mechanical ventilation for acute respiratory failure

8/12/2019 Mechanical Ventilation for Acute Respiratory Failure

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MECHANICAL VENTILATION forACUTE RESPIRATORY FAILURE

Dr. Malbar FerrerJanuary 21, 2014Group TwennyWAN

What, Why and How to Ad u!t "ent#lator $ett#n%!&Fro' A $#'ple (#)e $upport to An *th#+al D#le''a

Pulmonary Physiology Pion rs!Andre -ournand New /orD#+ #n!on W. #+hard! h#ladelph#aJul#u! -o'roe $an Fran+#!+oWalla+e Fenn o+he!terHer'an ahn o+he!terJa'e! Wh#ttenber%en 3o!ton

$+#en+e o) ntubat#on !tarted w#th ane!the!#a1540! e!p#rator be+a'e 'ore !oph#!t#+ated1950s ventilator became popular Life support with the respirator goes hand in handwith the development in anaesthesia

**Mechanical ventilation has evolved from a simplelife support to an ethical dilemma. At the end partof most respirator disorders! most especiall lungcancers and end"stage #$%&! putting the patienton mechanical vent is supposed to ma'e him

comfortable! but if it has been so long! then it also puts a strain on the finances.

(nfortunatel ! in that scenario! if ou are seeing our relative smile at ou even if the havetracheostom or communicate with ou as long asthe are on respirator! what will ou do) emovethe respirator because ou cannot pa an more)+ou are in a dilemma.

** %ulmonar medicine evolved onl in the 1950,s

** respirator" onl developed in the first half of the -0 th centur impetus for mech vent was triggeredb the #openhagen %olio /pidemic in the earl

0,s accompanied b the development of theblood gas machine

Copenhagen polio epidemic- people with poliodied of pulmonar complications respirator failure

Arterial 2lood 3as Machine **has acceleratedand provided the motivation for technicians todevelop a more sophisticated machine

"measures #$ - . $ - and p4

3ellow! traditional respirators cuff &F#re pla+ebellow!

!tart o) re!p#rator & tube is rigid and no cuff !eal

MECHANICAL VENTILATION The u!e o) a 'a+h#ne to a!!#!t or repla+e the

breath#n% e))ort o) a pat#ent The pro+e!! o) u!#n% de6#+e! to e#ther "o"ally or

#ar"ially pro6#de o7y%en and -82 between theen6#ron'ent and the al6eolar !pa+e o) thelun%!.

The de!#red re!ult #! to 'a#nta#n appropr#atele6el! o) 82 appropriate for age or 6ormal forthe individual 70"100 %$ - 8 and -82 #n arter#alblood wh#le al!o unload#n% the re!p#ratory'u!+le!.

* pirometr developed 50 rs ahead of /#3machine has variable interpretations and

limited understanding": lagging of devt82ronchoscope utili;ed in the clinics in the late1950s

99 (a%%#n% o) de6t o) !p#ro'etry due to1. Need! +o'pl#+at#on w#th '#nute nu'ber! &0.1,0.2 to +o'pute )or !p#ro'etry re!ult! 2. They thou%ht be)ore that -8 D #! #rre6er!#bleand w#ll only lead to a pro%re!!#6e, !low death.

Note: re6#ew pul'onary phy!#olo%y


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They ha6e not +orrelated +#%arette !'o #n% to-8 D. = 1 minute** increased wor' ofbreathing cannot besustained" will go to respifailure

" TA( -A A- T/ 1B 'l? %

MA .N$ AT8 /

*$$@ *

20 +' H28

-82 T *ND n+rea!#n%

** 4ow do ou establish atrend) 2 getting a series ofblood gases

" TA( $ GN$ n+rea!#n% H , 3

**>entilator failure refers to #$- in the 2lood gas

**?idal volume@ 500 ml %h siologic dead space@ 150 ml area includingthe airwa s or non"gas e=change portion of therespirator s stem

