Mechanical Ventilation in Special Conditions
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Transcript of Mechanical Ventilation in Special Conditions
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Mechanical Ventilation in Special Conditions
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Mechanical Ventilation: Outline
• Head injury• Chest Trauma• Bronchopleural Fistula
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Traumatic Brain Injury
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Prevalence of extracerebral organ dysfunction in TBI
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Cerebral Compliance Curve
Intracranial volume
Intracranial pressureCPP
CPP= MAP-ICP
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Cerebral Compliance Curve
50
Cerebral Blood Flow CPP
PaO2
PaCO2
100 150
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Head Injury: MV Monitoring
• Peak alveolar pressure, airway pressure, auto-PEEP
• PaCo2 end tidal PCO2• Intracranial pressure• Jugular venous oxygen saturation• Pulse oximetry• Heart rate and systemic blood pressure
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Hyperventilation in Traumatic Brain Injury
1. Causes cerebral vasoconstriction 2. Decreases cerebral blood flow3. Decreases cerebral blood volume4. Increases ICP5. Has been proven to be of benefit in head
injuries
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Head Trauma
• Cerebral physiology– ICP– CBF– Cerebral oxygenation : SJO2, PbrO2
• Hyperventilation• Lung protective strategy• PEEP• Extubation
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Hyperventilation in TBI
• Chronic hyperventilation (PCO2 < 25) should be avoided
• Prophylactic hyperventilation (PCO2 < 35) in the first 24 h should be avoided
• May be necessary for a brief period with acute neurologic deterioration
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Head Trauma• Lung protective strategy
– Hypoventilation PCO2 ICP – No evidence of detrimental effect– Use protective ventilation– Observe ICP and CPP if PCO2▲
• PEEP– ICP – MAP – Depends on compliance
• Extubation– LOC– Cough– Tracheal secretions
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Head Trauma
• Lung protective strategy– Hypoventilation PCO2 ICP – No evidence of detrimental effect– Use protective ventilation– Observe ICP and CPP if PCO2▲
• PEEP– ICP – MAP – Depends on compliance
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Head Trauma
• Extubation– LOC– Cough– Tracheal secretions
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Hyperventilation & CBF
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Head TraumaCBF and ICP with hyperventilation
▼ICP
►CBF◄
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Head Trauma
• Extubation– LOC– Cough– Tracheal secretions
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Intrathoracic Pressure (-3 cm H2O)
CPP = MAP – ICP
MAP (90)= CO X SVRVenous Return
ICP= 10
ICP =30
Maintain adequate MAP• Adequate CO• Use inotropic Agents• Adequate filling pressures• Avoid hypotensive agents• Treat infection abruptly
Avoid ↑ Intrathoracic Pressure• Suppress Valsalva
maneuvers• Suppress cough• ↓ Mean airway pressure• Minimize use of PEEP• Treat distended abdomen
CSF Drainage• HOB > 30 degree• Head in neutral
position• Vetriculostomy
Decrease Oxygen Demand• Prevent seizure• Sedation• Treat pain• Barbiturate coma• Avoid hyperthermia• ? hypothermia
Decrease Brain Water• Mannitol• Avoid D5%• Diuretics
VasoconstrictionPa co2 25-30
Decompressive Craniotomy
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Underlying lungdisease
Titrate FiO2 for SpO2 ≥ 92%
no ↓ rate
yes
↓ VT
yes
ICP <20
no↑ FiO2
70-100
FiO2 >0.6
↑ rate
<20
>20
ICP
More aggressiveMedical therapy
Slowly ↓ rate to initial setting
no
ICP
yes
↑ PEEP
CMV (A/C), PCV or VC, VT 4-8 mL/kg, FiO2 1, rate20/min TI1s, PEEP 5 cm H2O
yesCMV (A/C), PCV or VC, VT 4-8 mL/kg, FiO2 1, rate15/min TI1s, PEEP 5 cm H2O
no
>45↑ rate PCO2
↓ FiO2>100
>20
yes
FiO2 > 0.6
<70
MaintainVentilator
Setting
<20
no
Pplat > 30<35
PaO2
35-45
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Chest traumaWho Gets Admitted?
• Sternal fractures mediastinal injury• Any 1th, 2nd, 3rd Rib fractures• > 1 Rib fracture in any region• Pulmonary contusion• Subcutaneous emphysema• Traumatic asphyxia• Flail segment• Arrhythmia or myocardial injury
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Flail Chest
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Flail chest
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Flail Chest
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BPF
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BPF
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BPF
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Adverse effects of BPF in the ventilated patient
Incomplete lung
expansionLoss of TV
Inability to remove
CO2Loss of PEEP
Pleural space
infection
Factitious ventilator cycling
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Guidelines for ventilator management in the patient with BPF
Reduce MAP & RR• Wean patient completely if possible• Partial ventilatory support
– low-rate SIMV or PSV• Minimize minute ventilation• Use of permissive hypercapnia• Avoid patient positions that increase
the leak • Treat bronchospasm• Consider unconventional measures
– Bronchoscopic techniques– HFV– ILV
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Independent lung ventilation
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Independent Lung Ventilation
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