Pulmo-emergency

Panvilai

50

GAS S.aureaus

50

Hypoxemia

DO2 = 1.38 x Hb x Osat + Pao2x0.003

A-a gradient

Hypoxemia : acute decompensation

PaO2 < 60 mmHg activate peripheral chemoreceptor
Minute vent. Pul.art.vasoconstriction

Right heart failure

sympathetic CO

Diffusion of gas
CO2 > O2 > CO > NO Gas pulmonary edema Pulmonary capillary RBC rbc cell

Normal A-a gradient

Hypovantilation Low FiO2 ( high attitude)

Wide A-a gradient

Right to left shunt

Clinical : hypoxemia despite oxygen supplement , wide Aa gradient Pathology : pulmonary consolidation, pulmonary atelectasis, and vascular malformations.

V-q mismatch
Clinical : increased A-a O2 gradient and hypoxemia improves with supplemental oxygen. Pathology Pulmonary emboli, pneumonia, asthma, COPD, and extrinsic vascular compression

Respiratory center
central hypercapnic chemoreceptors in the central medulla. peripheral hypoxic chemoreceptors, primarily in the carotid body in concert with those in the aortic arch.

Respiratory physiology
Minute ventilation = TV (7 ml/kg)* f (respiratory rate) Min.vent maintain PaCO 2 = 4o Increase CO 2 production increase MV Decrease CO2 production decrease MV MV < 2 L /min respiratory acidosis

Minute ventilation
Minute VentilationVE = VT x f New PaCO2x VE = Old PaCO2x VE Case ICP set ventilator VT = 500 ml , f =12 PaCO2 = 50 mmHg if want PaCO2 = 40 mmHg setting VT

 New PaCO2x VE = Old PaCO2x VE 40 x 500 x f = 50 x 500 x 12 f = 15

Dead space
= Volume air Physiologic dead space (30 % TV)= 1. Anatomical dead space =trachea, bronchi, and bronchioles 2.Alveolar dead space = absent of alveolar capillary perfusion with normal ventilation (high v/q mismatch) Disease: COPD,ARDS

Expired air
In patients with normal lungs, ETCO2 is approximately 3 mm Hg lower than PACO2,

55

Cyanosis
Deoxy Hb > 5 g/dl Met Hb: 1.5 g/dl SulfHb: 0.5 g/dl

Pseudocyanosis
Clinical : not branch with pressure heavy metals [e.g., iron (hemochromatosis), gold, silver, lead, and arsenic] drugs (e.g., phenothiazine, minocycline, amiodarone, and chloroquine) Chrysiasis: rare complication of gold treatment Argyria; chronic ingestion /application of silver

Arterial blood gas interpretation

Normal ABG value

pH = 7.35 7.45 ( 7.4 +-0.5 ) PaO2 = 80 100 mmHg PaO2 < 80 mmHg = Mild hypoxemia PaO2 < 60 mmHg = Moderate hypoxemia PaO2 < 40 mmHg = Severe hypoxemia New born = 40 60 mmHg Age > 60 PaO2 = 100 [0.25 x Age (Yr)]

ABG error
Excessive heparin affects pH, PCO2, and PO2 Air bubbles lowering the PCO2 values with an increase in pH and PO2.

PaCO2 = 35 45 mmHg (40 +-5 mmHg) HCO3 = 22 26 mEq/L (24 +-2 ) BE = +-2.5 SaO2 = 95 100 %

Table 26-2 Expected PaO2 in Patients Inhaling Various Concentrations of Oxygen, mm Hg

FIO2

0.21 (room air)

0.4

0.6

0.8

1.0

PaO2*

100

227

370

512

655

Aa-gradient
measures how well alveolar oxygen is transferred from the lungs to the circulation
P(A-a)O2 = 145 PaCO2 PaO2. A normal P(A-a) O2 is under 10 mm Hg in young, healthy patients predicted by the formula P(A-a)O2 = 2.5 + 0.21 (age in years) ( 11).

