Post-Intubation and Ventilator Management

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PowerPoint Presentation:

You just got the tube !!! Congratulations !!!

Post-Intubation Management:

Hold the celebration…. your work is not over yet. What ’ s next in post-intubation management ? Post-Intubation Management

Post-Intubation Management:

1. CONFIRM PLACEMENT & SECURE TUBE Post-Intubation Management

2. Continue to monitor capnography:

2. Continue to monitor capnography

3. Post-Intubation Chest x-ray:

To evaluate depth of insertion as well as searching for signs of cardiopulmonary pathology. Tube placement confirmation should be performed clinically and with concomitant use of end-tidal capnography prior to obtaining a post-intubation chest x-ray. 3. Post-Intubation Chest x-ray

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And it keeps on hurting once the tube is in… Tradition Just because you ’ ve always done it that way doesn ’ t mean it ’ s not incredibly stupid. Intubation Hurts !

Post-Intubation Management:

4. Please don’t forget the Analgesia and Sedation Post-Intubation Management

Post-Intubation Management:

5. Raise the Head of the Bed to at Least 30° Post-Intubation Management

Post-Intubation Management:

6. Confirm Lung Protective Vent Settings Standard Initial Vent Settings Mode Assist Control (AC) Vt Tidal Volume 6-8 cc/kg IBW Rate 12-16 (10 in asthma/COPD) PEEP 5 IFR Inspiratory Flow Rate 60 l/min FiO 2 100% then titrate down to 40% Post-Intubation Management

Post-Intubation Management:

7. NG / OG tube Empty the stomach to reduce the chances of aspiration and to improve lung mechanics Post-Intubation Management

Post-Intubation Management:

8. Nebulizers/MDI If they were intubated for reactive airway disease, then they need frequent nebs Post-Intubation Management

Acute Deterioration after Intubation:

Acute Deterioration after Intubation D.O.P.E.S D isplacement O bstruction P neumothorax E quipment failure S tacked Breaths

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Basics of Post-Intubation Ventilator Management Adapted from Scott Weingart ’ s EMCrit Blog: Dominating the Vent Lectures

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Lung Injury Obstructive Lung Disease Use as Default Post-Intubation Vent Management

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Lung Injury Lung Protective Management 1. Mode: use A/C (assist control) Post-Intubation Vent Management

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Vt IFR FiO 2 PEEP RR Post-Intubation Vent Management

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Vt Tidal Volume 6-8 cc/kg IBW Vt = Lung Protection Post-Intubation Vent Management

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IFR Inspiratory Flow Rate = how quickly the breath is delivered 60-80 LPM IFR = Comfort Post-Intubation Vent Management

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RR Respiratory Rate 16-18 BPM RR = Ventilation Post-Intubation Vent Management

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FiO 2 PEEP Start @ 100% Wait 5 min Get ABG Drop to 40% FiO 2 Goal: Saturation of 88-95% Post-Intubation Vent Management

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FiO 2 PEEP Start with 5 Positive End-Expiratory Pressure - PEEP Post-Intubation Vent Management

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FiO 2 PEEP FiO 2 + PEEP = Oxygenation Post-Intubation Vent Management

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Peak Plateau Plateau Pressure < 30 cmH 2 O Must find and hold Inspiratory Hold button Ventilator will then display Plateau Pressure Inspiratory Plateau Pressure

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Vt = Lung Protection IFR = Comfort FiO 2 PEEP = oxygenation RR = Ventilation Post-Intubation Vent Management

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Analgesia 1st Sedation 2nd Post-Intubation Vent Management …and don ’ t forget

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Mark P.Brady PA-C Dept.of Emergency Medicine Cambridge Health Alliance

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References : http://emcrit.org/lectures/vent-part-1/ http://emcrit.org/podcasts/vent-part-2/ http://www.ashp.org/DocLibrary/Policy/EmergencyCare/Post-Intubation-Management-Handout.pdf http://emcrit.org/podcasts/post-intubation-sedation/ http://emedicine.medscape.com/article/810126-overview

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