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INDICATIONS FOR MECHANICAL

VENTILATION
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LIFE SUPPORT

17/04/2017 Chang W.David. Clinical Application of Mechanical Ventilation. 4th1 edition


PRECAUTION : COMPLICATIONS
Barotrauma : Injury resulting from high
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intrapulmonary air pressures.
Volutrauma : Direct injury to alveoli from
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overdistention of the lung.
Biotrauma : Lung and distant organ injury
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inflammatory mediators into the air
spaces and the systemic circulation.
Atelectrauma : Injury to alveoli resulting
from the cyclic collapse and opening of
atelectatic alveoli.

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TYPES OF VENTILATOR
NEGATIVE PRESSURE
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POSITIVE PRESSURE Non invasive and Invasive

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MODES OF VENTILATOR
1. Spontaneous
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2. Positive end-expiratory pressure (PEEP)
3. Continious positive airway pressure (CPAP)
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4. Bilevel positive airway pressure (BiPAP)
5. Controlled mandatory ventilationsubtitle
(CMV)
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6. Assist/control (AC)
7. Intermittent mandatory ventilation (IMV)
8. Synchronized intermittent mandatory ventilation (SIMV)
9. Mandatory minute ventilation (MMV)
10. Pressure support ventilation (PSV)
17/04/2017 Chang W.David. Clinical Application of Mechanical Ventilation. 4th edition 4
MODES OF VENTILATOR
11. Adaptive support ventilation (ASV) 18. Airway pressure release ventilation

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12. Proportional assist ventilation (PAV) (APRV)
13. Volume-assured pressure support 19. Biphasic positive airway pressure
(VAPS)
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14. Pressure-regulated volume control
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20. Inverse ratio ventilation (IRV)
(PRVC) 21. Automatic tube compensation (ATC)
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22. Neurally adjusted ventilator assist (NAVA)
15. Adaptive pressure control (APC) 23. Hight-frequency oscillatory ventilation
16. Volume ventilation plus (VV+) (HFOV)
17. Pressure-controlled ventilation (PCV)

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Terminology
MECHANICAL BREATH VARIABLES

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BREATH SEQUENCE

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MODE

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FULL VS PARTIAL
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P-VCV SIMV
A/C CPAP
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Control Mandatory Ventilation

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Ventilator delivers a preset tidal
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volume at a time triggered
frequency Master title
2. Seizure
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1. Initial setting
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injury
RR 4. Apnea
VT MV
CMV
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Chang W.David. Clinical Application of Mechanical Ventilation. 4th edition
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Assist/Control

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Patient may increase
ventilator frequency edit Master
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Low effort requirement to initiate
(assist) in addition to Click
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preset mechanical
frequency (control) Complications
Alveolar hyperventilation
leading to respiratory
alkalosis
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Intermittent Mandatory Ventilation
Ventilator deliver control Benefit
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breath (mandatory) and allows
the patient to breathe at any
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breathing
tidal volume
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Complications Master
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VT RRm/rrsp
Breath stacking leading
to barotrauma
IMV
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SIMV - Synchronized
Intermittent Mandatory Ventilation

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Indications
Ventilator delivers either assisted To provide partial Vent
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patient at the
beginning of spontaneous breath or
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support
time-triggered mandatory breathe
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Spontaneous breathing frequency Disadvantages
and tidal volume totally dependent if too fast weaning, leading to
on the patients breathing support
high of WOB, fatigue and
weaning failure

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Pressure Support
To lower the work of
spontaneous breathing and
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augment a patients spontaneous edit
tidal volume
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Vt Click to edit Master Click
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Spontaneous RR
RRsp WOB
Ps
Minute
Ventilation

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Pulse Oximetry

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Non invasive, Simple device, helpful and most frequency used to assess
patients oxygenation by Beer-Lambert Law and spectrophotometric
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Works by emitting dualClick
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vascular
PaO2
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Proper placement to obtain an accurate reading90% 60

SpO2 >95 % paO2 >70%


80% 50
75% 40
70% 35
60% 30
50% 27
30 20

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CLINICAL APPLICATION OF PULSE OXIMETRY

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FACTORS THAT EFFECTS Click
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Noise Artifact

Motion Artifact

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ET CO2
Non invasive, simple device to assess CO2 level in gas sample.
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When gas sample is collected at the end expiration : ETCO2
Under normal conditions, the PaCO2 is higher 2 mmHg than Pet
CO2 Master
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Normal waveform
MEASURED ET CO2

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HEMODYNAMIC
CONDITIONS THAT AFFECT THE BLOOD PRESSURE
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William A.Eric and Whitney M.Gina. SJCCA: Cardiopulmonary