ABG interpretation
PaCO2 =hypoventilation PaCO2 =hyperventilation

 gas
Alveolar air equation PAO2 = 713xFiO2-1.2xPaCO2 (FiO2 < 0.6) PAO2 = 713xFiO2-PaCO2 (FiO2 > 0.6) (A-a)DO2 = PAO2 PaO2 (A-a)DO2 = 140 (PaO2 + PaCO2) Normal (10-20mmHg)

 PaO2/FiO2 < 400

< 400 lung injury < 200 ARDS

Acid-base
pH predicted pH and measured pH Delta pH = Delta PaCO2 x (1/100) Delta pH = Delta PaCO2 x (1/200) predicted pH < measured pH = acidosis predicted pH > measured pH = alkalosis

PaCO2
PaCO2 If PaCO2 pH =Ventilatory Cause PaCO2 increase =respiratory acidosis PaCO2 decrease =respiratory alkalosis If PaCO2 pH =Ventilatory compensation

Respiratory acidosis
Acute PaCO2 10 mmHg HCO3 1 mEq/L

Chronic PaCO2 10 mmHg HCO3 4 mEq/L

Acute: HCO3 = 0.1 PaCO2 Chronic: HCO3 = 0.4 PaCO2

Respiratory Alkalosis
Acute PaCO2 10 mmHg HCO3 2 mEq/L
Chronic PaCO2 10 mmHg HCO3 5-6 mEq/L

Acute: HCO3 = 0.2 PaCO2 Chronic: HCO3 = 0.5 PaCO2

HCO3
HCO3 pH = metabolic cause HCO3 =metabolic acidosis HCO3=metabolic alkalosis PaCO2 and HCO3 Met acido PaCO2 = (1.5x HCO3)+8+/-2 mmHg Met alkalo PaCO2 = (0.7x HCO3)+20 mmHg

 Anion gapNa (HCO3 + Cl)

NaHCO30.2xBWxBE mEq 0.2xBWx(24-HCO3) mEq

Metabolic acidosis HCO3 < 22 Predicted PaCO2 = 1.5(HCO3)+82 AG = Na (Cl+ HCO3) -12 High AG - salicylate, methanol - -azotemic renal failure -DKA -uremia -lactic acid -carbonic anhydrase inhibitor -ion exchange resin

normal AG HCO3 -GI -diarrhea -small bowel fistula -ileostomy -ureterostomy colostomy -kidney -RTA Cl -Hydrochloric acid -NaCl -ammonium chloride

AG /

HCO3

< 0.8 mixed high gap, normal gap 0.8-1.2 pure high gap metabolic acidosis > 1.2 - mixed high gap ,metabolic alkalosis

= (Na+ + K+) Cl= Unmeasured anion- Unmeasured cation+ Increased AG

Increased UA- high AG metabolic acidosis, hyperalbuminemia, metabolic alkalosis

Decreased AG
Decreased UA- hypoalbuminemia Increased UC- Li+, cationic IgG

Metabolic alkalosis HCO3 >26 mEg/l predicted PaCO2= 0.7( HCO3 ) +20

PaCO2 55-60 mmHg - - ,NG suction - -NaHCO3 -Ringer lactate /acetate - citrate - K - - aldosterone - steriod - Insulin - CO2 (Eucapnic ventilation posthypercapnia)

hiccup
Vagal and phrenic nerve
Acute: Benign, Selflimited
Gastric distention Alcohol intoxication Excessive smoking Abrupt change in environmental temperature Psychogenic

Chronic: Persistent, Intractable

Central nervous system structural lesions Vagal or phrenic nerve irritation Metabolic: uremia, hyperglycemia General anesthesia

