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M V ICU: Echanical Entilation IN
M V ICU: Echanical Entilation IN
IN ICU
• Reduced cardiac
output: CHF
• Low pulmonary
perfusion : embolism,
Vasoconstriction
•ARDS, pneumonia
(consolidation),
pulmonary edema ,
atelectasis, interstitial
lung disease
• Prevented by the
normal reflex hypoxic
pulmonary
vasocinstriction
OXYGENATION FAILURE
Refers to hypoxemia not responsive to moderate to high levels
of supplemental oxygen.
Expiration – • Trigger
Inspiration
Inspiration - • Cycle
Expiration
Expiration • Baseline
Time trigger:
Breath is delivered once the preset time interval has elapsed.
If RR is 12/min, the ventilator will deliver breath every 5 secs. (60s /
12 = 5), irrespective of patient effort or requirement.
Pressure Trigger:
Breath is delivered once preset negative pressure is generated by
patients’ spontaneous effort.
Values of -1 to -5 cm of H20 (below end-expiratory pressure) is
acceptable.
Flow Trigger:
Breath is delivered when patients’ inspiratory flow reaches a specific
value.
More sensitive than pressure trigger to detect inspiratory effort, hence
less inspiratory work.
FIG: PRESSURE TRIGGER
Volume and pressure control are used most often, flow and time
are indirectly controlled.
• Inspiration ends when the pre set volume is reached, or after certain
time elapses (inspiratory hold)
Advantages Disadvantages
Settings:
Predictable Higher incidence VT , RR, Flow/ Time and
regulation of TV, of barotrauma, FiO2.
MV volutrauma and
VT set at 6 – 12 ml/kg IBW
VILI esp in ARDS
and ALI RR = 10 – 15 bpm
Better control During assisted FiO2 lowest possible to
over PaCO2 than breath, flow rates achieve oxygenation
PC may be
I:E – 1:2 – 1:4
insufficient
leading to dys- Flow rate is a measure of
synchrony and I:E, can be set separately in
auto PEEP some models.
Monitoring and alarms:
• PIP and PPlat relates to compliance.
Cstatic = Vt /Pplat – PEEP
Cdyn = Vt/ PIP – PEEP
• High pressure alarm set at 5 – 10 cm above ventilating pres.
• Low pressure alarm 5 – 10 cm H20 belowventilating pres.
• Low pressure and volume alarms signify leak in system.
PRESSURE CONTROL
Provides pre set pressure to the airways, not exceeding the set
level irrespective of changes in compliance and resistance.
Proportional Assist Ventilation + • Clinician only sets the % of WOB that the
ventilator should do.
• Compliance and resistance information is
collected every 4-10 breaths, F and V data
collected every 5 ms to know the patients’
demands.
• No target flow, volume or pressure
•Initially started at 80% WOB, then weaned
back to stabilise.
Neurally Adjusted Ventilatory Assist (NAVA) • Uses electrical signals from the
diaphragm as trigger in addition to flow/
pressure
• Signals measured trans-oesophagally
with use of a cathater ( doubles as Ryle’s
Tube)
• Clinician can set the level of amplification
of the signal – NAVA level
AIRWAY PRESSURE RELEASE VENTILATION
Relatively new mode of ventilation, available on the Drager
Sevina 300.
C
Dahaba HOICE
et al (40 patients)
OF DRUGRamifentanyl vs morphine R more effective, more rapid
wake up and extubation
Muellejans et al (152 cardiac, Ramifentanyl vs fentanyl Ramifentanyl requires lesser
general surgical and medical sedatives, but more
pts) painafterward
Muellejans et al (80 cardiac Ramifentanyl + propofol vs R + P: Fewer days on MV,
surgery pts) fentanyl + midazolam fewer days in ICU
Pohlman el at Lorazepam vs midazolam Lorazepam: more rapid wake
up
Swart et al Lorazepam vs midazolam Lorazepam: more effective
sedation and more cost
effective
Grounds et al, Aitkenhead et al, Propofol vs Midazolam Propofol more effective
Ronan et al, Kress et al sedation, fewer days on MV,
more rapid wale up
Weaning Success:
Absence of need of ventilatory support 48 hrs following
extubation.