50 ml in the alveoli where gas e=change occurs

150 500 B appro=. 0. or 1 1 of ventilation isdead space8

**h perventilation s ndrome" common in females

Management ou correct the #$ - retentionthrough increasing the tidal volume and ou correctthe severe respi al'alosis b increasing deadspace C but not too much8 dead space = volume that goes in correctionof respi al'alosis limited to the ratio8


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*%roblems in ventilation acute h percarbicrespirator failure8! inadeFuate o= genation acuteh po=ic respirator failure8 or impending respiratorfailure of either t pe. ?here will also be clinicalsituations where both will be evident.* espirator failure is a ventilator and o= genation

problem

V n"ila"ion= a'ount o) %a! that %oe! #n and out o) thelun%!

99 %a!= not u!t o7y%en aloneE +o2, o2, n#tr#+ o7#deand other %a!e! #n the at'o!phere, althou%h'a or#ty #! n#tro%en

99 at'o!pher#+ pre!!ure 0 '' H%

A%u" R s#ira"ory Failur*2efore it was categori;ed using A23

Two Types of Respiratory ailure!>entilator Dailure gas e=change8

= signified b increasing #$ - a s mbol ofgas e=change in the lungs the ventilatorf=n of lungs8

= managed b increasing tidal volumeintubation and ambu"bagging8

$= genation %roblem purel o= genation status8= managed b increasing the $ -

996ow! it is categori;ed based on the mechanism

of D@Type o7y%enat#on pure o7y%enat#on proble'Type 2 6ent#lat#on -82 retent#onE hyper+apne#+typeType < u!ually #n -N$ proble'!, F - #n po!t=op#! the 'a#n proble'Type 4= -" 99A F #! not a pr#'ary d#!ea!e but the end re!ult or+o'pl#+at#on o) another d#!ea!e or +ond#t#on.

99 de)#n#t#on !hould be l# e: A+ute e!p#ratoryFa#lure Type !e+ondary to A D$ or !e+ondary toblunt +he!t #n ury )ro' 6eh#+ular a++#dent,et+.

Ho( "o "r a" r s#ira"ory failur ro6#de 'e+han#+al 6ent#lat#on a! #nd#+ated Treat the +au!e

= "a!oa+t#6e therapy h potension8

= Ant#b#ot#+! infection@ ** should be startedearl ! once diagnosed! give in the ne=t -"Ghrs because it affects outcome8

= Nutr#t#on= *le+trolyte repla+e'ent especiall H and

6a8= 3ron+hod#lator! asthma and obstruction8= $tero#d!= $ur%ery

9Me+han#+al "ent#lat#on #! only one o) the treat'ent'odal#t#e! )or a+ute re!p#ratory )a#lure

Ess n"ial an$ Un#ro) n Ca#a*ili"i s ofM %hani%al V n"ila"ion

ESSENTIAL NONESSENTIAL

T#dal "olu'e -ontrol9=high@ 10"1-ml 'gLow@ "7ml 'g"improves survival b

-0 I

M", $ M"

-ontrol o) F 82 re!!ure !upport"ent#lat#on

Hu'#d#)#+at#on= coldair needshumidification/pista=is is d t cold airwhich dries up therespi mucosa

$#%h )eature

nternal Alar'! D#))erent pre!!ure wa6e)or'

Ad u!table )low rate D#!play o) )low wa6e)or'

A!!#!t and -ontrol'ode o) re!p. rate H#%h )re>uen+y 6ent#lat#on

"ar#able #n!p#rat#on Ie7p#rat#on t#'e!