Surgical procedures: thoracic, abdominal, prostate and urinary tract, craniotomy

Hiccup
Persistence during sleep suggests an organic cause, and resolution during sleep suggests a psychogenic cause Treatment 1. the pharynx will block the vagal portion of the reflex arc and abolish the hiccups 2. Med:chlorpromazine 25-50 mg IV q 2-4 hr Plasil 10 mg IV oral treatment can be initiated with nifedipine 10 to 20 mg tid or qid, valproic acid 15 mg/kg per d taken tid, or baclofen 10 mg tid

Pleural effusion
Positive sign of pleural effusion in upright chest film Fluid 150-200 ml In CHF: thoracentesis is reserved for those patients who do not resolve in 3 to 4 days after diuresis

Light criteria for pleural effusion

Sensitivity 98 % Specificity 65-86 % Exudate criteria 1. Pleural fluid/serum protein > 0.5 2. Pleural fluid /serum LDH > 0.6 3. Pleural fluid LDH > 2/3 upper limit LDH

Pleural fluid
Cytology : highest yield is with adenocarcinoma, much lower with squamous cell, lymphoma, or mesothelioma Neutrophil: parapneumonic, PE,pancreatitis Amylase; pancreatitis, rupture esophagus pH < 7.10 = empyema thoraces If diuretic use : serum to pleural albumin difference of greater than 1.2 g/dL = exudate

Thoracotomy indication
effusions with 1. positive cultures 2. positive Gram stain 3. pleural fluid pH below 7.10

Spontaneous pneumothorax
Spontaneous absorption rate 1-2% per d 100% 02increase rate 3-4x

Diagnosis of pneumothorax
"gold standard" the 6-foot upright PA chest radiograph the sensitivity = 83 percent

Diagnosis of pneumothorax
Ultrasonography : sensitivity 100 percent. Sonographic signs of a pneumothorax include (1) absence of lung sliding (2) "lung point" (3) absence of vertical comet-tail artifacts arising from the pleural line on a B-mode twodimensional view.

size of PTX ( in %) = ( 1 DL3 / DHT3 ) x 100

DL

DL = the diameter of the lung measured at the hilar level DHT is the internal diameter of the hemithorax measured at the hilar level.

Primary spontaneous Pneumothorax

Small (<3 cm apex to cupola) 6 hr

Oxygen 3-4 lpm

Large (>3 cm apex to cupola)

no increase in pneumothorax
ASPIRATE > 4 L
NO

repeat chest radiograph in 12 to 48 h

OBSERVE 6 HR

24 to 28 Fr tube with water seal (no suction).

NO RECURRENCE D/C FU 24 hr

Indication for ICD

1. secondary spontaneous pneumothorax, 2. recurrent pneumothorax 3. abnormal vital signs

Risk of reexpansion pulmonary edema

aged 20 to 39 years larger pneumothoraces present for >72 h rapidly expanded with suction.

Iatrogenic pneumothorax
Treatment for iatrogenic pneumothorax parallels that for spontaneous pneumothorax Hospitalization if post subclavian or pleural biosy

Treatment
ATB no indication

Pneumonia
Pneumococcal lobar Atypical-hilar adenopathy Lung abscess- staph, klebsiella Lung mass-staph, pneumococcal Alcohol-increase oral GN pathogenpneumococcal and increase klebsiella,Haemophilus spp. DM- pneumonia and mycolplasma

Atypical pneumonia
Legionella : GI symptom Chlamydia : associate with adult onset asthma Mycoplasma : extrapulmonary symptoms 1. bullous myringitis 2. Rash 3. neurologic symptoms 4. arthritis and arthralgia 5. hematologic abnormalities 6. rarely, renal failure.

