abg’s, cpap, & vents
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Respiratory Care for Paramedics
ABG, CPAP, Ventilation
1-13 Voitek A. Novakovski BSRC, RRT, NREMT-P, CCEMT-P 1
Ventilation vs. Respiration
1-13 Voitek A. Novakovski RRT, CCEMT-P 2
1-13 Voitek A. Novakovski RRT, CCEMT-P 3
1-13 Voitek A. Novakovski RRT, CCEMT-P 4
Respiratory Cycle, Capacities, and Volume
Physiology of Respiration
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Normal ABG Values
Abnormalities of Respiration Ventilation / perfusion (V/Q) defect
– Ratio of pulmonary alveolar ventilation to pulmonary capillary perfusion is disrupted
– Normal V/Q ratio is 1:0.8 = VA/CO – Area of lung receives ventilation little or no blood
flow = dead space ventilation u Increased FIO2 results in increased SpO2
u PCO2 may be normal or increased
– Area of lung receives blood flow but no ventilation = shunt unit
u Increased FIO2 does not result in increased SpO2
u PCO2 may be normal or decreased
© 2011 UMBC Breathing Management CCEMT-P SM 1-13 8
Pathophysiology of Respiratory Disorders
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Shunt Normal Dead Space
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Types of Failure u Hypoxemic
– Room air PaO2 ≤ 50 or SpO2 ≤ 85% u Hypercarbic
– PaCO2 ≥ 50 – pH ≤ 7.32
u Caution with patients that have acute on chronic failure – Their normal SpO2 may be ≈ 88% – Their normal PCO2 may be ≥ 50
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Manifestations of Respiratory Distress
u Altered Mental Status u Increased Work of Breathing
– Tachypnea -the single most important indicator of critical illness
– Accessory muscle use, retractions, paradoxical breathing pattern
u Catecholamine release – Tachycardia, diaphoresis, hypertension
u Abnormal blood gas values – Oxyhemaglobin Saturation
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Pulse Oximetry u IR spectroscopy u Arterial oxygen saturation u False readings
– CO poisoning – Temperature extremes – Medications causing vasoconstriction – Nitrates – Movement – Extraneous light sources
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Oxygen Saturation Curve
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Pathophysiology of Hypoxemia u Ventilation/Perfusion Mismatch
– Shunt effect – Increased Dead Space
u Alveolar Hypoventilation
u Decreased Diffusion – Pulmonary Contusion – High Altitude – Pulmonary Edema
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A nasty mosis
9/11/2011 Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, 17
Pathophysiology of Hypercapnia
u Bradypnia – decreased f (resp rate) u Hypopnia – decreased Vt (tidal vol)
a. VT=VA+VD Average VD=150 ml or≈30% b. Minute Volume = the total amount of
air going in and out of the lungs per minute
c. Minute Alveolar Ventilation = the total amount of air going into and out of the alveoli per minute = f X (VT-VD)
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Pathophysiology of Hypercapnia
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Pathophysiology of Hypercapnia
A. f=12, VT=400ml A. ? VA=
B. f=24, VT=250ml A. ? VA=
1. Which patient will have a higher CO2?
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Pathophysiology of Hypercapnia
u Hypovolemia u Low cardiac output u Pulmonary embolus u High mean airway pressures u Short-term compensation by
increasing tidal volume and/or respiratory rate
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Capnography u IR spectroscopy u CO2 levels at airway entrance u Alveolar CO2 levels may be
estimated u Excellent detector of cardiac output
– CPR – Keep ETCO2 ≥ 10 – ROSC – Sudden increase to ≥ 35-40
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Arterial Blood Gas (ABG) Acid-base balance / respiratory involvement
– pH, PO2, & PCO2 are measured (HCO3 is calculated)
– Assess pH: acidosis / alkalosis e.g. ± pH 7.40 – Assess pCO2: hyper / hypocapnea ± 40 – Changes in pH from changes in PCO2
u Acute: 10 mmHg change in PCO2 = 0.08 change in pH
u Chronic: 10 mmHg change in PCO2 = 0.03 change in pH
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Arterial Blood Gas (ABG)
– There is no such thing as complete compensation u If change in pH not from PCO2 than there is a metabolic component
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ABG Sampling
u Radial artery puncture – Modified Allen Test – needs to
be done u Indwelling access
– Procedure varies by device
u I-STAT, IRMA etc. portable blood gas analyzers known as POC devices. Know the law, CLIA determines who can analyze.
