logging in or signing up Ventilator settings in ARDS & COPD & weaning drdeepac2007 Download Post to : URL : Related Presentations : Let's Connect Share Add to Flag Embed Email Send to Blogs and Networks Add to Channel Copy embed code: Embed: Flash iPad Dynamic Copy Does not support media & animations Automatically changes to Flash or non-Flash embed WordPress Embed Customize Embed URL: Copy Thumbnail: Copy The presentation is successfully added In Your Favorites. Views: 1933 Category: Education License: Some Rights Reserved Like it (0) Dislike it (0) Added: November 13, 2011 This Presentation is Public Favorites: 2 Presentation Description A presentation on the basic settings in specific diseases, with particular emphasis on ARDS & COPD; also deals with WEANING from ventilator. Comments Posting comment... Premium member Presentation Transcript PowerPoint Presentation: MECHANICAL VENTILATION IN ARDS & COPD WEANING FROM VENTILATOR Dr Deepa C MD 27 Oct 2011PowerPoint Presentation: RESPIRATORY SYSTEM Ventilating pump - Respiratory control centres in the brain - Connecting tracts and nerves - Chest wall and respiratory muscles Gas-exchange system - LungsPowerPoint Presentation: INDICATIONS FOR MECHANICAL VENTILATION Ventilatory failure Oxygenation failure Excessive ventilatory workload Impending respiratory failurePowerPoint Presentation: VENTILATORY FAILURE Drug overdose Spinal cord injury Head injury & stroke Neuromuscular dysfunction Sleep disorders Acute airflow obstruction Chest trauma Postoperative – thoracic & upper abdominal Electrolyte imbalance General anaesthesiaPowerPoint Presentation: OXYGENATION FAILURE & INCREASED VENTILATORY WORKLOAD Acute lung injury/ARDS Acute severe airflow obstruction Dead space ventilation Shunts Congenital heart diseases Shock High metabolic rate & obesity General anaesthesia & postopPowerPoint Presentation: ACUTE LUNG INJURY & ARDS COPDPowerPoint Presentation: ACUTE LUNG INJURY & ARDS Acute onset dyspnoea Chest radiograph - bilateral alveolar or interstitial infiltrates PCWP < 18 mmHg or no clinical evidence of increased left atrial pressure Poor oxygenation status - PaO ₂ /FiO ₂ < 300 in ALI < 200 in ARDS Diagnostic Criteria for ALI and ARDSPowerPoint Presentation: Chest X-ray in ARDSPowerPoint Presentation: CT thorax – Lungs in ARDSPowerPoint Presentation: CT thorax – Lungs in ARDSPowerPoint Presentation: RECRUITMENT MANOEUVRES PEEP Increasing inspiratory pressure Increasing inspiratory pause Inverse ratio ventilation High frequency oscillatory ventilation Prone position ventilationPowerPoint Presentation: Re-expands collapsed dorsal areas of the lung Chest wall has more favorable compliance curve in prone position Heart moves away from the lungs Net result is usually improved oxygenation Care of patient (suctioning, lines, decubiti) trickier, but not impossible PRONINGPowerPoint Presentation: Vasodilator with very short half-life that can be delivered via ETT Vasodilate blood vessels that supply ventilated alveoli and thus improve V/Q No systemic effects due to rapid inactivation by binding to Hb Improves oxygenation but does not improve outcome INHALED NITRIC OXIDEPowerPoint Presentation: COPD - chronic airflow limitation; not fully reversible mixture of small airway disease (obstructive bronchiolitis) and parenchymal destruction (emphysema) and their relative contributions vary from person to person excludes asthma ( reversible airflow limitation) COPD & ASTHMAPowerPoint Presentation: INDICATIONS FOR NIV Moderate to severe dyspnea with use of accessory muscles and paradoxical abdominal motion Moderate to severe acidosis (pH<7.35) and/or hypercapnia (PaCO₂ > 45 mm Hg) Respiratory rate > 25 breaths/ minutePowerPoint Presentation: EXCLUSION CRITERIA FOR NIV Respiratory arrest Cardiovascular instability Change in mental status Non-co-operative patient High aspiration risk Viscous or copious secretions Recent facial or gastro-esophageal surgery Craniofacial trauma Fixed nasopharyngeal abnormalities Burns Extreme obesityPowerPoint Presentation: Success rates of 80-85% Improves CO₂ elimination Improves respiratory acidosis Decreases respiratory rate Unloading of respiratory muscles Lower rate of nosocomial pneumonia Lower intubation rate Reduction in duration of mechanical ventilation Decreases the length of hospital stay & mortality rate BENEFITS OF NIVPowerPoint Presentation: NIV should be considered in patients of COPD in addition to standard medical therapy, when they present in acute exacerbation (pH < 7.35, PaCO ₂ > 45 mm Hg). (Level I) NIV may be useful in appropriately selected patients of hypoxemic respiratory failure . (Level I) CPAP/NIV are recommended in addition to standard medical treatment in cases of cardiogenic pulmonary edema . (Level I) NIV is recommended early in the course of hypoxic respiratory failure in immunocompromised patients, particularly in those with hematological malignancies . (Level I)PowerPoint Presentation: INDICATIONS FOR INVASIVE VENTILATION Unable to tolerate NIV or NIV failure Severe dyspnea