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Lung protective Ventilation

DR. sadeghnia

Murphy-type Endotracheal tube

Tip bevel

Thermolabile

Polyurethane

Silicon

Correct placement of ETT

Tip should be kept at the level of the first or second thoracic vertebra

Carina adjacent to the third or forth thoracic vertebra

T2

Magnitude of Humidity

Cold and dry air,

25°C, 30% rH

37°C

, 85%

100%

37°C

, 100%

90%

Gas Saturation

Point

The human body will heat up the gas to 37°C and humidify it to 100% rH (44 mg of Water per Liter)

Inspiration

Expiration

Structure of the Airways

• BR = Bronchus

• BL = Bronchiole

• TBL = terminal Bronchiole

• RBL = respiratory bronchiole

• AD = alveolar duct

• AS = alveolar sac

• Till the 16 Generation =Gastransportation

• From the 17 Generation = Gasexchange / Oxygenation

Respiratory Gaseous Exchange

Magnitude of Humidity

Inappropriate humidification:

Increased secretion

Mucus thick

Clearance stopped

Cilia stopped

Cell damage:

Surfactant dysfunction

infection

Hemorrhage

Active Humidification

PMH7000 MR850

Evaqua

Active Humidification

Invasive

Noninvasive

Active Humidification

Active

Humidification

Optimal lung volume strategy

Open Lung Ventilation Facts

Open lung ventilation strategy more important than the ventilation mode

A few injurious inflation in lung evolving trigger the VILI

Low (if lung be atelectatic with regional overdistention or EELV be high with exceed TLC) and high volume can induced volutrauma

Optimizing EELV for recruitment (reversing atelectasis) and stabilizing lung units throughout ventilator cycle (avoiding atelectrauma)

Adequate recruitment with adequate PEEP (above the critical closing pressure) stabilize the previously opened alveoli)

Open lung ventilation is feasible with optimal using Pmax and PEEP to, respectively recruit and stabilize the lung

Larger alveolus

r = 1.5

T = 3

P = (2 x 3) / 1.5

P = 4

Smaller alveolus

r = 1

T = 3

P = (2 x 3) / 1

P = 6

Law of Laplace : P = 2T/r P : pressure T : surface tension r : radius

CDP

Single Alveolus During PPV

Critical closing pressure Critical Opening Pressure

Vt

LITERS

Paw

cmH2O 0

Optimal Lung Volume Strategy/Open Lung Ventilation Strategy

6 25

0.4

0.2

•Upper Inflection Point where

overdistension starts

•Pinsp should not be set beyond

this point

UIP

LIP

•Lower Inflection Point or critical

opening pressure

•PEEP should be set above this

point to prevent derecruitment

Hysteresis

Relationship to FRC

Respiratory Mechanic During Mechanical Ventilation

Rectangular

Exponential Decay

Sinusoidal

Front End Loaded Breath Specific CL=1-2 mL/cm H2O/kg

CL=1 mL/cm H2O TV=15 mL PIP=20 cm/H2O PEEP=5 cmH2O

CL=2 mL/cm H2O TV=15 mL x 2 PIP=20cm/H2O PEEP=5 cmH2O

Exponential Rise

Who is the BOSS?

Resistance (P1-P2/Flow rate)

Normal Airway Resistance=20-30 cm H2O/L/s

Resistance described L×η/r4 (Poiseuille law)

At intubation R=85-100 cm H20/L/s

Compliance (V2-V1/P2-P1)

Normal compliance=1-2 mL/cm H2O per kilogram

Tc=RXC

Optimal Ti=3-5 times of TC (R×C)

0

Time (ms)

150

Flow (ml)

300 700

Flow Triggering

Delay of the Data Acquisition Chain

– (typically 20 ms)

Speed of Flow and Pressure Valves

– (typically 20 ms)

Ventilator delay time = 0.04s

Spont Ti = 0.3s

Ventilator Ti setting = 0.26s

Dial Lag

Cycle of Respiration Flow (ml)

Time (ms)

0 100 200 300 400 500 600 700

Asynchronies Triggering Time

0

Time (ms)

