Airways, ARDS & ventilatory strategies Nov 2013. Outline Endotracheal tubes, tracheostomies and...
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Transcript of Airways, ARDS & ventilatory strategies Nov 2013. Outline Endotracheal tubes, tracheostomies and...
Airways, ARDS & ventilatory strategiesNov 2013
Outline Endotracheal tubes, tracheostomies and laryngectomies
ARDS
Evidence based ventilation
Proning, HFOV & ECMO
Airways Oral vs nasal ETT
Does size matter?
Tracheostomy Insertion Care When they “fall out” TRACMAN, JAMA, 2013
Laryngectomy
ICU is the lair of the difficult airway
Acute Respiratory Distress Syndrome “acute diffuse, inflammatory lung injury, leading to increased
pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space, and decreased lung compliance.”
ARDSnet, NEJM, 2000.
Acute Respiratory Distress Syndrome Within 7 days of a trigger
PaO2/FiO2 <300 (40kPa)
Bilateral CXR changes
Not solely due to cardiac failure
Lung protective ventilation 6ml/kg IBW
RR up to 35 to achieve desired MV
Plateau pressure less than 30cmH2O
I:E ratio
Permissive hypercapnia
Paralysis
High PEEP?
Fixing the broken patient Is there…
Patient-ventilator asynchrony? Fixable contributory problems i.e. effusions, pneumothorax,
bronchospasm? Actually a problem?
Consider… Recruitment Paralysis I:E ratio PEEP Fluid status
And then consider…
Proning Improves
Distribution of ventilation and perfusion Recruitment Secretion clearance
Problems Tube/line displacement Pressure injury Facial oedema
Early and for prolonged periods = improved mortality? Guerin, NEJM, 2013
High Frequency Oscillatory Ventilation RR 60-3000bpm
TV < dead space
Convection, molecular diffusion, streaming, Pendelluft & cardiogenic mixing
Now predominantly discredited OSCAR & OSCILLATE, NEJM, 2013
Extra Corporeal Membrane Oxygenation Made famous by H1N1
Severe, reversible, respiratory failure where conventional methods are failing
Early rather than late
Venovenous vs venoarterial
Evidence in adults not (IMO!) conclusive CESAR, Lancet, 2009
Summary Types of airway & what to do if they fall out
ARDS
Ventilatory strategy
Proning, HFOV and ECMO