
.When Should HFOV be Initiated? If FIO2 > .60 and PEEP > 10 cmH2O and unable to maintain SpO2 > 88% Unable to maintain Pplat < 30 cmH2O mPaw on CV is > 24 cmH2O Oxygen Index > 24 Patient requiring paralysis for oxygenation ARDSnet or APRV not providing improvement Earlier intervention produces better outcomes!!!! Derdak S et al. 2002. Am J Respir Crit Care Med.166:801-808.
Mechanics of HFOV • FORGET any thing you apply in any other ventilation support mode (except Fi02) • How does it work? – Gas Exchange • • • • MAP Power/Amplitude Frequency Inspiratory Time % 107 .
Oxygenation and Ventilation P (Amplitude) Hz (Frequency) mPaw (Mean Airway) 108 .
Mean Airway Pressure (mPaw) Amplitude (DP) Power Knob I-Time % Frequency (Hz) mPaw Bias Flow Adjust .
HFOV 3100B Mean Airway Pressure • Mean Airway Pressure (mPaw) is created by the continuous flow of gas 25-40 LPM .
HFOV 3100B Power/Amplitude • Amplitude is a measurement created by the force that the piston moves with based on the POWER setting. resulting in a volume displacement and a visual CHEST WIGGLE • It is represented by a peakto-trough pressure swing across the mean airway pressure • Primary control for ventilation (PaCO2 removal) .
HFOV Amplitude Attenuation proximal trachea alveoli P T .
the greater the volume displaced .HFOV 3100B Frequency/Hertz • Secondary control for ventilation • Frequency controls the time allowed for the piston to move forward and backward • Frequency has the largest impact on “tidal volume” than any other setting • The lower the frequency.
let us look at 2 different frequencies • 4 Hz • 8 Hz .Principles of Ventilation • Frequency – To evaluate the effects of changes in frequency with regards to CO2 elimination.
lower 4 Hz frequencies result in larger volume displacement which improves CO2 elimination 8 Hz .Principles of Ventilation Therefore.
HFOV 3100B Inspiratory Time % • % IT controls the time for the movement of the piston during inhalation and therefore can assist with ventilation • Increasing % IT may also have an impact on lung recruitment by increasing delivered mPaw Allows more time for piston travel resulting in larger tidal volume .
.Theory of Operation • Controls for Oxygenation and Ventilation are mutually exclusive • Oxygenation is primarily controlled by the Mean Airway Pressure (mPaw) and the FiO2 • Ventilation is primarily determined by – amplitude which effects stroke tidal volume (DeltaP) – frequency of the ventilator.
HFOV Simplified • CPAP with a wiggle – CPAP used to maintain Open Lung • control the CPAP level with mean airway pressure (mPaw) – “Wiggle” used to ventilate • We control the wiggle with amplitude (DP) .
Safe Zone Oscillations .
Principles of Ventilation .
4 PEEP < 5 At risk for pneumonia. atelectasis.4 PEEP > 5 P/F < 200 Fi02 > 0.5 PEEP > 10 Alternative ventilation pPlat > 35 CMV PC APRV Used with permission from B.Choosing Rotation Must not have contraindications CLRT or Kinetic Therapy Soft surface P/F > 300 Fi02 < 0. decubitius ulcer. immobility issues Roto Rest Platform Prone Roto Prone Prone P/F < 300 Fi02 > 0. McLean .
Vent settings to improve ventilation RR and TV are adjusted to maintain VE and PaCO2 • Respiratory rate • Max RR at 35 breaths/min • Efficiency of ventilation decreases with increasing RR • Decreased time for alveolar emptying • TV • Goal of 10 ml/kg • Risk of volutrauma • Other means to decrease PaCO2 • Reduce muscular activity/seizures • Minimizing exogenous carb load • Controlling hypermetabolic states • Permissive hypercapnea • Preferable to dangerously high RR and TV.15 . as long as pH > 7.
not PaO2. catheter) • May lead to ARDS • Rupture: PTX.Vent settings to improve oxygenation MawP and FiO2 are adjusted in tandem • Increased MawP • Increases FRC • Prevents progressive atelectasis and intrapulmonary shunting • Prevents repetitive opening/closing (injury) • Recruits collapsed alveoli and improves V/Q matching • Resolves intrapulmonary shunting • Improves compliance • Enables maintenance of adequate PaO2 at a safe FiO2 level • Disadvantages • Increases intrathoracic pressure (may require pulmonary a. . should be used to assess optimal PEEP. pulmonary edema Oxygen delivery (DO2).
Current Strategies for ARDS • Toolbox for this disease process – ARDSnet Study (6 ml/kg) • High PEEP lower Vt strategies – APRV. Bi-Vent – HFOV – Therapeutic Modalities • Lung Recruitment Maneuvers • Kinetic Therapy . Bi-Level.
Summary • • • • • • • Discuss. defend. discuss Protect Recruit turn turn turn oygenate? ventilate? flow that blood .
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