Venti
- 1. MANAGEMENT OFPATIENTS ON MECHANICALVENTILATION DR. PINAKI MAZUMDERAssistant Professor , Dept. of Anesthesiology, Calcutta Medical College.
- 2. INDICATIONS OF MECHANICAL VENTILATION Inadequate tissue oxygenation Inadequate tissue perfusion Inadequate ventilationMECHANISM OF OXYGEN TRANSPORT
- 3. Inadequate oxygenationBronchospasm Pneumonia Pulmonary edema – ARDS, Heart FailurePneumothoraxInadequate PerfusionShock Haemorrhagic
- 4. Neurogenic (spinal injury)
- 5. Septic shock Inadequate ventilation Central cause Head injury
- 6. CVA
- 7. Meningitis/ Encephalitis Peripheral causePolyneuritis
- 10. Neurotoxic snake bite
- 11. Organophosphorus poisoningPurpose of ventilation Assist respiration Increase oxygenation Wash out CO2
- 12. Initiation of mechanical ventilationOral/ Nasal intubation
- 13. Tracheostomy for long term ventilation
- 14. Size of endotracheal tube
- 15. 8.0 to 8.5 mm for adult males
- 16. 7.0 to 7.5 mm for adult femalesChecklist prior to intubationPillow or 10 cm height block under the headSelf inflating AMBU bag with oxygen supplyFace maskLaryngoscope with different size bladesEndotracheal tubesStylet and Gum elastic bougieOral and nasal airwaysLaryngeal mask airwaySuction apparatusNecessary drugs
- 17. Oral tubes are secured at
- 20. Nasal tubes require 5 cm additional length.
- 21. Adhesive tape with counter-traction force for tube fixation
- 22. Head is kept at neutral position
- 23. Confirmation of tube position by x ray, capnography.Setting up of Ventilatory parameters Mode of ventilation Volume cycled Pressure cycled Time cycled
- 24. Volume/ Pressure cycled ventilation Controlled mode ventilation (CMV): delivers fixed volume/ pressure at fixed rate
- 25. Assist Control mode ventilation (ACV): delivers fixed volume/ pressure in response to spontaneous breath.
- 26. Synchronized Intermittent Mandatory ventilation (SIMV): delivers fixed volume / pressure at fixed rate synchronized with spontaneous breath.Initial Ventilator settingVolume controlled ACV most commonly used.parameters to be set Tidal volume :
- 29. Plateau pressure < 30 cm H2O
- 30. High volume -> barotrauma/volutrauma
- 31. Low volume -> lung collapseRespiratory rateNormally set at 10 – 14 /min
- 32. High rate ( 20 – 25/ min) in ARDS
- 33. Low rate for COPDMinute ventilation : 5 – 10 lt/minInspiration expiration ratio: 1:2 to 1: 3Oxygen concentration :start with 100% , decrease to 60 % to achieve SpO2 >90% or PaO2 > 60 mm Hg
- 34. Inspiratory flow rate : 40 – 60 lt/min Positive End Expiratory Pressure (PEEP) : prevents lung collapse and improves oxygenation
- 36. start with 3-5 cm H2O , increase up to 15 cm H2O
- 37. Activate all the alarms ( high pressure , low pressure , apnoea)Monitoring during ventilationOxygenation : SpO2 > 90% , Pa O2 > 60 mm HgVentilation: PaCO2 35- 40 mm HgTissue perfusion : Arterial pH 7.35 to 7.45
- 39. Plasma lactateAirway pressure Peak Inspiratory Airway Pressure ( PiAP)End Inspiratory Plateau Pressure ( PiEP) When peak pressure increases but plateau pressure is unchanged , it indicates increased airway resistance; manage with tube suction with or without bronchodilator nebulization.If peak and plateau pressure both are increased it indicates decreased lung or chest wall compliance.
- 40. Additional monitoringFlowchart of vital signs
- 42. Tidal volume
- 46. Static and Dynamic compliance
- 47. Gas exchange parameters- PaO2. FiO2 periodically recorded.
- 48. Goal of VentilationAdequate oxygenation and ventilationPrevent oxygen toxicity by using FiO2 < 0.6Use PEEP in refractory hypoxiaMaintain normal blood volume, pump function, cardiovascular parameters.Adequate Hb concentrationHumidification of the inspired gasFrequent aseptic tracheo-bronchial suctionGood physiotherapy and Organ support.
- 49. Problems during VentilationAsynchrony between patient and ventilator :Reassure the patient , give sedative analgesic.Increase minute ventilationGive higher FiO2Increase inspiratory flow rate Manually ventilate with 100% oxygen for 5 minutes- if severe resistance felt, change the tube.Rule out associated problems- acidosis, electrolyte disorders, pain, fever , shock, full bladder or stomach.Neuromuscular blocker - as last resort.
- 50. Managing alarm system Low airway pressure alarm
- 51. Disconnection/ leak in circuit
- 52. Leakage in cuff
- 54. High airway pressure alarm
- 55. Kinking /Blockade of ET tube/ tracheostomy tube
- 56. Bronchospasm
- 57. Decreased lung compliance
- 58. Oxygen alarm
- 59. Apnoea alarmHypotension due to high inflation pressure , PEEP , COPD .
- 60. Preexisting hypovolemia Rx : fluid, vasopressorsInfection control Hand washing
- 61. Aseptic suction
- 62. Physiotherapy
- 63. Postural drainage
- 64. Sterilization of humidifier/breathing circuitGastro intestinal complications Gastric distension GI bleedingWater retentionPressure sore
- 65. Weaning from ventilatorPatient clinically stable ,underlying disease improvedPaO2 > 70 mmHg , PCO2 < 45 mm Hg on FiO2 0.4 , acid base status, electrolytes, blood biochemistry, and chest x ray are near normal Hemodynamically stableNo fever or Organ failure or BleedingNutritional status is goodNeuromuscular function is adequate.bedside test: if respiratory rate > 30 or tidal volume < 300 ml then continue ventilation
- 66. Modes of weaningPatient connected to ventilator Pressure Support Ventilation (PSV) SIMV with gradual decrease of rate.Patient removed from ventilator Daily T piece trial of 60 mins or initial 15 – 30 mins trial followed by progressive increase in trial duration over the whole day.Extubate if no respiratory distress / clinically stable.
- 67. Thank you.