interfacing with the ventilator€¦ · interfacing with the ventilator david j. dries, mse, md...
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Interfacing With The
Ventilator
David J. Dries, MSE, MD
Assistant Medical Director
Surgical Care
HealthPartners Medical Group
Professor of Surgery & Anesthesiology
John F. Perry, Jr. Chair of Trauma Surgery
University of Minnesota
Regions Hospital - St. Paul, MN
The airway opens the
door to the critical care
unit…
Mechanical ventilation is
the defining event in
critical care medicine.
Spontaneous
Breathing
Extracorporeal
Pulmonary
Support
Nasal O2
Rebreather
Mask
Non-Rebreather
Mask
Mask Ventilation
Intubation and Mechanical
Ventilation
BIPAP CPAP
Continuum of Pulmonary Support
Respiratory Failure
• Intrinsic
– ARDS / ALI
• Cardiovascular
• Toxins
• Intrinsic
– Asthma / COPD
• Cardiovascular
• Anatomic
– OSA
• Neurologic
• Metabolic
Hypoxic Hypercarbic
Indications for Oral Intubation
The Gold Standard
• Emergent intubation (cardiopulmonary resuscitation, unconsciousness or apnea)
• Nasal or midfacial trauma
• Basilar skull fracture
• Epiglottitis
• Nasal obstruction
• Paranasal disease
• Bleeding diathesis
• Need for bronchoscopy
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 115
Indications for Nasal Intubation
The Old Standard
• Anticipated long-term translaryngeal tube
• Cervical spine ankylosis, arthritis or trauma
• Oral or mandibular trauma, surgery or deformity
• Temporomandibular joint disease
• Awake intubation
• Gagging and vomiting
• Short (bull) neck
• Agitation
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 115
How We Do It: Steps and Timing of Rapid Sequence Intubation in a 70 kg Adult
Step Timing Action
Preparation Zero – 10 min. Prepare equipment
Assess patient
Position personnel
Select drugs
Preoxygenation Zero – 5 min. Passive administration of high flow oxygen
via bag valve mask
Premedication Zero – 2 min. Lidocaine 100 mg IVP
Vecuronium 1.0 mg IVP
Etomidate 20 mg IVP
Paralysis Zero Succinylcholine 100 mg IVP
Placement Zero + 20 s
Zero + 45 s
Zero + 1 min.
Sellick’s maneuver
Intubation
Tube confirmation
In: Trauma, Six Edition, 2008, p.194
AIRWAY/REVIEW ARTICLE
Preoxygenation and Prevention of Desaturation During
Emergency Airway Management Scott D. Weingart, MD, Richard M. Levitan, MD
Ann Emerg Med 2012; 59:165-175
• 3 minutes / high FiO2
• CPAP / PEEP
• Head up
• Rocuronium vs Succinylcholine
• 8 minutes apnea
• Apnea – high flow O2
Ann Emerg Med 2012; 59:165-175
Oxyhemoglobin Dissocation Curve
Intubation
Physiologic Responses
• Heart rate
• Blood pressure
• Medications
– etomidate
– benzodiazepines
– ketamine
– propofol
Complications
• Local trauma
• Hypoxemia
• Aspiration
• Laryngospasm
• Bronchospasm
• Mainstem intubation
Indications for Supraglottic
Airways
Oral
• Removal of retropharyngeal secretions
• Maintain patency of orophryngeal airway
• Obtunded patient without gag
• Prevention of biting
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 116
In: Trauma, Sixth Edition, 2008, p.196-197
Indications for Supraglottic
Airways
Nasal
• Removal of supraglottic secretions
• Conscious or unconscious patient
• Need for repeated cannulation of trachea
• Limited value in preventing closure of the
retropharynx
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 116
NONINVASIVE POSITIVE-PRESSURE VENTILATION VS. MECHANICAL VENTILATINO IN ACUTE RESPIRATORY FAILURE
A COMPARISON OF NONINVASIVE POSITIVE-PRESSURE VENTILATION AND
CONVENTIONAL MECHANICAL VENTILATION IN PATIETNS WITH ACUTE
RESPIRATORY FAILURE
Massimo Antonelli, MD, Giorgio Contri, MD, Monica Rocco, MD, Maurizio Bufl, MD,
Roberto Alberto De Blasi, MD, Gabriella Vivino, MD, Alessandro Gasparetto, MD,
and Gianfranco Umberto Meduri, MD
N Engl J Med 1998; 339:429-435
NONINVASIVE POSITIVE-PRESSURE VENTILATION VS. MECHANICAL VENTILATINO IN ACUTE RESPIRATORY FAILURE
A COMPARISON OF NONINVASIVE POSITIVE-PRESSURE VENTILATION AND
CONVENTIONAL MECHANICAL VENTILATION IN PATIETNS WITH ACUTE
RESPIRATORY FAILURE
Massimo Antonelli, MD, Giorgio Contri, MD, Monica Rocco, MD, Maurizio Bufl, MD,
Roberto Alberto De Blasi, MD, Gabriella Vivino, MD, Alessandro Gasparetto, MD,
and Gianfranco Umberto Meduri, MD
N Engl J Med 1998; 339:429-435
Serious Complications
and Complications
Resulting in Death
Indications for Noninvasive
Ventilation
In: Evidence-Based Practice of Critical Care, 2010, p.23
Strength of
Recommendation
Indication for
Noninvasive Ventilation
Quality of
Evidence
Strong COPD exacerbations A
Acute cardiogenic pulmonary edema A
Immunocompromised states A
Facilitating extubation in COPD A
A = multiple randomized controlled trials showing benefit with NIV.