with use of accessory muscles and paradoxical abdominal motion Respiratory rate > 35 breaths/ minute Life-threatening hypoxemia (PaO ₂ < 60 mm Hg) Severe acidosis (pH <7.25) and/or hypercapnia (PaCO₂ > 60 mm Hg)PowerPoint Presentation: Respiratory arrest Cardiovascular complications Somnolence, impaired mental status Other complications – metabolic abnormalities, sepsis, pneumonia, pulmonary embolism, barotrauma, massive pleural effusion Contd …PowerPoint Presentation: Airflow obstruction Low I:E ratios Increased respiratory rate Low flows Leads to dynamic hyperinflation (DHI) AUTO-PEEP or INTRINSIC PEEPPowerPoint Presentation: AUTO-PEEP or INTRINSIC PEEPPowerPoint Presentation: DYNAMIC HYPERINFLATION Expiratory flow obstruction Increased rate Decreased expiratory timePowerPoint Presentation: DIMINISH DHI Diminish minute ventilation Low V T (6-8 mL/kg) Low RR (8-10 /min) Maximize expiratory time (Low I:E ratio) High flowsPowerPoint Presentation: GOALS OF VENTILATION IN COPD Diminish dynamic hyperinflation Diminish work of breathing Controlled hypoventilation (permissive hypercapnia)PowerPoint Presentation: Provide V E that does not cause alkalosis Initiate low tidal volume : 6- 8 mL/kg RR : 8-12/min I:E with prolonged expiration to minimise DHI Adjust PEEPe to match at least 85% of PEEPi (diminish work of breathing) FiO ₂ to achieve PaO ₂ > 55 - 60 mmHg Insp. flow - initially 60L/min, then ↑ till the demands are satisfied Trigger : 2L/min or -2cm H ₂ OPowerPoint Presentation: PERMISSIVE HYPERCAPNIA Control the ventilation to keep adequate pressures up to a pH > 7.20 and/or a PaCO ₂ upto 80 mmHg Head pathologies and raised ICP Severe HTN Severe metabolic acidosis Hypovolemia Severe refractory hypoxia Severe pulmonary HTN Coronary artery disease CONTRAINDICATIONSPowerPoint Presentation: Neuromuscular disorders – dependent areas atelectatic Traumatic brain injury – aim for normoacpnia (NOT hypocapnia ) Pressure mode vs Volume mode Which is BETTER/IDEAL ? Are Dual modes an answer? Are they PERFECT ?PowerPoint Presentation: Defined as effective spontaneous breathing without any mechanical assistance for 24 hours or more The spontaneous breaths are unassisted by mechanical means Supplemental oxygen, bronchodilators, pressure support, or continuous positive airway pressure are often used to support and maintain adequate spontaneous ventilation and oxygenation WEANING SUCCESSPowerPoint Presentation: PaO₂ >60 mm Hg with FiO₂ < 0.5 and PEEP ≤ 5 cm H₂O PaCO ₂ < 45 mm Hg pH : 7.35–7.45 A minimal spontaneous Vt > 5-10 ml/kg Vital capacity > 10 ml/kg Minute ventilation (either spontaneous or assisted) less than 10 L/min (assuming PaCO ₂ is normal) Negative inspiratory force > -20 to -30 cm H ₂ O Rapid, shallow breathing index (RSBI) - f/Vt < 105 Predictors of weaning successPowerPoint Presentation: General approaches for weaning SIMV Pressure Support Ventilation (PSV) - prolonged weaning process because of slowly resolving lung disease Spontaneous Breathing Trials (SBT) no positive pressure to the airway a low level of CPAP a low level of PSV ( eg ., 5 - 8 cm H ₂ O)PowerPoint Presentation: Explain the process to the patient and encourage co-operation Begin during day time, allow patient to rest at night and between trials of weaning Place patient in propped-up position PEEP = 5, PS = 0 – 5, FiO ₂ < 40% Breathe independently for 30 – 120 min ABG obtained at end of SBTPowerPoint Presentation: Tachypnea (RR >35 breaths/min for ≥ 5min) Hypoxemia (SpO ₂ by pulse oximeter < 90%) Tachycardia (HR >140 beats/min or sustained rate increase > 20%) Bradycardia (sustained rate decrease by > 20%) Hypertension (systolic BP > 180 mm Hg) Hypotension (systolic BP < 90 mm Hg) Agitation, diaphoresis, anxiety, respiratory distress (use of accessory muscles, abdominal paradox..) Optional ABG criteria: Increase in PaCO ₂ >10 mm Hg or decrease in pH > 0.1 Criteria for the discontinuation of a weaning trialPowerPoint Presentation: Rapid breathingPowerPoint Presentation: EXTUBATION Control of airway reflexes Patent upper airway (air leak around tube?) Minimal oxygen requirement Minimal rate Minimize pressure support (0-10 cm H ₂ O) “Awake ” patientPowerPoint Presentation: TROUBLESHOOTINGPowerPoint Presentation: Remove patient from ventilator Initiate manual ventilation Perform physical examination and assess monitoring indices Check patency of airway If death is imminent, consider and treat most likely causes Once patient is stabilized, undertake more detailed assessment and managementPowerPoint Presentation: PATIENT-RELATED CAUSES Artificial airway problems Secretions Bronchospasm Pneumothorax Pulmonary embolism Dynamic hyperinflation Abnormal respiratory drive Drug-induced problems Abdominal distension Agitation VENTILATOR-RELATED CAUSES System leak Circuit malfunction Inadequate FiO ₂ Inadequate ventilator support PATIENT-VENTILATOR ASYNCHRONYPowerPoint Presentation: Thank you You do not have the permission to view this presentation. In order to view it, please contact the author of the presentation.