Principles of Mechanical Ventilation in ICU Raafat Abdel Azim.
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Transcript of Principles of Mechanical Ventilation in ICU Raafat Abdel Azim.
Principles ofPrinciples of
Mechanical VentilationMechanical Ventilationin ICUin ICU
Raafat Abdel AzimRaafat Abdel Azim
TTT of the cause
ETI + MV
PEEP
O2
DrugsIVFV
Secretions
ECMO
ECCO2R
CFAV
Treatment of Respiratory Failure
NPPV
22
Oxygen SupplementationOxygen Supplementation
Aim: Aim: PPAAOO2 PaO PaO2 > 60 mmHg (60:100) > 60 mmHg (60:100) If < 60 If < 60 abrupt abrupt of saturation & content of saturation & content If > 100 If > 100 no more benefit no more benefit
Not > 50% > 24hNot > 50% > 24h Potential complication: OPotential complication: O2 PaCOPaCO2
33
Methods of OMethods of O22 Supplementation Supplementation
(O(O22 Devices) Devices)
100%
OO22
AIR
(21% OO22)
?% OO22
Flow Rate? Patient’s IFR?
44
OO22 Devices Classification Devices Classification
High O2
(up to 100%)Controlled O2
(set)%
Delivered O2 %
Flow Capacity
High Flow Low Flow
55
1.1. Nasal CannulaNasal Cannula
Low flow, low O2
OO22 Devices Devices
•Low flow 0.5 – 5 L/min
•Maximal tracheal FIO2 0.4 – 0.5
(cannot be precisely controlled, VE)FR No in FIO2
Drying and irritating effect
66
2.2. Air-Entrainment Face Masks Air-Entrainment Face Masks (Venturi Masks)(Venturi Masks)
OO22 Devices Devices
High flow, controlled O2
O2
Air
•High FR
•FIO2 precisely controlled (0.24 – 0.5)
by changing jet nozzle
adjusting FR•Most useful in COPD patients (titratable)
77
3.3. Aerosol Face MasksAerosol Face Masks
Moderate flow, variable O2
OO22 Devices Devices
•Large side holes, large bore tubing, a nebulizer
•Flow matching can be evaluated by observing the aerosol mist
88
4.4. Reservoir Face MasksReservoir Face Masks
High flow, high O2
OO22 Devices Devices
FR is adjusted so that the reservoir bag remains distended
99
5.5. Resuscitation Bag-Mask-Valve UnitResuscitation Bag-Mask-Valve Unit
OO22 Devices Devices
Mask held firmly over the face air entrainment
High flow > 15 L/min
Bag need not be compressed to supply O2
High flow, high O2
1010
ABGABG PaOPaO22??
SaOSaO22??
PaCOPaCO2 2 > 6 mmHg (in 30 min) = significant > 6 mmHg (in 30 min) = significant
retentionretention
1111
NPPVNPPV
NPPV ventilator
Nasal mask
Face mask
or or
Standard Ventilator
PS Volume cycled
Patient triggered
•Better tolerated
•Less effective in mouth breathers and edentulous patients
1212
NPPVNPPV
Not recommended unless the patient is:Not recommended unless the patient is: Alert, oriented & cooperativeAlert, oriented & cooperative Not having:Not having:
Swallowing dysfunctionSwallowing dysfunction Difficulty clearing secretionsDifficulty clearing secretions HypotensionHypotension Uncontrolled arrhythmiasUncontrolled arrhythmias Acute cardiac ischemiaAcute cardiac ischemia Acute GI hemorrhageAcute GI hemorrhage
1313
May not be desirable with:May not be desirable with: levels of ventilatory requirementslevels of ventilatory requirements
(( C requires C requires P) P) ability to adequately clear secretionsability to adequately clear secretions
(especially with face mask)(especially with face mask) Careful observation and monitoringCareful observation and monitoring Possible G distension & aspiration riskPossible G distension & aspiration risk
NPPVNPPV
1414
NPPVNPPVSettings
Specialized Unit Standard Ventilator
PS mode
8-12 cmH2O IPAP
AC mode10 ml/kgPEEP or EPAP
Titrate P, V & FIO2 PaO2 & PaCO2
1515
ETI and MVETI and MVETI when?ETI when?
PaOPaO2 2 < 60 (F< 60 (FIIOO22 >> 0.5) 0.5)
PaCOPaCO2 2 + + pHpH Respiratory muscle fatigueRespiratory muscle fatigue Loss of protective upper airway reflexesLoss of protective upper airway reflexes Ineffective cough + Ineffective cough + secretionssecretions Level of consciousnessLevel of consciousness
1616
Seconds%I:E
Time
I E
Mode
MVO2 in air
How?