Pneumonia in elderly
High mortality Atypical legionella Postinfluenza bacterial pneumonia is most commonly caused by S. pneumoniae, S. aureus, and H. Influenzae Initially afebrile 1/3 no leukocytosis

Pneumonia in elderly
Poor prognostic indicators 1. hypothermia or T > 38.3C (100.9F) 2. a low white blood cell count 3. Immunosuppression 4. gram-negative or staphylococcal infection 5. cardiac disease 6. bilateral infiltrates 7. extrapulmonary disease

Nursing home acquired pneumonia

Streptococcus pneumoniae, gram-negative bacilli, and Haemophilus influenzae

Pneumonia in transplant
First 3 mo. : GNB (especially Pseudomonas aeruginosa), Staphylococcus aureus, and Legionella predominate > 6 mo.= CAP pathogen

Lung abscess
Most = anaerobe Aerobe bacteria -- More common in immunocompromise Rx; clinda + 2nd ceph or ampi/sulbactam

pathogen
Community acquire Streptococcus pneumoniae, Staphylococcus aureus, Haemophilus influenzae, and Enterobacteriaceae hospital-acquired aspiration pneumonia Pseudomonas aeruginosa and gram-negative organisms in Anaerobe: chronic alcoholism, putrid sputum, lung abscess, periodontal disease

Syndrome and Clinical Situation Aspiration pneumonitis Signs or symptoms lasting >48 h Small bowel obstruction or use of antacids or antisecretory agents

Antibiotic (Usual Dose)*

Levofloxacin 500 mg per d or Ceftriaxone 12 g per d Levofloxacin 500 mg per d or Ceftriaxone 12 g per d, or Ciprofloxacin 400 mg every 12 h or Piperacillintazobactam 3.375 g every 6 h or Ceftazidime 2 g every 8 h

Aspiration pneumonia Communityacquired Residence in a long-term care facility Levofloxacin or Ceftriaxone Levofloxacin 500 mg per d or Piperacillintazobactam 3.375 g every 6 h or Ceftazidime 2 g every 8 h Piperacillintazobactam 3.375 g every 6 h Imipenem 0.51.0 g every 68 h Levofloxacin 500 mg per d plus clindamycin 600 mg every 8 h metronidazole 500 mg every 8 h Ciprofloxacin 400 mg every 12 h plus clindamycin 600 mg every 8 h or metronidazole 500 mg every 8 h Ceftriaxone 12 g per d plus clindamycin 600 mg every 8 h metronidazole 500 mg every 8 h

Severe periodontal disease, putrid sputum, or alcoholism

Hemoptysis
Mild < 20 mL of blood in 24 h moderate : 20 to 600 mL in 24 h massive hemoptysis >600 mL in 24 h, > 200 ml/time

Etiology of hemoptysis
Infectious: bronchitis, pneumonia, lung abscess, TB Neoplastic: lung cancer, bronchial adenoma Cardiovascular: PE, MS, CHF, pulmonary hypertension, pulmonary angiodysplasia Alveolar hemorrhage syndromes: Behet syndrome, Goodpasture syndrome, Wegener granulomatosus Hematologic: uremia, platelet dysfunction, anticoagulant therapy Traumatic: FB aspiration, ruptured bronchus, arteriotracheobronchial fistula (aortic aneurysm) Iatrogenic: bronchoscopy, lung biopsy Inflammatory: bronchiectasis, cystic fibrosis

Common cause of massive hemoptysis

Bronchiectasis TB CA Aneurysm Pulmonary angiodysplasia Lung abscess

treatment
Position bleeding lung down ET tube No 8 to allow bronchoscope coagulopathy : FFP Med; cough suppressant

Lung transplant
Signs of rejection include cough, chest tightness, fever ( 0.5C above baseline), hypoxemia, decline in FEV1 ( 10 percent), and the development of infiltrates on the chest radiograph Ddx from infection by bronchoscopy Rx: methylprednisolone 500-1000 mg Cytomegalovirus is the most commonly encountered viral agent implicated in posttransplant pulmonary infection

Active TB
thin-walled cavities (5 mm) tend to be infective and, when thick-walled (10 mm), squamous cell carcinoma of the lung enters into the differential diagnosis differential diagnoses of cavitary pulmonary lesions include infections from Staphylococcus, Klebsiella, anaerobes, and non-infectious causes like squamous cell carcinoma of the lung, pulmonary infarcts, Wegeners granulomatosis, and rheumatoid nodules