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Quiz Time 2. pH 7.28, PCO2 55, PO2 58 3. pH 7.52, PCO2 25, PO2 48 4. pH 7.25, PCO2 50, PO2 70 5. pH 7.50, PCO2 30, PO2 75 6. pH 7.22, PCO2 34, PO2 94 7. pH 7.37, PCO2 52, PO2 50
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Ventilator Management
9/11/2011 Voitek A. Novakovski BSRC, RRT, NREMT-P, CCEMT-P 27
Insufflation of Tobacco Smoke per Rectum
Copyright Intensive Care On-line Network 2002
Ventilator Procedures
In case of instability or mechanical difficulty, disconnect the ventilator and use manual ventilation.
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u To calculate how long an oxygen tank will last (safety factor ≠ 200 psig)
– Know the tank factors: u H or K = 3.14 u M = 1.65 u E = 0.28 u D = 0.16
u Tank Life in Minutes = (tank pressure in psi x factor) liters per minute
8. You have a Pt on a non-rebreather @ 15 Lpm. You are using an E cylinder with 1800 psig. How long will it last before you should change it?
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On-Board O2 Calculation
Terminology u Fraction of Inspired
Oxygen (FiO2) u Tidal Volume (VT) u Deadspace (VD) u Frequency (f) u Minute Ventilation (VE) u Minute Alveolar
Ventilation (VA) u Flow Rate u Inspiratory Time
u I:E Ratio u Airway Pressure
– Actual – Mean – Peak
u Compliance u PEEP
(Positive End Expiratory Pressure)/CPAP
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Fraction of Inspired Oxygen u Oxygen concentration, expressed as
fraction in decimal form – e.g. 50% O2 = FiO2 0.5 – FiO2 of 0.65 = 65% O2
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Airway Pressure u Actual (Paw)
– Real-time airway pressure u Mean (MAP)
– Mean pressure over one complete ventilatory cycle or over a specific period of time
u Peak (PIP) – Highest pressure over a single
ventilatory cycle CCEMT-P SM 6/98
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Inspiratory (I) Time u Amount of time to deliver a single
breath, measured in seconds u In Time Cycled Ventilation:
I time x flow rate = VT 9. If frequency is 12, and I time is 1.5
seconds, what is the Expiratory (E) time?
10. How long is each breath cycle
© 2001 UMBC Breathing Management CCEMT-P SM 6/98
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Flow Rate u Inspiratory (I) flow measured in lpm u Maintain desired I : E ratio u Flow may affect pressures u In Time Cycled Ventilation:
flow rate x I time = VT 30 Lpm x 1.5 seconds = 750 ml 60 Lpm x 0.5 seconds = 500 ml
11. 40 Lpm x 0.75 second = ? VT
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I:E Ratio u Ratio of time for I:E for normal
breathing is 1:2 u Clinical situations may require ratio
to change (ET tubes cause resistance to exhalation and may require longer expiratory times and I:E of 1:3 or longer.
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Compliance u Measure of the willingness of the
lungs to expand with a positive pressure breath – Increased compliance
u Lungs are more receptive to a mechanical breath
u Reflected in lower airway pressures
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Spontaneous vs. Mechanical breathing - supine
u increases ventilation to non-perfused areas u increases V/Q mismatch u increases posterior consolidation/atelectasis u increased diaphragmatic tone decreases
atelectasis u decreases venous return and cardiac output
9/11/2011 Voitek A. Novakovski BSRC, RRT, NREMT-P, CCEMT-P, AE-C
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– Decreased compliance u Lungs are less receptive to a mechanical
breath, and airway pressures increase – Patient may be developing a pneumo or
hemothorax, – Restrictive lung disease or process such as
pneumonia, or atelecasis – Developing ARDS or pulmonary edema
u Patients with COPD usually have high compliance with increased expiratory resistance.