Indications for Noninvasive
Ventilation
In: Evidence-Based Practice of Critical Care, 2010, p.23
Strength of
Recommendation
Indication for
Noninvasive Ventilation
Quality of
Evidence
Intermediate Postoperative respiratory failure B
Preoxygenation in hypoxemic respiratory
failure
B
Facilitation of flexible bronchoscopy B
Palliation in DNR/DNI patients B
Postextubation respiratory failure B
B = single randomized trial or nonrandomized trails showing benefit with NIV.
Indications for Noninvasive
Ventilation
In: Evidence-Based Practice of Critical Care, 2010, p.23
Strength of
Recommendation
Indication for
Noninvasive Ventilation
Quality of
Evidence
Weak ALI / ARDS C
Neuromuscular disease C
Pneumonia C
Status asthmaticus C
C = conflicting evidence or evidence of harm with NIV.
Desirable Characteristics of a
Mask for Noninvasive Ventilation
• Low dead space
• Transparent
• Lightweight
• Easy to secure
• Adequate seal with low facial pressure
• Disposable or easy to clean
• Nonirritating to skin (nonallergenic)
• Inexpensive
Potential Advantages and Disadvantages to
Nasal vs Oronasal Masks
Oronasal
Advantages Disadvantages
Better oral leak control Increased dead space
Use for mouth breathers Difficult to maintain adequate seal
Risk of nasal and facial pressure sores
Claustrophobia
Increased aspiration risk
Increased difficulty speaking and eating
Asphyxiation with ventilator malfunction
More difficult to fit
Potential Advantages and Disadvantages to
Nasal vs Oronasal Masks
Nasal
Advantages Disadvantages
Less risk of aspiration Mouth leak
Easier secretion clearance Higher resistance through nasal passages
Less claustrophobia Less effective with nasal obstruction
Easier speech Nasal irritation and rhinorrhea
May be able to eat Mouth dryness
Easy to fit and secure Nasal bridge redness and ulceration
Less dead space
Problems Related to Masks During
NPPV
Oronasal Masks
Problem Incidence Remedy Mask discomfort 30-50% Minimize strap tension,
try different mask sizes,
or types
Claustrophobia 10-20% Reassure, switch to
different mask type
Skin rashes, nasal bridge 10-20% Same as for nasal mask
sores
Increased dead space depends on mask Insert foam rubber to
reduce dead space
Antiasphyxia valve
Aspiration/vomiting rare Quick release strap
Problems Related to Masks During
NPPV
Nasal Masks
Problem Incidence Remedy Mask discomfort 30-50% Adjust strap tension, reseat
mask, try different mask
size or type
Skin rashes 10-20% Topical steroids or
clindamycin, dermatologic
consultation
Nasal bridge sores 5-10% Minimize strap tension, use
forehead spacer, artificial
skin, switch to different
mask type
Nasal obstruction occasional Topical decongestants,
oronasal mask
Problems Related to Air Pressure and
Flow
Pressure
Problem Incidence Remedy Discomfort 20-50% Reduce inspiratory
pressure
Ear, sinus pain 10-20% Reduce inspiratory
pressure
Gastric insufflation 30-40% Reduce pressure,
simethacone, gastric suction
if ventilation impaired
Pneumothorax rare Avoid excessive inflation
pressures, consider
thoracostomy tube drainage
Problems Related to Air Pressure and
Flow
Flow
Problem Incidence Remedy Nasal/oral congestion 50% Topical steroids,
decongestants,
antihistamine/decongestant
combinations
Nasal/oral dryness 30-50% Nasal saline,
humidification, control of
air leaks
Eye irritation 33% Reduce air leakage, eye
emollients, try adjusting
strap tension, different
mask
Major Complications
Problem Occurrence Remedy Aspiration 5% Careful patient selection,
gastric drainage when
appropriate
Mucus plugging infrequent Careful patient selection,
adequate rehydration,
cough assistance,
respiratory treatments
Severe hypoxemia ** Proper patient selection,
high flow O2, increased
expiratory pressure
Hypotension infrequent Proper patient selection,
adequate hydration, lower
inspiratory pressures **Depends on etiology of respiratory failure.