** = 99 can benonessential! not allthe time it is beingused


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*%ermissive #$- retention %a#$-B50"55 mm4g8as long as p4 is normal p4 has more significancethan the value of #$- the purpose is to maintainlow tidal volume to minimi;e barotraumas

** if our p4 is J. 5"J.G5 and our #o- is 50 or 55!it is still o'a as long as the purpose of which is tomaintain the low tidal volume ventilation** low tidal volume ventilation" has a protectivemechanism on our alveoli

** >olume ventilator" the ?idal >olume is assured

**%ressure ventilator" assured pressure! usuallused if without pulmonar problem! not applicableto patients with #$%&! asthma and restrictive lungdisease

Th %hoi% of ) n"ila"or s ""ings shoul$ *gui$ $ *y %l arly $ fin $ "h ra# u"i% n$#oin"s! A+ute 6ent#lator )a#lure

the respirator should be able to@= Nor'al# e -82= edu+e dyna'#+ hyper#n)lat#on= re6ent auto= ** = 99 reflection of air

trapping during e=piration" can result tobarotrauma and pneumothora=

= e!t the re!p#ratory 'u!+le!

Hypo7#+ re!p#ratory )a#lure= 'pro6e o7y%enat#on

Am*u*ag ) n"ila"ion+ temporar wa beforeintubating

hyth' "olu'e o) a#r Fre>uen+y "elo+#ty o) a#r del#6ery -on+entrat#on o) o7y%en del#6ered

M %hani%al V n"ila"ion

Mode T#dal "olu'e

3@ &re!p#ratory rate F F#82 :* rat#o **

MO&ES OF VENTILATION

o!#t#6e re!!ure "ent#lat#on -ontrolled Mandatory "ent#lat#on A!!#!t -ontrol= 99 most popular

$yn+hron# ed nter'#ttent Mandatory"ent#lat#on re!!ure $upport

**Last - are also used in weaning the patient

CONTROLLE& MAN&ATORY VENTILATION No pat#ent=6ent#lator #ntera+t#on "ent#lator per)or'! all the wor o) breath#n% *a+h breath #! a 'a+h#ne &)#7ed t#dal 6olu'e

del#6ered at !et ba+ up rate &t#'e tr#%%ered Ter'#nated a)ter t#dal 6olu'e &" T #! del#6ered

&6olu'e +y+led


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In$i%a"ions for CMV!

No re!p#ratory e))ort $ub e+ted to phar'a+olo%#+ paraly!#! When the pat#ent )#%ht! the 6ent#lator #n the

#n#t#al !ta%e! o) 'e+han#+al 6ent#latory !upport=sedate pt

-he!t #n ury, +o'ato!e po!t op hea6#ly !edated

Tetanu!, !e# ure d#!order! Head trau'a pat#ent

** wave form does not go lower than the linebecause the ventilator is giving all the initiative forthe ventilation! no patient effort at all! no pressurecoming from the patient

**putting patient on a mechanical ventilation willalter the mechanics of the lungs! that is wh ! asmuch as possible! ou have to provide anatmosphere where the normal ph siolog will be

maintained

** Ehat is the normal ph siolog ) ?he pulmonars stem is operating on a ;ero or negative pressure.6o positive pressure. ?he moment ou intubate!

ou shift that from negative to positive. ?he pressure from the airwa to the alveoli will change.

** Ehat will that change do) Alter mechanics andresult to complications li'e erosion of bronchialmucosa! predisposition to pneumonia! alveolardamage alveoli operates on a ;ero to negative

pressure8! bronchial circulation affectation

* ecretions provide resistance in giving tidalvolume which increases pressure ": decreaseso= gen deliver leading to h po=emia

*Dibrotic stenosis of the trachea" due to use ofinappropriate si;e of cuff. More air needed to inflatecuff":higher pressure radiating to the tranchealmucosa from the cuff. ?his leads to ischemia and fibrosis of the mucosa upon removal of /?.