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Compliance
Resistance u This is reflected when there is a high
PIP but low plateau pressures and a long exhalation time. – Common with Asthma or Acute COPD
exacerbation
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Mechanical Ventilation u Complications
– Bio-mechanical Trauma/Pneumothorax u Reduced by PEEP u Avoid overdistention
– Airway trauma u Keep head aligned with torso
– Atelectasis u Humidify the air (HME) u Avoid excessive suction u Vary Pt’s position
– Oxygen toxicity u Use the lowest FIO2 that results in adequate PaO2
– Device dependence
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Portable Ventilators u Complications
– Machine failure – Hypotension – Pulmonary infection – GI malfunction – Renal malfunction – CNS malfunction – Psychological trauma
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Potential Complications of MV u Ventilator malfunction
– Manually ventilate patient u Cardiovascular compromise
– Especially initial hypotension which responds well to fluid bolus
– Careful to avoid fluid overload u Check BS for crackles
u Dysrhythmias – Monitor vital signs
u Monitor PIP for changes – Breath sound equality
Potential Complications of MV u Pulmonary oxygen toxicity
– goal: FIO2 as low as possible while maintaining a PaO2 > 70, SpO2 ≥ 94%
u Positive fluid balance – monitor BP, I/O, and breath sounds
u Gastric distention – monitor bowel sounds, NG tube
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Principles of Ventilatory Support u Oxygenation
– PO2 u Affected by controlling FiO2, FRC, and/or
Mean Paw
u Ventilation – pH – PCO2
u Affected by controlling VA (Minute Alveolar Ventilation)
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Common Mechanical Ventilator Characteristics (1 of 2)
u Power source: pneumatic or electric – External – Internal
u Cycling – Which variable terminates inspiratory
phase of breath: vol, time, flow, or pressure
u Breath delivery – Either positive or negative pressure
Common Mechanical Ventilator Characteristics (2 of 2)
u Parameters – Mode, tidal volume, respiratory rate,
flow, FiO2, PEEP selected by clinician u Ventilator circuit
– Reusable or disposable u Alarms
– Vary in type – Set for individual patient, never disabled
Ventilator Setup Procedures – FiO2: Always start at 1.0 and adjust by SpO2 – Select mode (if Pt transport try to mimic
settings of ventilator patient is on) – Set respiratory rate – Set tidal volume, Insp time, or Pressure – Set flow rate; if adjustable – Set PEEP – Connect ventilator and observe for stability – Check PIP, Plateau Pressure, and return Vol, – Set alarms – Patency of circuitry and all connections – Check vital signs, SpO2, and ETCO2
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Modes of Ventilation u Overview
– Control – Assist/Control – Synchronized Intermittent Mandatory
Ventilation (SIMV) – Pressure Control – Pressure Support – Continuous Positive Airway Pressure
(CPAP)
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Control All parameters of the ventilator cycle
(frequency, VT, flow rate) are controlled by the ventilator – Patient is “locked out” from triggering a
breath – Patient has no active role in ventilatory
cycle – Rarely used
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Assist/Control u Usually Volume cycled ventilation
– Most popular and easily applied – Essential parameter to control is volume
delivery, inspiratory flow (time), f (rate), FiO2, and sensitivity (-2cmH2O)
u Tidal volume (VT) and minute volume (VE) are predictable, PIP variable
u Anxious patients may create stacking u Ventilator may be triggered by road
vibrations. 53
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 54
SIMV or SIMV with PS u Ventilator delivers set number of machine
breaths at set FiO2 – Respiratory rate, Insp Flow, and VT are set – Synchronized with patient’s spontaneous efforts
u Additional spontaneous breaths possible through circuit – Spontaneous breaths may Pressure assisted – Flow rate and VT are patient controlled – Keeps respiratory muscles active and
coordinated u Decreases stacking and need for sedation
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9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 56
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 57
Pressure Control u Pressure limited-time cycled ventilation
– Inspiration ends at a pre-set time and airway pressure
– Volume per breath may be variable – Often used with ARDS to limit applied pressure – Exhaled volume must be monitored closely – Not well tolerated by awake patients and
usually requires deep sedation
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9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 59
Pressure Support u Pressure limited-flow cycled ventilation
– Inspiration limited by applied pressure, and ends at a pre-set terminal flow
– Volume per breath may be variable – Lungs should be relatively free of resistance and
compliant – Patient sedated or cooperative – Usually support needed for less than 24 hours or
weaning from long term ventilation – May be used for long-term chronic support
u Often used with SIMV to enchance spontaneous breaths and overcome ET tube resistance.