Contraindications to Noninvasive
Ventilation
• Cardiopulmonary arrest, shock
• Uncontrolled cardiac ischemia or arrhythmias
• Uncooperative or agitated
• Severe upper gastrointestinal hemorrhage
• Coma, nonhypercapnic
• High aspiration risk, vomiting
• Copious secretions
• Upper airway obstruction
• Severe bulbar dysfunction
• Recent esophageal or upper airway surgery
• Multiorgan dysfunction
• Inability to fit mask due to craniofacial abnormalities
In: Evidence-Based Practice of Critical Care, 2010, p.22
Risk Factors for Failure of
Noninvasive Ventilation
• pH <7.25
• Respiratory rate >35
• APACHE II score >29
• ALI / ARDS
• Pneumonia
• Severe hypoxemia
• Shock
• Metabolic acidosis
• Impaired mental
status
In: Evidence-Based Practice of Critical Care, 2010, p.22
Predictors of Difficult Intubation
• Invisibility of faucial pillars, soft palate, uvula
• Mentohyoid distance less than three finger breadths
• Restricted temporomandibular joint excursion
• Restricted excursion of atlanto-occipital joint
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 120
In: Critical Care Study Guide: Text and Review, Second Edition, 2010, p.14
Mental Portion
Thyroid
Cartilage
Distance from mental portion of mandible to
the thyroid cartilage notch is known as
“thyromental distance”
Mallampati Structures Visible
Class I Class I soft palate, fauces, uvula, pillars
Class II Class II soft palate, fauces, uvula
Class III soft palate, base of uvula
Class III Class IV hard palate, soft palate not visible
Class I Class II Class III Class IV
Aids and Precautions for
Difficult Intubation
• Optimal positioning
• Availability of: – gum elastic bougies
– tracheal tubes of various sizes
– tube introducers
– varied types and sizes of laryngoscope blade
– lighted stylet
– LMA and cricothyroidotomy kit
• BURP maneuver
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 121
Distinguishing Tracheal From
Esophageal Intubation
• Conventional
– symmetrical breath sounds
– visualization of vocal cords during insertion
– ease of insufflation and recovery of tidal volume
– expiratory fogging of ET tube
– palpation of larynx
– loss of voice
– coughing of airway secretions through tube
– upper chest expansion
– absence of progressive abdominal distention
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 122
Distinguishing Tracheal From
Esophageal Intubation
• Devices and aids
– CO2 excretion color detector
– capnometry
– tidal gas recovery
– squeeze bulb syringe
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 122
CHEST Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Technologic Advances in Endotracheal Tube for
Prevention of Ventilator-Associated Pneumonia
Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP
The two most important mechanisms implicated in
the development of VAP are microaspiration and
biofilm formation.
Chest 2012; 142:231-238
• Microaspiration
– cuff pressure control
– ultrathin cuffs
• 7 μm vs >50 μm
– channel formation
– subglottic secretion drainage
Chest 2012; 142:231-238
CHEST Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Technologic Advances in Endotracheal Tube for
Prevention of Ventilator-Associated Pneumonia
Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP
• Subglottic secretion drainage
– VAP rate ↓ 50%
– +/- decrease ICU LOSA
– no change mortality
– mechanical integrity
– continuous vs intermittent suction
Chest 2012; 142:231-238
CHEST Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Technologic Advances in Endotracheal Tube for
Prevention of Ventilator-Associated Pneumonia
Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP
Continuous Aspiration of Subglottic Secretions in
Preventing Ventilator-Associated Pneumonia Jordi Vallés, MD; Antonio Artigas, MD; Jordi Rello, MD; Natalia Bonsoms, MD;
Dionisia Fontanals, PharmD; Lluis Blanch, MD; Rafael Fernández, MD; Francisco Baigorri, MD;
and Jaume Mestre, MD
Ann Intern Med 1995; 122:179-186
Diagram of continuous aspiration
of subglottic secretions.