150

Flow (ml)

300 700

Synchronise Triggering

0

Time (ms)

150

Flow (ml)

300 700

Asynchronies Triggering Set Ti too long

0 Time (ms)

300 150

Flow (ml)

700

Pneumatometer

pneumotachograph

Hot-Wire anemometer Pneumotachometer

P1 P2

Ventilator Patient

Patient

Ventilator

Hot Wire Anemometers

Babylog 8000 plus

High sensitivity = 0.2 LPM

Bear Cub 750PSV High sensitivity = 0.2 LPM

Servo-i

High sensitivity = 0.05 LPM

Differential Pressure Transducer/Wane Flowmeter

Christina

High sensitivity = 0.2 LPM

Stephanie

High sensitivity = 0.1 LPM

0,5 1,0033,3

40

Futile Sensitivity

Little or no change in Vt

Prevention of BEAK with optimal Pmax and Ti

Hysteresis

C20/C Ratio

Volume

Pressure

Overdistention begins

C20

C

PEEP

Pressure - volume loops with C20/C ratios < 0.8 were considered to be overdistended

Stress Index

FSV

Action:

Extend Ti to allow inspiratory flow to return to base line

Set Ti

Appropriate Ti for

this lung

Flo

w L

/min

Time ( sec)

Flow

Peak Flow (100%)

Time

10%

Set (max) Tinsp.

Tinsp. (eff.)

Flow sensitive Ventilation

Open lung strategy The Impulsator® HC (Percussionaire Corp.)

Scheid P, Piiper J. Aerodynamic valving in the avian lung. Acta Anaesthesiologica scandinavica 1969; 33 (Suppl. 90): 28-32.

Open lung strategy

CDP in HFOV

Lung recruitment maneuver

Recruitment Maneuvers and PEEP Titration. Dean R Hess PhD RRT FAARC RESPIRATORY CARE •

NOVEMBER 2015 VOL 60 NO 11

Optimize lung volume

Weaning

Clin in Perin September 2012; Advances in Respiratory Care of the Newborn:

Weaning Infants from Mechanical Ventilation

Little or no change in Vt

Prevention of BEAK with optimal Pmax and Ti

Hysteresis

End-Expiratory Lung Volume

Vt

LITERS

Paw

cmH2O 0

Optimal Lung Volume Strategy/Open Lung Ventilation Strategy

20 40

0.4

0.2

•Upper Inflection Point where

overdistension starts

•Pinsp should not be set beyond

this point

UIP

LIP

•Lower Inflection Point or critical

opening pressure

•PEEP should be set above this

point to prevent derecruitment

Optimal lung volume strategy

Optimal lung volume strategy

Electrical Impedance Tomography

Open Lung Ventilation Facts

A few injurious inflation in lung evolving trigger the VILI

Low (if lung be atelectatic with regional overdistention or EELV be high with exceed TLC) and high volume can induced volutrauma

Optimizing EELV for recruitment (reversing atelectasis) and stabilizing lung units throughout ventilator cycle (avoiding atelectrauma)

Adequate recruitment with adequate PEEP (above the critical closing pressure) stabilize the previously opened alveoli)

Open lung ventilation is feasible with optimal using Pmax and PEEP to, respectively recruit and stabilize the lung

Open lung ventilation strategy more important than the ventilation mode

Tidal Volume-Targeted Ventilation

Tidal Volume-Targeted Ventilation

Flow Triggering

Hot-Wire anemometer Pneumotachometer

P1 P2

Ventilator Patient

Patient

Ventilator

Flow

Peak Flow (100%)

Time

10%

Set (max) Tinsp.

Tinsp. (eff.)

