mv complications
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Adverse Effects and Complications
of Mechanical Ventilation
Ibrahim Al-Sanouri,MD, FCCP, FAAAAI
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4 major concepts
` Know thy patient
` Know thy ventilator
` Put the ventilator between you and the patient` Alive ventilated patients
` The illness caused the need for mechanical ventilation
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MVcomplications
MechanicalsBiophysical
InflammatoryCytokines
Biochemical
MedicationModes
Disease
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Unable to Open Mouth
Trismus
Small mouth
Peri-oral scarring
Fascial swealling
Unable to insert laryngoscope
Short neckLarge chest
Prominent upper incisors
Small mandible
Edema
Unable to see glottis
Fixed position of the head
Small jaw
Anterior larynx
Obstructed by blood or vomit
Unable to pass tube into
trachea
Fixed Unrecognizable glottis
Too small glottis or sub-
glottic diameter
Trauma
Endobronchial
intubation
Esophageal intubation
Severe hypoxiaSevere hypotension
Death
Environment
No skilled help
No specialized equipments
Missing of defective
equipmentPoor positioning
Mechanical
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Maxillary Sinus and Middle Ear Effusion
` Maxillary effusion
` 20% in patients intubated for > 7 days and oral intubation or
oral gastric tubes` 47% when the gastric tube is placed nasally
` 95%
` Secondarily infected maxillary effusion (45-71% ofeffusions)
` Middle ear effusion (29%) with 22% of them become
infected` Hearing impairment that may contributes to the
confusion and delirium ion elderly population
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Pharyngo-laryngeal Dysfunction
` Post-extubation discomfort (40% regardless of theduration)
` Hoarsness
` 52% in short-term intubation
` 70% in patients with prolonged intubation
` Slowing of the reflex swallowing mechanism and risk ofaspiration
` 15.8% of patients who were intubated more than 4 days didnot have a gag refelex
` Silent aspiration:` 20% in young population
` 36% in older population
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Laryngeal Injuries
` Some degree of glottic injury is seen in 94% of patients
intubated for 4 days or longer
` Erosive ulcers of vocal cords (posterior commisure)` Swelling and edema of the vocal cords
` Granulomas (7% in patients intubated for 4 days or more)
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Tracheal Injuries
` Cuff pressure tracheal damage: tracheal ulceration, edema
and submucosal hemmorrhage
` Tracheal dilatation` Tracheal stenosis:
` At he site of the cuff (50%)
` At the site of the tracheostomy (35%)
` Unclear (15%)
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Cardiovascular Effects of
Mechanical Ventilation
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Decreased pressure Gradient for venous
return and decrease RV preload
PPV
Decreased CO due to decreased RV fi ll ing
Volume due to decreased venous
return
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-2 mm Hg
3 mm Hg
5 mm Hg
6 mm Hg
8 mm Hg
2 mm Hg
Effect of Positive Pressure Ventilation on
Right Atrial Distension
PPV
Decreased CO due to decreased RV fi ll ingVolume due to decrease RA compliance
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Spontaneous Ventilation
0
5
3
-3
120
0
10
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Spontaneous Ventilation
0
5
3
-3
110
0
8
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Hypotension following MV
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Cyclic BP effects is related to Volume
status
Ventilation on sick individual
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PPV could increase CO and BP
` Ventricular interdependence: decrease CO during
spontaneous breathing due to : increase RV filling volume
with shifting the intraventricular septum causing mechanicimpedance for LV decreasing its compliance causing
decrease CO and BP
` In this situation PEEP will be beneficial` Increase in transmural pressure of the great arteries in
the thorax, Transmural pressure represent how easy the
blood vessels could distend once accommodating for thestroke volume to enter
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Cyclic changes in Gas exchange and partial
pressures
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Hemodynamic effects of mechanical insufflations
.
End of inspiration
Maximum of
SBP, PP, Aortic velocity
End of inspiration
Minimum of
SBP, PP, Aortic velocity
Inc.
LV ejection
Dec.