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9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 61
Dual Modes u Starts as a Pressure Limited mode which
adjusts the pressure limit on a breath by breath basis in order to achieve a desired Tidal Vol (VT) and/or Minute Vol (VE)
u Utilize the advantages of pressure limited modes which allow flow to more accurately meet patient demand. – PRVC: Pressure Regulated Volume Control – Volume Control Plus – Volume Support – Automode
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General Clinical Guidelines Tidal volume (VT) Respiratory rate (f) FiO2 Flowrate PIP Minute volume (VE) Sensitivity High Pressure Limit Low Pressure Limit
6-8 ml/Kg 10-14 bpm (ETCO2 35-40) ABG (PO2) or SpO2≥94% 40-60 lpm (I:E ratio) ≤ 40 cmH2O ABG(PCO2/pH)ETCO2 -2 cm, adjust as needed 10 cm above PIP 10 cm below PIP
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Monitors u Airway Pressure (Paw or PIP)
– Real time manometer or graph – Range: 0-120 cm H2O (depends on vent)
u Monitor Display – Breath rate – Flow – High pressure alarm – Low pressure alarm – PEEP – I time or I:E – VT – VE
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Ventilator Alarms u High airway pressure (PIP) u Low airway pressure u High respiratory rate u Low respiratory rate u High minute volume u Low minute volume u Low exhaled tidal volume u Apnea
Ventilator Alarms (con’t) u High pressure limit
– Usually set 10 cm H2O above patient’s average PIP
– When activated, ventilator terminates breath u Causes of high pressure alarm violation
– Resistance to gas flow: kinks or water in tubing, secretions, bronchospasm, patient coughing, gagging, “fighting the ventilator”
– Decrease in lung compliance, lungs become “stiffer”: atelectasis, pneumothorax, pulmonary edema
Ventilator Alarms (con’t) u Low pressure limit
– Primary cause: patient disconnect, or leak in system
– Inspiratory flow too low and patient gasping for air (increase flow to meet demand)
u Low exhaled volume or minute ventilation – Usually set ~10% below set VT and average VE – Ensures adequate alveolar ventilation is
maintained – Causes: air leaks, decrease in compliance with
PSV and PCV, high pressure alarm triggered and breath delivery terminated
– Check for bubbling in chest tubes
u High Rate: usually set ≈ 10 over average rate – Alarm indicates agitation, hypoxia, or
insufficient VT – Check vital signs, SpO2, ETCO2, exhaled
VT, or provide sedation – May be due to “auto-cycling”, check
sensitivity, or check for leaks in circuit
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Ventilator Alarms (con’t)
Ventilator Alarms (cont) u High exhaled tidal volume or minute
ventilation – Increased metabolic demand – Neurologic abnormality – May indicate hypoxemia – Anxiety – Pain – Fever – Acidosis
Ventilator Alarms (con’t) u Low Rate: usually set ≈ 10 below
average rate – For spontaneous breathing modes like
PS or CPAP this alarm is critical and indicates either patient is fatigued or over sedated.
u Low tidal volume: usually ≈ 10% below average or set VT – Alarm usually due to leak in the system – In PS or CPAP pt fatigued or over
sedated 1-13 Voitek A. Novakovski RRT, CCEMT-P 70
Ventilator Alarms (cont)
u Apnea Alarm: this alarm is mostly used with PS or CPAP: – Patient has stopped breathing – May initiate apnea backup ventilation on
some ventilators u Disconnect: some ventilators have
this alarm in addition to a low pressure alarm.