Ann Intern Med 1995; 122:179-186
Proportion of Patients Remaining Without VAP
• Biofilm formation
– colonization within hours
– biofilm protective treatment
• antimicrobial coating
• silver
Chest 2012; 142:231-238
CHEST Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Technologic Advances in Endotracheal Tube for
Prevention of Ventilator-Associated Pneumonia
Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP
• Silver-coated tubes
– >1,500 patients studied
– VAP: silver : 4.8%; control : 7.5%
– delayed onset VAP
Chest 2012; 142:231-238
CHEST Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Technologic Advances in Endotracheal Tube for
Prevention of Ventilator-Associated Pneumonia
Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP
Silver-Coated Endotracheal Tubes and Incidence of
Ventilator-Associated Pneumonia
The NASCENT Randomized Trial
CARING FOR THE CRITICALLY
ILL PATIENT
Marin H. Kollef, MD
Bekele Afessa, MD Antonio
Anzueto, MD Christopher
Veremakis, MD Kim M.
Kerr, MD Benjamin D.
Margolis, MD Donald E.
Craven, MD Pamela R.
Roberts, MD Alejandro C.
Arroliga, MD Rolf D.
Hubmayr, MD Marcos I.
Restrepo, MD William R.
Auger, MD Regina
Schinner, Dipl-Stat For the
NASCENT Investigation
Group
JAMA 2008; 300:805-813
Silver-Coated Endotracheal Tubes and Incidence of
Ventilator-Associated Pneumonia
The NASCENT Randomized Trial
CARING FOR THE CRITICALLY
ILL PATIENT
Marin H. Kollef, MD
Bekele Afessa, MD Antonio
Anzueto, MD Christopher
Veremakis, MD Kim M.
Kerr, MD Benjamin D.
Margolis, MD Donald E.
Craven, MD Pamela R.
Roberts, MD Alejandro C.
Arroliga, MD Rolf D.
Hubmayr, MD Marcos I.
Restrepo, MD William R.
Auger, MD Regina
Schinner, Dipl-Stat For the
NASCENT Investigation
Group
JAMA 2008; 300:805-813
Incidence of Microbilogically Confirmed VAP
• Biofilm removal
– mucus shaver
– chlorhexidine
– gentian violet combinations
Chest 2012; 142:231-238
CHEST Postgraduate Education Corner
CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE
Technologic Advances in Endotracheal Tube for
Prevention of Ventilator-Associated Pneumonia
Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP
Acta oto-rhino-laryngologica bel., 1995, 49, 341-346
Prevention of postintubation laryngotracheal stenosis P. Ferdinande* and Dong-Ok Kim**
*Professor Department of Intensive Care Medicine, University Hospital, K.U. Leuven, Belgium;
**Assistant Professor of the Department of Anesthesiology, Kyung Hee University Hosiptal, Seoul, Korea
1. Pressure necrosis by overinflated endotracheal tube cuff
2. Endotracheal tube and cuff material, size and design
3. Duration of endotracheal intubation
4. Macrotrauma during insertion and microtrauma during maintenance
5. Technique of tracheal intubation
6. Severity of respiratory failure
7. Infection
8. Hemodynamic instability
CHEST Special Features
The Incidence of Dysphagia Following
Endotracheal Intubation
A Systematic Review
Stacey A. Skoretz, MSc; Heather L. Flowers, Med, MHSc;
and Rosemary Martino, MA, PhD
• 3-62%
• Prolonged intubation
• Effect of age
• Poor quality data
Chest 2010; 137:665-673
Translaryngeal Intubation versus Tracheostomy
Advantages
Translaryngeal Intubation Tracheostomy
Ease of placement Comfort
Inexpensive Ease of mouth care
Fewer severe complications Secretion removal
No specialized venue needed for insertion Stability
Less airway resistance
Improved communication
Ease of swallowing and enteral feeding
Reduced work of breathing
Improved mobility
Ease of reinsertion and ventilator
reconnection
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 127
Translaryngeal Intubation Tracheostomy
Discomfort Expense
Swallowing Severity of complications
Secretion clearance Swallowing impairment
Greater work of breathing Reduced cough efficiency postdecannulation
Impaired speech
Upper airway and larynx damage
Translaryngeal Intubation versus Tracheostomy
Disadvantages
In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 127
ORIGINAL ARTICLE
Early Tracheostomy in Intensive Care Unit: A Retrospective Study
of 506 Cases of Video-Guided Ciaglia Blue Rhino Tracheostomies
Giovanni Zagli, MD, PhD, Manuel Linden, MD, Rosario Spina, MD, Maneula Bonizzoli, MD,
Giovanni Cianchi, MD, Valentina Anichini, MD, Stefania Matano, MD,
Silvia Benemei, MD, Paola Nicoletti, MD, and Adriano Peris, MD
Kaplan-Meier curves of duration of MV days Kaplan-Meier curves of LOS days in the ICU
J Trauma 2010; 68:367-372
Duration of
MV
ICU LOS
clinical investigations in critical care
A Meta-analysis of Prospective Trials
Comparing Percutaneous and Surgical
Tracheostomy in Critically Ill Patients Bradley D. Freeman, MD; Karen Isabella, RN; Natatia Lin, BS; and Timothy G. Buchman, PhD, MD
Chest 2000; 118:1412-1418
ORs with 95% CIs
(represented by arrowheads and horizontal bars,
respectively) for operative and postoperative complications comparing SCT and PDT.