LV ejection
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Effect of Mechanical Ventilation on
Pulmonary Vascular Resistance
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Effect of Changing Lung Volume on
Pulmonary Vascular Resistance
Pulm
onaryvascularResistance
Lung Volume
Total pulmonary vascular resistance
Intra-alveolar vaso-compression
Hypoxic vasoconstriction
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Effect of Lung Volume on RV afterload
` No effect in Normal indiidul with PEEP less than 10
cmH2o
` Major effect In patients with dynamic hyperinflaiton suchas asthmatic and COPD, and in pre-existing pumonary
hypertension
` Samll changes in PVR can cause considerablehaemodynamic comproise secondery toacute increase in
PVR
` Avoid gas traping in these patient
Know the patient, Know
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Alveolar pressure and Gas exchange
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Pleural pressure
Venous Return
V/Q Matching
LV afterload
Work of Breathing
Fully
Spontaneous
Partial
Ventilator
support
Fully
Controlled
Effects of PPV on hemodynamic
B d di d i i l
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Bradycardia and intra-arteriolar
vasodilatation
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Biochemical effect
of Mechanical VentilationInflammatory cytokines
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Inflammatory Biochemical injury
Local and systemic
Inflammation cascade
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Micro vascular, Alveolar Fracture
Hotchkiss et allCritical care Med, 2002
Prot for Gas and Bacteria
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Biochemical effect of MV
Pro- Inflammatory Cytokines during PPV
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Oxygen Toxicity
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` Tracheobronchitis
` Absorpetive atelctasis
` Hypercarbia` Diffuse alveolar damage
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Intrinsic PEEP, Auto PEEP
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Gastrointestinal Effects of
Mechanical Ventilation
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GI Effects of MV
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Esophagus, Stomach and Small Intestine
` Erosive esophagitis (30-50% of patients ventilated >48
hours)
`
NG tube` Poor lower esophageal sphincter tone and reflux
` Opiates and adrenergic agonists
`
Duodenogastroesophageal reflux through the action of trypsin` Upper gastrointestinal hemorrhage:
` Stress
` Decreased gastric mucosal protection secondary to a fall insplanchnic blood flow
` Decreased motility of stomach and small intestine
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Liver and Gallbladder
` Reduction in portal venous flow secondary to the fall in
cardiac output
`
Increased hepatic arterial flow hepatic arterial bufferresponse
` Normal total hepatic perfusion
` Hepatic engorgement` Venous ischemia and elevation of serum transaminases
and hyperbilirubinemia
` Reduction in drug clearance secondary to reduction of
hepatic blood flow
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Large Bowel
` Constipation
` Abdominal distension
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GI Effects of PPV
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Renal Functions during
Mechanical Ventilation
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Neurological Functions during
Mechanical Ventilation
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Acute Effects
` Vasoconstriction secondary to hypercapnia
` Decreased intra-cerebral blood volume and intracranial
pressure` PEEP reduces cerebral perfusion pressure by decreasing
venous return and increasing intracranial pressure
` 20-25% of is transmitted to the central venous pressure in anormal compliant lung
` >20% is transmitted in patients with decreased lung
compliance
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8 10 12 14 16 18 20 22 0 2 4 6 8
Stage 1
Stage 2
Stage 3
Stage 4
REM
Normal Sleep Pattern
H f P ti t M h i l
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8 10 12 14 16 18 20 22 0 2 4 6 8
Stage 1
Stage 2
Stage 3
Stage 4
REM
Hyponogram for a Patient on Mechanical
Ventilation
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0
100
200
300
100
Stage 1
Stage 2
Stage 3
Stage 4
REM
NonREM
Age 40 Age 40 MV
SleepTim
e(minutes)
M h i b hi h h i l
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Mechanisms by which mechanical
Ventilation Disrupt Sleep
` Noise disruption` Ventilator alarm:
` inappropriate threshold
` Delayed alarm inactivation` Humidifier alarms
` Disruption by nursing interventions` Airway suction
` Nebulizer delivery` Ventilation-related pharmacological disruption
` Benzodiazepines (REM, deep NREM)
` Oipoids (REM, deep NREM)
` Neuromuscular blocking drugs
` Ventilator mode` Pressure support ventilation
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Asynchrony with the patient
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Asynchrony with the ventiaitor
` Fighting the ventilators
` Inconsistent tidal volume
` Increase work of breathing
` Barotraumas and thoracic air leak` Insufficient gas exchange
` Disturbances in the cerebral blood flow
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Ventilation complications
Mode specific
CMV
CMV
IPPVIPPV
SIMV
SIMV
MMVMMV
BIPAPBIPAP
CPAP
CPAP
SPONT
SPONT
PCVPCV
VCVVCV
APRVAPRV
PLVPLVPSPS
ASBASB
ILV
PRVCPRVC
VAPSVAPS
PAV
PAV
What About New Modes?
Auto ModeAuto Mode
AutoFlowAutoFlow
PPSPPS
VSVS
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