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Ventilator Alarms (cont) u Apnea Alarm: this alarm is mostly
used with PS or CPAP: – Patient has stopped breathing – May initiate apnea backup ventilation on
some ventilators u Disconnect: some ventilators have
this alarm in addition to a low pressure alarm.
Ventilator Alarms (continued) u Ventilator Inoperative (some vents)
– normal operation ceases u Breathe room air if spontaneous breathing is present
– recoverable u Loss of external power or voltage out of range u Mode switch temporarily set to Off
– non-recoverable u Software or CPU problem
u External Power Low/Fail – Ventilators with this alarm switch to internal
battery
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Ventilator Alarms (cont) u Battery Low/Fail
– Switch to external power u Low PEEP
– Monitored PEEP value deviates from manually set value: check for leaks in system
u Transducer Calibration – Self test shows baseline pressure +/- 2 cm
H2O from zero – Calibrate ventilator
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Flow-Restricted, Oxygen-Powered Ventilation Device (1 of 4)
u Third potential source for artificial ventilation – Manually triggered ventilator or demand
valve – Used to ventilate apneic patients or to
administer supplemental oxygen to spontaneously breathing patients
Flow-Restricted, Oxygen-Powered Ventilation Device (2 of 4)
Demand valve triggered by the negative pressure generated during inhalation
Valve automatically delivers 100% oxygen and stops the flow of gas at the end of inhalation.
Patients find it most comfortable if they hold the mask to their face themselves.
Flow-Restricted, Oxygen-Powered Ventilation Device (3 of 4)
u Apneic patients – Pushbutton on top of the FROPVD can control
the flow of oxygen. – When depressed, 100% oxygen flows at a rate
of 40 L/min. u Requires an oxygen source
– Operator cannot feel whether the patient is being adequately ventilated with this device.
Flow-Restricted, Oxygen-Powered Ventilation Device (4 of 4)
u Use – Has been used for several years – Recent findings suggest that it should not be
used routinely because of the high incidence of gastric distention and damage to intrathoracic structures caused by barotraumas.
– Should not be used when ventilating infants or children or for patients with possible cervical spine or chest injury
– Cricoid pressure may need to be maintained to ventilate nonintubated patients.
Skill Drill 11-21: Flow-Restricted, Oxygen-Powered Ventilation for Apneic Patients (1 of 2)
Step 1
Step 2
Step 3
Skill Drill 11-21: Flow-Restricted, Oxygen-Powered Ventilation for Apneic Patients (2 of 2)
Step 4 Step 5
Skill Drill 11-22: Flow-Restricted, Oxygen-Powered Ventilation Device for Conscious, Spontaneously Breathing Patients
Step 1 Step 2 Step 3
PEEP vs. CPAP
? ? ?
?
?
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 83
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 84
Lung Volume
Inspiratory Capacity
F.R.C. Functional Residual Capacity
TOTA
L LU
NG
CA
PAC
ITY
(600
0 cc
)
500 cc
3100 cc
1200 cc
1200 cc
Inspiratory Reserve
Tidal volume
Expiratory Reserve
Residual Volume
PEEP u Positive end expiratory pressure u Increases functional residual
capacity (FRC)
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P, CCEMT-P,
AE-C 85
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 86
Collateral channels of ventilation: Pendeluft
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PEEP u Definition
– Positive End Expiratory Pressure: The Application of positive pressure to the airway at end exhalation.