Interaction. September 2006, 22,1
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William A.Eric and Whitney M.Gina. SJCCA: Cardiopulmonary Interaction. September 2006, 22,1.
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BGA Henderson Hasselbalch
PRIMARY DISORDER PRIMARY DISTURBANCE PRIMARY
COMPENSATION

RESPIRATORY ACIDOSIS
PCO2
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HCO3 -

RESPIRATORY ALKALOSIS
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Mastertitletitle
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PCO2 HCO3-
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Renal HCO3 excretion
METABOLIC ACIDOSIS
HCO3- PCO2
Lung CO2 removal
METABOLIC ALKALOSIS
HCO3- PCO2
Lung CO2 retention
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Simple Lung Protective Strategy
Low Tidal Volume Permissive Hypercapnia
PEEP Click
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Pplat < 35

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Recent clinical trials have demonstrated that in patients with ARDS, protective
ventilatory strategies are associated with decreased serum cytokine levels, decreased
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levels of organ dysfunction, and decreased mortality ,edit Master
perhaps by text stylesmitigating
partially
the development of MODS.

Slutsky S. Arthur, Imai Yumiko. Applied Physiology in Intensive care 2, 3rd edition.
Ventilator-induced lung injury, cytokine, PEEP, and mortality : implication for practice
and for clinical trials

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PEEP

DECREASES THE PRESSURE THRESHOLD


FOR ALVEOLAR INFLATION
USEFUL
TO TREAT REFRACTORY
HYPOXEMIA
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(LOW PaO2
NOT RESPONDING
TO HIGH FIO2)
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INCREASES FRC
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IMPROVES VENTILATION

3 types of alveoli in ARDS INCREASES V/Q


CONSOLIDATED ALV
RECRUITABLE ALV IMPROVES OXYGENATION
NORMAL FUNCTIONAL ALV
DECREASES WOB
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MECHANISM & PHYSIOLOGIC CHANGES
IN PERMISSIVE HYPERCAPNIA

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INITIAL VENTILATOR SETTING
DETERMINE :
1. MODE Click
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2. FREQUENCY
3. TIDAL VOLUME Master
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4. FIO2 Click to edit Master Click
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5. I : E ratio
6. inspiratory flow pattern
7. ALARM LIMIT

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MODE SELECTION

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FREQUENCY
NUMBER OF BREATHS PER MINUTE TO
MAINTAIN CO2 LEVEL
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USUALLY SET BETWEEN 10-12/MIN edit
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COUPLED WITH 10-12 ML/KG TIDAL
VOLUME title
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ESTIMATE MINUTE VOLUME
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TIDAL VOLUME

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TIDAL VOLUME
Initial tidal volume : 10 12 ml/kg
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Lower VT as 6 ml/kg : ARDS, to avoid barotrauma, minimize airway
pressure
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FiO2
Initially may be set at 100 %
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Should be evaluated by BGA to maintain good level of PaO2
FiO2 < 50% to avoid Oxygen Induced Lung Injury
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I : E RATIO
Ratio of Inspiratory time to expiratory time
Between 1:1,5 and 1:3 Click
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A larger i:e ratio to give more exhalation time (air trapping or auto
PEEP) Master
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Inverse Ratio for refractory hypoxemia
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ARDS
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after fail to improve with PEEP

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CONSEQOUENCES MANAGEMENT AUTO PEEP


HYPOTENSION LENGTHEN INSPIRATORY TIME
INCREASE WOB STEROID
INCREASE INSPIRATORY PRESSURE BRONCHODILATOR
WORSEN OXYGENATION REDUCE TIDAL VOLUME
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ALARM SETTING
Pass the diagnostic test
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To alert the clinician to undesirable technical or patient event
To detect failure of the airway pressure to return to the baseline value
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( it could be by airway obstruction, circuit obstruction or ventriculer )
Volume alarm : to detect Click to edit Master
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supported breaths and spontaneous breaths
Flow alarm : to detect high/low minute ventilation
Time alarm : to detect high/low frequency, excessive or inadequate
inspiratory or expiratory time
Inspired gas alarm : to detect in oxygenation concentration
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CALCULATION ie Ratio
Given RR 20, desire i:e ratio 1:2
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Calculate : the I time needed for an ie ratio 1:2
Solution :
since RR=20 Master
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RR 15
time for @ breath 60 / 20 = 3 time for Master
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I time : I time :
Time of @breath x ( 1/sum of ie ratio) 4 x ( 1/ 1+2.5)
1.1248 sec
3 x ( 1 / 1+2 ) Exp time 4-1.1248 = 2.8752
1 second

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Thank you

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