TB
Gold standard = C/s XDR = INF + Rifam

Pulmonary embolism
Site of clot Most = lower ext. Risk Hereditary: antithrimbun/proteinc-s def, factor V laden, antiphospholipid Acquire : malignancy, trauma, major surgery, post partum in 1 month, pregnancy, polycythemia vera, reduced mortality, obese, central venous catheter, bedrest > 48 hr

52

Chest film in PE
Unilateral basilar atelectasis Western mark (oligemia) Hamptonhump

Pleural based opacity

Lung infarction Hamptons hump

Pulmonary oligemia

Western Mark Sign

tintinalli

ECG
Symmetrical T inversion can present in lead V1V4 Most = sinus tachycardia S13T3 is nonspecific

echo
Differential with V-infarcgood apex motion RV dilate (Normal RV diameter is not greater than 2.5 cm)

All of the following statements are TRUE about diagnostic tests for PE EXCEPT

10% (A) The V /Q scan is 98 percent sensitive and 35 percent specific for PE
(B) Duplex ultrasound is 95 percent sensitive and 95 percent specific for DVT (C) The difficulty in using V/Q scan findings for the diagnosis of PE is the lack of a standardized definition for clinical suspicion (D) A D-dimer of less than 500 U/mL has a negative predictive value of 90 percent (E) Spiral CT is up to 90 percent sensitive and 96 percent specific for PE

D-dimer

D-dimer
Best = elisa assay At 500 ng/dl (sense 94,spec 55) False negative; on warfarin False positive 1 wk after surgery, pregnancy or post partum, malignancy pretest propability < 40 %

Diagnosis
Low to moderate prop in VQ CTA Normal VQ ruled out High prop with negative CTA further investigation Positive VQ in case of pretest propability < 40 %-> further investigation Positive VQ in case of pretest propability > 40%=diagnosis

PE: spiral CT versus VQ

Specificity of spiral CT= high probability VQ Sensitivity of spiral CT=low probability VQ
Spiral Use of contrast False negative in subsegmental PE Helpful in non diagnostic VQ(COPD,
PARENCHYMAL LUNG DIS.)

Negative VQ more sense than negative spiral CT

pregnancy
upper limit of a normal D-dimer increases with each trimester of pregnancy but should not exceed 1000 g/L at any time half-dose injection of radioactive material to perform a perfusion lung scan Or a CT angiogram without indirect venography can be performed and the uterus shielded during image acquisition (< VQ)

obese
> 190 kg Use doppler us and D-dimer to guide

You respond to a code blue on the labor-and-delivery ward. The nurse tells you that the patient is a previously healthy 41-year-old African-American woman, 4 days status post normal spontaneous vaginal delivery. She complained of chest pain and dyspnea and then fell to the floor unconscious. No seizure activity was noted. Although initially pulseless, vital signs returned with assisted ventilations. You find the patient confused, grunting, and cyanotic. Vital signs are BP 68/50 mm Hg, HR 121 beats per minute (sinus tachycardia), and RR 28, with pulse oximetry of 78 percent on high-flow oxygen. Physical examination shows distended neck veins, normal heart sounds with a prominent S2, a thready pulse with cool, cyanotic extremities, and adequate tidal volume with no rales or wheezes. Chest x-ray is normal. Bedside ultrasound of the heart shows a dilated right ventricle with parodoxical septal wall motion. In addition to immediate intubation and fluid resuscitation, what is the MOST appropriate therapeutic intervention? (A) Emergent diagnostic spiral CT (B) Heparin bolus of 80 U/kg intravenously followed by 18 U/kg infusion (C) LMWH 1 U/kg every 12 h (D) r-tPA at a dose of 100 mg over 2 h (E) Emergent transfer to the angiography suite for pulmonary arteriography and local infusion of urokinase

