Monitoring of Mechanical Ventilation by OluAlbert
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Transcript of Monitoring of Mechanical Ventilation by OluAlbert
Monitoring of Mechanical Ventilation
Olu Albert, MPH,RRTClinical ManagerRespiratory Care, ASIA PACIFICPhilips Health
Monitoring of Mechanical Ventilation
• Pressure, Flow, and Volume in ventilator circuit
• Calculated “Monitored” Parameters– Compliance
– Resistance
– MAP
– Time Constants
• Waveform Analysis (Measured Parameters)– Pressure
– Flow
– Volume
• Loops– Pressure volume
– Flow volume
PEEP
PIP
PplatRaw= Pta /V
compliancetidal volume
end-inspiratory
alveolar pressure
Pta = PIP - Pplat
normal 100 mL/cm H2O
Cst =Pplat - PEEP
Tidal Volume
Compliance
• Mainstem Intubation
• Congestive Heart Failure
• ARDS
• Atelectasis
• Consolidation
• Fibrosis
• Hyperinflation
• Tension Pneumothorax
• Pleural Effusion
• Abdominal Distension
• Chest Wall Edema
• Thoracic Deformity
Decreased with:
Correct for gas compression
Total PEEP
Increased with:
Raw = PIP - Pplat
flow
Airway Resistance (Raw)
• Secretions
• Bronchospasm
• Small endotracheal tube
• Mucosal edema
Normal: 5 - 10 cm H2O/L/s for intubated ventilated adults
measure with 60 L/min (1 L/s)
constant flow
Calculation of Cs & Raw
A patient is volume ventilated at the following settings: PIP = 24 cmH20, Pplt= 17 cmH20, and VT = 400 ml, PEEP = 5 cmH20. What is Pta? What is the Cst? Flow was 35 L/min. What is the Raw? Is the Raw normal?
• Pta = PIP – Pplt = 24-17 = 7 cmH20
• Cst = VT /Pplt-PEEP =400 ml/(17-5cmH20)= 33.3mL/cmH20
• Raw = Pta/Flow
Flow = 35 L/min, 35 L/60 sec = 0.58 L/s
Raw = 7 cmH20/0.58 L/s = 12 cmH20/L/sec
Pplat 30 cm H2O
TranspulmonaryPressure = 15 cm H2O
Pplat = Palv; Pplat = Transpulmonary Pressure?
+15 cm H2O
Stiff chest wall
PCV 20 cm H2O,
PEEP 10 cm
H2O =Pplat 30
cm H2O
-15 cm H2OTranspulmonaryPressure = 45 cm H2O
Active inspiratory effort
Pplat = Palv; Pplat = Transpulmonary Pressure?
Pplat 30 cm H2O,
VCV
Pplat 30 cm H2O,
PCV
Active inspiratory effort
Pplat 30 cm H2O,
VCV
Pplat = Palv; Pplat = Transpulmonary Pressure?
Risk of VILI may be different with the same Pplat
Mean Airway Pressure (MAP)
• MAP is affected by PIP, PEEP, Total Cycle Time (TCT) and RR
• MAP = ½ (PIP-PEEP) x (Ti/TCT) + PEEP
• MAP is useful to monitor to assess the benefits and side effects of Positive Pressure Ventilation (= Mean Alveolar Pressure)
Time Constants
• Is the length of time lung units require to fill & empty
• T = Raw X Cst where: T = Time ConstantsRaw = Airway ResistanceCst = Static Compliance
Clinical Applications: Time Constant
• “Fast” alveoli = short time constant (fast filling)
--Pulmonary fibrosis (low Cst & low Raw)
• “Slow” alveoli = long time constant (slow filling)
--Asthma (high Cst & high Raw)
Pressure-Controlled Ventilation
Increasing airways resistance
Decreasing lung compliance
Lucangelo, Respir Care 2005; 50:55
set PEEP
auto PEEP
pre
ssu
re
time
PIP PIP
No active exhalation or inspiratory effort
Treats lungs as single compartment
Problems with Auto-PEEP
• Increased Pplat and over-distention
– Increase work-of-breathing
– Hemodynamic effects
– Pneumothorax
• Difficulty triggering ventilator
sensitivity
-1 cm H2Oauto-PEEP
10 cm H2O
trigger effort = 11 cm H2O
sensitivity
-1 cm H2Oauto-PEEP
3 cm H2O
trigger effort = 4 cm H2O
PEEP
7 cm H2O
PEEP
10 cm H2O
PEEP
10 cm H2O
Auto-PEEP should be measured with set PEEP = 0
Ways to reduce Auto-PEEP:
• Increasing inspiratory flow
• Reduce minute ventilation (Ve)
• Suctioning the patient
• Changing the modes to allow for more spontaneous breaths
In VCV, use the following to evaluate the graphics:
• What is the flow pattern?
• What is the PEFR
• Is auto-PEEP present?
• Is a leak present?
• What is PIP?
• Is flow to the patient adequate?
• Has the sensitivity been set appropriately?
0 10 20 30 40
0 0
.4
0.8
1
.2 1
.6
normal
ARDS
airway pressure (cm H2O)
vo
lum
e a
bo
ve F
RC
(li
ters
)
lower inflection
point
upper inflection
point