mechanical ventilation 1 - ubc critical care medicine of... · mechanical ventilation 1 shari...
TRANSCRIPT
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Mechanical Ventilation 1
Shari McKeown, RRTRespiratory Services - VGH
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Objectives
Describe indications for mcventDescribe types of breaths and modes of ventilationDescribe compliance and resistance and how this affects ventilationDescribe ventilator troubleshooting
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Indications for McVent
Oxygenation abnormalitiesRefractory hypoxemiaNeed for positive end expiratory pressure (PEEP)Excessive work of breathing
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Indications for McVent –cont’d
Ventilation abnormalitiesRespiratory muscle dysfunction
• Respiratory muscle fatigue• Chest wall abnormalities• Neuromuscular disease
Decreased ventilatory driveIncreased airway resistance and/or obstruction
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Modes of Ventilation
ASV, APRV, AV, AutoMode, Bilevel, BiPAP, EPAP, Fluid Logic, HFJV, HFOV, IPPV, IPAP, MMV, NEEP, PAV, PCV+, PCIRV, PCSIMV, PRVS, PRVC, PV, VCIRV, IRV, VS, etc, etc, etc!!!
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Types of Ventilator Modes
Mandatory Operator sets RROperator sets start, stop, and everything in betweenPatient can trigger extra mandatory breaths
SpontaneousPatient sets RRPatient controls start, stopPatient triggers all breaths
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Types of Ventilator BreathsMandatory
Volume Breath• Flow set• Volume cycled
Pressure Breath• Pressure set• Time cycled
SpontaneousPressure supported breath
• Pressure set• Patient insp flow cycled
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Choosing a Mode
Consider trial of NPPVDetermine patient needsIdentify goals
Adequate ventilation and oxygenationDecreased work of breathingPatient comfort and synchronyRemove vent asap
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Spontaneous Ventilation
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Continuous Positive Airway Pressure (CPAP)
No machine breaths deliveredAllows spontaneous breathing at elevated baseline pressurePatient has complete control over RR and tidal volume
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Pressure SupportRR triggered by patientPreset level of inspiratory support delivered Cycles to expiration when inspiratory flow slows to preset levelVT depends on compliance, resistance, pressure level, and patient effort
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Pressure Support – cont’dAdvantages
Patient comfortDecreased work of breathingMay enhance patient-ventilator synchrony
DisadvantagesVariable volumesInappropriate supportRelies on apnea backupLeaks may interfere with cycling
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Assist-Control (Volume)Set RR, set tidal volume, insp pressure variablePatient triggers extra breaths with full tidal volumeAdvantages: guarantees minute ventilationDisadvantages: hyperventilation, hemodynamic effects, ‘breath stacking’
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Assist-Control (Pressure)Set RR, set insp pressure, tidal volume variablePatient triggers extra breaths with full pressureAdvantages: limits pressureDisadvantages: hyperventilation, hemodynamic effects, ‘breath stacking’
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Synchronized Intermittent Mandatory Ventilation (SIMV)
Mandatory breaths – volume or pressure breathsSpontaneous breaths – pressure support
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SIMV – cont’d
AdvantagesLess hemodynamic effectsLess inappropriate hyperventilationGuarantees some minute ventilation
Disadvantages:Not physiological
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Measurements
ComplianceResistancePeak airway pressurePlateau pressure
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Compliance
Measures compliance of the lung and thoraxTidal volume / Plateau-PEEPUnits = ml/cmH20
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Resistance
Measures airway resistanceLengthViscosityFlowRadius4
Peak-plateau / FlowrateUnits = cmH20/Lps
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Peak and Plateau Pressures
Peak airway pressure reflectsBaseline (PEEP)Pressure due to compliance (L+T)Pressure due to resistance
Plateau pressure (breath hold) reflectsBaseline (PEEP)Pressure due to compliance (L+T)(alveolar distending pressure)
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Waveform
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Troubleshooting
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Mechanical Ventilation 2
Fundamentals of Critical Care Support
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Objectives
Initiation of mcventMonitoringImproving oxygenationImproving ventilationObstructive Lung DisordersRestrictive Lung DisordersPediatric considerations
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Initiation of McVentChoose your modeSet minute ventilation for pH
RRVT (8-10 ml/kg)I:E
Set oxygenation for SpO2 or SaO2PEEPFiO2
Trigger level
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Set sedation, analgesia, NM blockadeMonitors
ECG, SpO2, Vitals, ObservationAlarms
Hi/Low pressureLow volumeApnea
Humidification
Initiation cont’d
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Initiation cont’d
EvaluationCXRPeak/plateauExhaled VT and RR(TOT)Patient-Ventilator synchronyAutopeepSpO2, ABGHemodynamics
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Improving Oxygenation
FiO2Mean Airway Pressure
PEEP• Recruit lung• Improve compliance• Redistribute lung water/blood
Insp pressureInspiratory time
Goal Sp02 >92%, FiO2 <0.50
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Improving Ventilation
Tidal VolumeWatch Plateau
Respiratory RateWatch for Autopeep
Goal pH = normal
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Obstructive Lung Disorders
Asthma/COPDInflammationBronchoconstrictionInc. mucous prod/Dec. clearanceDecreased expiratory flowrates
• Autopeep• Hemodynamic compromise• Barotrauma
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Obstructive Lung Disorders -Ventilator Strategies
Decrease RRSedation to decrease drive
Permissive HypercapniapH >7.25Contraindications Heads, Hearts
Plateau <30cmH20
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Restrictive Lung Disorders
Intrapulmonary ARDSCHFPneumoniaFibrosis
ExtrapulmonaryObesityPregnancyAscites
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Restrictive Lung Disorders –Ventilatory Strategies
IntrapulmonaryRecruit collapsed lung
• High PEEP• Increase TI
Prevent overdistension• Plateau <30cmH20• VT 4-6 ml/kg
Goal FiO2 <0.50?Extrapulmonary
Same as above, with Plateau <40cmH20
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Pediatric Considerations
Infants (<5 kg)Time-cycled, pressure limited modesStart Peak pressure 18-20 cmH20TI .5-.6 secVT to chest expansion or 8 ml/kgPEEP 2-4
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Pediatric Considerations –cont’d
ChildrenSIMV modeVT 8-10 ml/kgTI
• Infants - .5-.6 sec• Toddlers - .6-.8 sec• Older - .8-1.0 sec
RR < 18-20 Peep 5
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Mechanical Ventilation