Anticoagulant
IV UFH or SC LMWH for initial treatment of PTE With/without overlapping with warfarin Recommend LMWH SC over IV UFH in acute nonmassive PTE LMWH SC/IV UFH for at least 5 days In renal failure recommend IV UFH over LMWH SC

anticoagulant
Prefer LMWH (grade Ia) if high risk for bleeding ,obese, renal insufficiency monitor factor 10 A Massive PE heparin 80 U/kg bolus then 18 /kg/hr Enoxaparin 1 mg/kg sc bid with a pretest probability >50 percent, empiric heparin should be administered

Thrombolytic
Definite= PE with cardiogenic shock Other clinical judge case by case including severe hypoxia Use sk- 250,000 u IV over 30 min then 100,000 /hr for 24 hr

Surgery;
RV emboli Severe refractory hypotension

PE with arrest
CPRno pulse returns within a few minutes bolus inject 100 mg of alteplase or an equivalent dose of fibrinolytic therapy while cardiopulmonary resuscitation is continued for at least 20 min ROSC image to locate embolus surgical thrombectomy

Pitfall
hypercoag state heparin(LMWH has no effect) Ventilation/Perfusion scintigraphy
Required cooperation Not proper for unstable cases

Pulmonary CTA
Not available Required contrast agent

Systemic/local thrombolysis
Acute massive PTE with clinical unstable Systemic thrombolysis is recommend, unless contraindicated Recommend not to use local thrombosis Short term thrombolysis over long term infusion In those case, CVT should be consulted as initial management

Thrombus defragmentation therapy Surgical thromboembolectomy

Only in unstable case with contraindicate for thrombolysis Until now no evidence of benefit over lytic therapy

COPD with AE

Acute asthmatic attack

Asthma in Pregnancy
No side effect of medication (B2-agonists,sterods) but fetal hypoxia may be greater risk Physiologic hyperventilation leads to higher PaO2 ;
if PaO2 less than 70 mmHg represents severe hypoxemia less than 35 mmHg represents respiratory failure

Anterior mediastinal mass

Obscure heart border differential diagnoses of masses in the anterior mediastinum include the 5 Ts: thyroid masses, teratoma, thymic masses, (terrible) lymphoma, and thoracic aneurysm.

53

 74 yo man with COPD WITH AE. After start bipap with I 10 E 4 20 , rate 10, 20 min later the patient oxygenation is not improve which of the following change most likely increase patient oxygenation. a) increase in IPAP for 10-15 b) Increase rate from 10-12 c) Decrease EPAP from 4 to 2 d) Increase EPAP from 4 to 7 IPAP from 10-15 e) Decrease EPAP from 4 to 2 and IPAP from 10 to 5

BIPAP
oxygenation.: PEEP(concomitantly increase IPAP to maintain positive pressure differentiation during inspiration) and Fio2 PaCO2: rr

Non invasive
1. 2. 3. 4. 5. Consciousness( CO2 retension 1530 ) Co-operate CVS stable Asphyxia, aspiration, airway obstruction ect PaO2 < 60 with 100%O2

Problem with NPPV

Oxygen concentration Rebreathing esp EPAP< 4 cmH2O Dyssynchrony Rise time

BiPAP
IPAP ~8 cmH2O acute 10-16 20 ( OSA 40) EPAP;Rebreathing esp EPAP< 4 cmH2O Back up rate 12-24 Rise time 0.05-0.1 sec 0.3-0.4 sec Maximum inspiratory time I:E 1:1 Blender, Humidifier

COPD pH > 7.30-7.35 PaCO2 45-60 mmHg RR >25 Accessory muscle,paradoxical abdominalmotion