99 h#%h 6olu'e, low pre!!ure +u)) #! pre)erred thana !'all tube w#th a h#%h pre!!ure, h#%h 6olu'e +u))

**/? tube si;es@Males@ 7Demales@ J.5

** bul' musculature can use up to si;e 10**si;e of cuff is also a factor in weaning the patientoff

ASSIST CONTROL VENTILATION ,A-C MO&E. at#ent=6ent#lator #ntera+t#on 3reath 'ay be 'a+h#ne= or pat#ent=tr#%%ered

99 one o) the 'o!t +o''on99 alternate a!!#!tE #) the pat#ent breathe!, the'a+h#ne w#ll u!t a!!#!t, but #) the pat#ent doe! notbreathe, then the 'a+h#ne w#ll %#6e the ne+e!!arybreath or 6ent#lat#on

Com#arison * "( n CMV an$ Assis" Con"rolCMV ASSIST CONTROL

nd#+at#on!: n#t#al !et=up at#ent! w#thout any

re!p#ratory dr#6e orha6e been !ub e+tedto neuro'u!+ularparaly!#!

Full 6ent#latory!upport

nd#+at#on!: ro6#de! )ull

6ent#latory !upport at#ent! w#th

!pontaneou!re!p#ratory dr#6e

Ad6anta%e!: No wor o) breath#n%

Ad6anta%e!: M#n#'al wor o)

breath#n% Allow! pat#ent to

+ontrol there!p#ratory rate

D#!ad6anta%e!: A!yn+hrony


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-o'pl#+at#on!:&99e!pe+#ally #n a!th'a and -8 D Al6eolarhyper6ent#lat#on K re!p#ratory al alo!#!

SYNCHRONI/E& INTERMITTENT MAN&ATORYVENTILATION at#ent=6ent#lator #ntera+t#on "ent#lator del#6er! pre!et 'andatory breath! to

the pat#ent at or near the be%#nn#n% o)!pontaneou! breathE 'a+h#ne= or pat#ent=tr#%%ered a!!#!ted breath!

n between, breath! are !pontaneou! anda!!#!ted

**(sed as weaning mode ** used if the patient has a high degree of

an=iet

In$i%a"ions! art#al 6ent#latory !upport Wean#n% 'ode

A$)an"ag s! Ma#nta#n! re!p#ratory 'u!+le !tren%th A6o#d! 'u!+le atrophy -an be u!ed a! a wean#n% 'ode&isa$)an"ag s! -an #ndu+e 'u!+le )at#%ue

PRESSURE SUPPORT VENTILATION $pontaneou! breath! &pat#ent tr#%%ered are

!upported by a pre!et pre!!ure le6el,ter'#nated when )low drop! to #nd#+ate end o)#n!p#rat#on and e7p#rat#on &)low +y+led

"ar#able #n!p#ratory t#'e and t#dal 6olu'e

A$)an"ag s! @!ed to lower the wor o) !pontaneou!

breath#n% and au%'ent a pat#ent;! !pontaneou!" T

When +o'b#ned w#th $ M", !#%n#)#+antlyredu+e! 8 2 +on!u'pt#on by de+rea!#n% the

wor o) breath#n% -an be appl#ed to any 'ode o) M" that per'#t!

!pontaneou! breath#n%

TI&AL VOLUME 3a!ed on 3W =L 'l? % =12 'l? % 99 high tidal volume alread

discouraged $pe+#al !#tuat#on!:

= A D$= A!th'a?-8 D= e!tr#+t#6e d#!ea!e &!?p lun% re!e+t#on

4ow much do ou give) Low tidal volume@ "7ml 'g #hec' A23


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8/11

*FF*-T 8F -HANG NG "T 8N :* AT 8

S nsi"i)i"y$ett#n%:

re!!ure tr#%%er#n% !hould be !et at the 'o!t!en!#t#6e le6el that pre6ent! !el)=+y+l#n%. Generally,th#! #! 0.B to 1.B +' H28.Flow tr#%%er#n% !y!te'! are %enerally 'ore e))#+#entthan pre!!ure tr#%%er#n%, but the +l#n#+al!#%n#)#+an+e o) th#! #! un+lear. The!e !y!te'!

!hould al!o be !et at 'a7#'u' !en!#t#6#ty &1 to

mechanical ventilation for acute respiratory failure

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