– Used to increase FRC to normal levels. u Used with other mechanical ventilation modes
such as A/C, SIMV, PS, or PCV
5 cm H2O PEEP
CPAP u Definition: PEEP applied to a spontaneously
breathing patient: without mechanical assist. – Continuous Positive Airway Pressure: Constant
positive pressure throughout the ventilatory cycle
– Requires spontaneous respiratory drive – Rate and VT determined entirely by the patient
10 cm H2O PEEP
Time
Spontaneous Breathing
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 90
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 91
CPAP u Must set back-up ventilation
parameters if available u Benefits by normalizing FRC:
– Increases compliance – Decreases atelectasis – Reduces pulmonary edema – Increases PaO2 – Decreases work of breathing (WOB) – Splints airways in Asthma and COPD
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CPAP The National Association of EMS Physicians (NAEMSP) believes that noninvasive positive pressure ventilation
(NIPPV) is an important treatment modality for the prehospital management of acute dyspnea. This document is the official position of the NAEMSP.
Read More: http://informahealthcare.com/doi/abs/
10.3109/10903127.2011.561418
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 93
10 Commandments of Transport Ventilation
1) Maintain set PEEP (bagging) 2) Hold ETT when switching 3) Your vent = their vent 4) Transition to vent early and observe 5) Security of airway. Re-tape if necessary 6) Adequate portable oxygen supply 7) Judicious use of paralytics or sedatives 8) Track plateau versus PIP 9) Maintain EtCO2 and SpO2 10) Minimal to no changes
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 94
Critical Care Ventilator Transport u It is important that you set your ventilator to
settings as close as possible to what kept the patient stable in the hospital. Adjust as needed
u If you are unable to stabilize the patient on your ventilator, then a respiratory therapist may be required to accompany you using the hospital ventilator, or you may have to refuse transport.
u If you take their ventilator, make sure it is compatible with your power source.
u Do not attempt to transport a patient that is beyond your capability to maintain.
9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 95
Pharmacologic Adjuncts u Bronchodilators
– β2-agonists – Anticholinergics (ipratropium)
u Corticosteroids u Sedatives u Paralytics u Pressors u Inotropic agents
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9/11/2011 CCEMT-P Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P, AE-C 97
Paul Andrate
Quiz u Pt 32 y/o intubated on vent, VT
450ml, f 14, FiO2 1.0 – ABG pH 7.37, PCO2 42, PO2 64 – What would you change or add?
u Pt 17 y/o Asthmatic on 4L/NC with bilat insp and exp wheezes. – ABG pH 7.43, PCO2 36, PO2 92 – What 2 classes of drugs plus other
options might help this young man?
1-13 Voitek A. Novakovski BSRC, RRT, NREMT-P,
CCEMT-P 98
Noninvasive Positive-Pressure Ventilation (NPPV)
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Relative Contraindications for NPPV
u Decreased level of consciousness u Poor airway protective reflexes u Copious secretions u Cardiovascular instability u Progressive pulmonary
decompensation u Upper gastrointestinal hemorrhage
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Initiation of NPPV u Set FIO2 at 1.00 u Hypoxemic failure
– Inspiratory pressure (IPAP) 10 cm H2O – Expiratory pressure (EPAP) 5 cm H2O – Titrate EPAP in 2 cm H2O increments
u Ventilatory failure – IPAP 10 and EPAP 2 cm H2O – Titrate IPAP in 2 cm H2O increments
Initiation of NPPV u Make changes every 15-30 minutes u Monitor vital signs, appearance,
pulse oximetry and blood gases u Head of bed at 45° angle u Consider gastric decompression u Intubation if patient deteriorates
Airway pressure release ventilation
Copyright Intensive Care On-line Network 2002
APRV
Copyright Intensive Care On-line Network 2002
APRV u Advantages
– Lower peak/plateau – Spontaneous
breathing permitted – Decreased sedation – Elimination of NMB
u (Frawley & Habashi 2001)
u Potential disadvantages – Change in compliance
= change in volume – New technology – Limited access – More research – Transports
Copyright Intensive Care On-line Network 2002
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