 63 yo woman present with ARDS. Which of the following summarized best ventilation strategies in ARDS? a) Owing to low compliance, pt need higher TV, higher PEEP to ensure adewuate ventilaiton b) Owing to significant airway obstruction, pt require very low or no PEEP similar to asthma to avoid air trapping c) Owing to low compliance , pt require low TV, and higher PEEP to avoid barotrauma d) Owing to high compliance, pt donot require PEEP

ALI and ARDS

Bilateral pulmonary infiltration or edema without LV failure (PCWP <18) Hypoxemia PaO2/FiO2 < 300 = ALI < 200 = ARDS Direct insult and indirect insult

condition setting

Periop A A/C or SIMV 0.4-0.6 10-12

ARDS B A/C 1.0 6-8

COPD C A/C, SIMV 0.4-0.6 8-10

Neuro D musc

CHF E A/C, SIMV 0.4-0.6 8-12

Mode FiO2 VT (ml/kg) RR Peak flow (L/min) PEEP waveform

A/C 0.21 12-14

8-12 10-14 Due 12-20 to low TV,8-12 give higher PEEP 10-14 to keep adequate oxygenation 40 40-80(FiO2 60-100 60 < 0.5) 60 5
Decelerating

5-15
Decelerating

3
Decelerating or square

0-3
Decelerating or square

5-10
Decelerating or square

condition setting

Periop A A/C or SIMV 0.4-0.6 10-12 8-12 40 5

Decelerating

ARDS B A/C 1.0 6-8 12-20 40-80 5-15

Decelerating

COPD C A/C, SIMV 0.4-0.6

Neuro D musc

CHF E A/C, SIMV 0.4-0.6

Mode FiO2 VT (ml/kg) RR Peak flow (L/min) PEEP waveform

A/C 0.21

Goal 8-10

12-14 8-12 Keep pH normal O2Sat >90% 8-12 <3510-14 Pplat cmH20 10-14 sedative 60-100 60 60 TV Permisive hypercapnia 3 0-3 5-10
Decelerating or square Decelerating or square Decelerating or square

 The most widely used ventilatory stratagy in acute asthmatic attack aims to accomplish which of the following objective a) Pt purposefully hypoventilated, maintaining elevated PaCO2 to keep airway pressure at safe level b) Pt purposefully hyperventilated to bring PaCO2 back to normal because ventilatory failure is primary reason for intubation c) Initial ventilator setting are no different than patient intubated for altered mental status d) Inspiratory flow rates are set very low to avoid causing very high peak airway pressures e) The inspiratory flow curve should be ramp-style wave instead of square style wave to maximized expiratory times

condition setting

Periop A A/C or SIMV 0.4-0.6 10-12 8-12 40 5

Decelerating

ARDS B A/C 1.0 6-8 12-20 40-80 5-15

Decelerating

COPD C A/C, SIMV 0.4-0.6 8-10 8-12 60-100 3

Decelerating or square

Neuro D musc

CHF E A/C, SIMV 0.4-0.6 8-12 10-14 60 5-10

Decelerating or square

Mode FiO2 VT (ml/kg) RR Peak flow (L/min) PEEP waveform

A/C 0.21 12-14 10-14 60 0-3

Decelerating or square

condition setting

Periop A

ARDS B

COPD C A/C, SIMV 0.4-0.6 8-10 8-12 60-100 3

Decelerating or square

Neuro D musc

CHF E A/C, SIMV

Mode FiO2 VT (ml/kg) RR Peak flow (L/min) PEEP waveform

A/C A/C DHIor SIMV IntrinsicPEEP autoPEEP 0.4-0.6 1.0 Dynamic airway 10-12 collapse 6-8 8-12 40 5
Decelerating

A/C

0.21 0.4-0.6 Maximize

exp.time to 12-14 avoid air8-12 trap by shorten inspitime(high 10-14 10-14 insp.flow) and square wave 60 60 form, decrease min.vent ( Vt or RR)

12-20 40-80 5-15

Decelerating

0-3

5-10

Decelerating or square

Decelerating or square