Flow sensitive Ventilation

C20/C Ratio

Volume

Pressure

Overdistention begins

C20

C

PEEP

Pressure - volume loops with C20/C ratios < 0.8 were considered to be overdistended

Stress Index

Air Leak

Volume

Air Leak

Flow

Air Leak

Weaning

Clin in Perin September 2012; Advances in Respiratory Care of the Newborn:

Weaning Infants from Mechanical Ventilation

Structure of the Airways

• BR = Bronchus

• BL = Bronchiole

• TBL = terminal Bronchiole

• RBL = respiratory bronchiole

• AD = alveolar duct

• AS = alveolar sac

• Till the 16 Generation =Gastransportation

• From the 17 Generation = Gasexchange / Oxygenation

Development of Airway Generations

TB = terminal bronchiolus RB = respiratory bronchiolus TD = transitional duct AD = alveolar duct S = sacculae AS = alveolar sac

The Lung

At birth numbers of alveoli at each lung

= 500,000

Oxygen Therapy

Indication:

Central cyanosis

PaO2 < 50 mmHg

Spo2 < 86%

Needs for resuscitation

Oxygen Therapy

Target:

PaO2 = 50-70 mm Hg

Alarm Confine

Spo2

PMA

85%-95%

88%-92%

< 32 wk

87%-95%

90%-94%

> 32 wk

Oxygen Therapy

Fixed Performance Oxygen Th.

Variable Performance Oxygen Th.

Fixed Performance Oxygen Th.

Invasive

Non invasive:

CDP

HFT:

HHHFNC

Headbox

Masks

Tent

Fixed Performance Oxygen Th.

HHHFNC:

Flow = 0.92 + 0.68 weight (kg)

Pressure = 0.7 + 1.1 F/W

Headbox:

Size 1: 6-7 Liter (W < 1500gr & RR=60-80)

Flow = 12 l/m

Size 2: 8-10 Liter (W = 1500gr-2500gr & RR=60-80)

Flow = 14 l/m

Size 3: 12 Liter (W > 2500gr & RR=60-80)

Flow = 16 l/m

Flow Driven CPAP

Bilevel PAP (BiPAP)

Nonsynchronized

Synchronized

NIPPV

NSIPPV

NHFV

Noninvasive Respiratory Support

Humidification

PMH7000 MR850

Medijet (Benveniste Device)

Flow Driven CPAP

IFD (Arabella-Alladine)

Flow Driven CPAP

BiPAP (Nonsynchronized) duoPAP (Fabian)

BiPAP (Synchronized) SiPAP (Viasys)

BiPAP (Synchronized)/NHFV CNO

NSIPPV Giulia

NSIPPV (NIV-NAVA) Servo-i

HFV

Conventional Ventilation

HFO

Invasive Ventilation Volume-Target (VG)

Working Principle of Volume Guarantee: inspiratory pressure is automatically regulated by the ventilator to achieve set tidal volume. The Babylog 8000plus may take up to 6 - 8 breath to reach set tidal volume.

Invasive Ventilation Volume-Target (PRVC)

Working Principle of PRVC: The ventilator delivers a test volume controlled breath based on the selected volume. The ventilator then automatically sets the target pressure of end inspiratory pressure.

VT

LITERS

Paw

cmH2O 0

Identifying Lower and Upper Inflection Points

20 40

0.4

0.2

•Upper Inflection Point where

overdistension starts

•Pinsp should not be set beyond

this point

UIP

LIP

•Lower Inflection Point or critical

opening pressure

•PEEP should be set above this

point to prevent derecruitment

FSV

Action:

Extend Ti to allow inspiratory flow to return to base line

Set Ti

Appropriate Ti for

this lung

Flo

w L

/min

Time ( sec)

Invasive Ventilation Volume-Target (VAPS)

PSV

Decelerating Flow

Constant Flow

Invasive Ventilation Volume-Target (MMV & ASV)

Target Minute Volume (MMV)

PSV

SIMV

Averages every 7.5 sec

Minimum Minute Volume (ASV)

PSV

SIMV

Volume Target (Volume Bracketing) (Volume Limation-MVG)

Flow -Volume Curve Pressure-Volume Curve

compliance inverse time constant

menue: measurement

Proportional Assist Ventilation (CLV)

Flow proportional assiat

Volume proportinal assist

Neurally adjusted ventilatory assist

Knowledge-based system (SmartCare ventilation)

Regional Oximetry

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