The effect of tracheostomy timing during critical illness on
long-term survival
Damon C. Scales, MD, PhD, FRCPC; Deva Thiruchelvam, MSc: Alexander Kiss, PhD; Donald
A. Redelmeier, MD, MSHSR, FRCPC, FACP
Crit Care Med 2008; 36:2547-2557
• 10 day threshold
• 10,927 patients
• Early tracheostomy – less mortality
– 1.008 x/day mortality
Survival of tracheostomized patients after initiation
of mechanical ventilation
Crit Care Med 2008; 36:2547-2557
The effect of tracheostomy timing during critical illness on
long-term survival
Damon C. Scales, MD, PhD, FRCPC; Deva Thiruchelvam, MSc: Alexander Kiss, PhD; Donald
A. Redelmeier, MD, MSHSR, FRCPC, FACP
Time from mechanical ventilation (day 1)
to death (months)
Time from mechanical ventilation (day 1)
to death (months)
Early vs Late Tracheotomy for Prevention of
Pneumonia in Mechanically Ventilated Adult
ICU Patients A Randomized Controlled Trial
CARING FOR THE CRITICALLY
ILL PATIENT
Pier Paolo Terragni, MD
Massimo Antonelli, MD
Roberto Fumagalli, MD
Chiara Faggiano, MD
Mauizio Berardino, MD
Franco Bobbio Pallavicini, MD
Antonio Miletto, MD
Salvatore Magione, MD
Angelo U. Sinardi, MD
Mauro Pastorelli, MD
Nicoletta Vivaldi, MD
Alberto Pasetto, MD
Giorgio Della Rocca, MD
Rosario Urbino, MD
Claudia Filippini, PhD
Eva Pagano, PhD
Andrea Evangelista, PhD
Gianni Ciocone, MD
Luciana Mascia, MD, PhD
V. Marco Ranieri, MD JAMA 2010; 303:1483-1489
Development of VAP
according to whether
patients received an
early or late
tracheotomy
Cricothyroidotomy
• Technique
– landmarks
• thyroid / cricoid cartilage
• 2 cm below cords
– open approach
• vertical incision
• transverse opening (membrane)
– percutaneous
The Bottom Line…
• Mechanical ventilation defines critical care
• Airway choices reflect disease process and
affect outcomes
• Multitude of new technologies have
changed practice patterns and will
continue to change practice patterns
Source Complication SCT PDT
Friedman, et al. Parathracheal insertion 0 4
Transient hypotension 11 15
Transient hypoxia 11 0
Subcutaneous emphysema 4 0
Minor bleeding (25-100 mL) 11 13
Loss of airway (>20 s) 4 0
Other 0 4
Holdgaard, et al. Minor bleeding 80 20
Major bleeding 7 0
Cuff puncture 0 17
Resistance to insertion 0 27
Porter and Loss of airway/death 0 8
Ivatury Hypoxia 8 25
Hypotension 0 0
Blood loss >100 mL 0 0
Chest 2000; 118:1412-1418
Description and
Frequencies of
Operative
Complications
Crit Care Med 2008; 36:2547-2557
Relative reduction in risk
of death at 90 days.
Relative risk of death for
patients receiving early
tracheostomy compared to
patients receiving late
tracheostomy.