The patient is able to pass a Spontaneous Breathing
Trial (SBT).
1. Boles JM et al. International Consensus Conferences – Weaning from mechanical ventilation. Eur Respir J 2007; 29
2. LermitteJ et al. Weaning from mechanical ventilation. Contin Edu Anesth Crit Care Pain 2005;5(4)
ASSESMENT OF READYNESS TO WEAN
Objective values:
Minute Ventilation <10l/min
General preconditions:
Vital Capacity > 10 ml/kg
Reversal of primary problem
causing need for mechanical RR <35
ventilation Tidal volume > 5ml/kg
Patient is awake and Max inspiratory pressure <-25
responsive cm H2O
Good analgesia, ability to RR /Vt <100 b/min/L
cough PaCO2 < 50 mmHg
No or minimal inotropic PaO2 > 90 mm Hg at FiO2 0.4
support PaO2/ FiO2 > 200
Ideally – functioning bowels,
abscense of distention
1. Boles JM et al. International Consensus Conferences – Weaning
Normalising metabolic status from mechanical ventilation. Eur Respir J 2007; 29
2. LermitteJ et al. Weaning from mechanical ventilation. Contin Edu
Adequate Hb concentration Anesth Crit Care Pain 2005;5(4)
WEANING INCICES
Rapid Shallow Breathing Index (RSBI):
Ratio of RR/VT (spontaneous)
Value > 100 suggests potential weaning failure
Patient is allowed to breathe spontaneously for 3 mins, MV is
measured and avg VT over one min is divided by RR
Prost DN et al. Ventilator induced lung injury: historical perspectives and clinical implications. Annals of Intensive Care
2011.
VENTILATOR ASSOCIATED PNEUMONIA (VAP)
Defined as pneumonia occuring
DIAGNOSIS: Presence of a new
more than 48 hrs after intubation
or progressive infiltrate in CXR
and mechanical ventilation.
plus two of the following:
Fever > 38 C
Estimated incidence is 10-25%, Leukocytosis/ Leukopenia
mortality of 33-76% Purulent tracheo- bronchial
secretions
Early onset (2-5 days) – S. Respiratory tract sampling using
Pneumoniae, H. Influenzae, BAL, mini BAL, tracheo-bronchial
MSSA, E.Coli, Klebsiella, less aspiration for microscopy and
severe, minimal mortality quantitative culture
Late onset (> 7 days) – P. 1. CDC- Ventilator Associated Event Protocol .Jan 2013
Aeruginosa, Acinetobacter, 2. Guidelines for the management of hosppital aquired,
ventilator associated and healthcare associated
MRSA, other MDR pathogens; pneumonia. AmJRespirCritCare 2005; 171
higher morbidity and mortality
PREVENTION using ‘bundled TREATMENT
approach’ has shown to reduce the
incidence of VAP by as much as 95%
Emperical antibiotic therapy after
sampling.
Components may be as:
Appropriate cuff to prevent aspiration
Change of circuit every 7 days/ visible
Choice of antibiotic depends on local
soiling prevalance of organisms and the
HME and suction devices changed daily patient’s risk for MDR infection.
ETT with dorsal lumen for sub-glottic
secretions High risk group incude hospitalisation
Elevation of head 30-45% > 5 days, antibiotic use in last 90
Strict hand hygiene days, haemo-dialysis, residence in
Oropharyngeal decontamination – nursing home
chlorhexidine, iodine
Sedative vacation; early extubation
Non invasive ventilation Low risk – Ceftriaxone/ Levo,
ciprofloxacin/ Ampicillin sulbactam/
Ertapenem
Prophylactic antibiotics are not
recommended by any route High risk –
(including aerosol) because of Antipseudomonal (Cefipime/
inconsistency and risk of resistance Ceftazidime/ carbapenems/ Piperacillin
TZ) +
Fluroquinolone/ Aminoglycoside +
Linezolid/ Vancomycin
NON- INVASIVE PPV
VILI and VAP are dreaded complications - prevention is better than cure
THANK YOU