Volume
f
VT
% (FIO2)
PEEPOthers
Alarms & LimitsWave form
FlowTrig. sensitivity 1717
Mechanism of action of the ventilator (Mode of operation):
4 phases
Inspiratory phase
Expiratory phase
Cycling from I to ECycling from E to I
1818
Two phases: I & ETwo phase transitions:
From I to E = expiratory cyclingBetween E and I = inspiratory cycling
Inspiration can itself sometimes have two phases: an active ‘flow’ (TI flow) phase during which gas is being delivered to the patientan end-inspiratory pause (TI pause )The total duration of inspiration is made of the sum of these two:
TI = TI flow + TI pause
Respiratory cycle
1919
2020
Intra-thoracic pressures
2121
Pressure gradients within the thorax
Distending pressures
2222
Control of Parameters of Ventilation
• VT
• f (frequency= rate)
• VM
• I:E ratio
• Flow Rate
• Flow Profile
• Trigger Sensitivity
2323
IFR (Inspiratory Flow Rate)IFR (Inspiratory Flow Rate)VT (ml)f (b/min)Cycle time
(s)IFRTI (s)TE (s)I:E
L/minL/sml/s
5002060/20 = 360110000.52.51:5
300.5500121:2
Time (sec)
0.500
100
200
300
400
500
600
1.5 2.5 3.5 4.5 5.51 2 3 4 5 6
60 L/min30 L/min
2424
Inspiratory WaveformsInspiratory Waveforms
30
30
60
60
0
Constant Decelerating Accelerating (ramp)
Sinusoidal (reverse ramp)
TI TI TI TI
2525
The Ventilation Cycle
2626
Paw
0 t
PmaxPplat
IF E
ZEEP
IPPV
20
I EP
ause2727
• Duration of ventilation cycle (sec)
• f (60/duration)
• I phase (IF period, IP period)
• E phase
• VT, VM
• TI, TE, I:E
FVPT2828
Inspiratory Phase
During the IF period:Paw depends on:
• The airway resistance (R)
• The total thoracic compliance (C) (V/P)
RC2929
PP PP
P
P
P
PP
PP
P
P
P
Resistance
Flow Rate: FRP3030
Paw
0 t
20
N R F R F
Resistance
3131
Calculation of Airway Resistance (Raw) in a Ventilated Patient
Raw = (PIP – Pplat) / Flow
Example: If in a given situation,PIP = 40 cm H2O,Pplat = 38 cm H2O,flow = 60 L/min (i.e., 1 L/s),Raw will be:= (40 − 38)/1= 2 cm H2O/L/s.
3232
Compliance
C
C
P PVolume
3333
PVolume: VP
P
Compliance
3434
During I pause
• No gas F into or out of the lungs Paw depends only on VI & CT
• Gas redistributes among alveoli
• This improves gas distribution in the lungs of patients with small AWD (BA, smokers).
Pause
3535
Paw
0 t
20
C R
Secretions
Bronchospasm
Kinked ETT
EB intubation
CW rigidity
Pulmonary edema
3636
Compliance = V/P
Dynamic compliance:
= VT/(PIP-PEEP) L/cmH2O Static compliance:
= VT/(Pplat-PEEP) L/cmH2O
3737
Time Constants of the LungTime Constants of the LungIn most diseases, the involvement of the lung is not uniform. Regional differences in C and R occur. Owing to this, alveoli in different parts of the lung behave differently; diseased alveoli take longer to fill and to empty.
The rate of filling of an individual lung unit is referred to as its time constant.
For a particular lung unit
Time Constant = R x C3838
It takes the equivalent of 5 time constants for the lung to completely fill (or to empty).
In the time afforded by one time constant, 63% of the lung will fill (or empty); two time constants allow 86% of the inspiratory or expiratory phase to be completed; three time constants allow for 95%, and four time constants for 98%.
63 86 95 98 10012
34
5
3939
Example:
A lung unit with a normal Raw of 1 cm H2O/L/sand a normal compliance of 0.1 L/cm H2O would have a time constant of:
= 1 × 0.1= 0.1 s
Five times this is 0.5 s, which would be the time required for this unit to fill or empty satisfactorily. This information comes useful while setting a ventilator’s TI and TESince diseased air units take longer to fill, deliberatelyprolonging the TI may enable such units to participatemore meaningfully in gas exchange
4040
Goals of Mechanical Ventilation
4141
Provide appropriate O2 supplementation
Assure adequate alveolar VM
work of breathing (WOB)
patient comfort during respiration
4242
• To provide adequate minute alveolar ventilation
• and to side effects
necessary to maintain the desired PaCO2
PPV ITP
4343
Adequate Ventilation
• PaCO2 of 40 mmHg = 5.3% of 760 mmHg40/760 = 0.053
• Normal resting VCO2= 200 ml/min= 0.2 L/min• This requires VM of 3.8 L
0.2/ ? = 0.0530.2/ 0.053 =
• Add dead space (VD)
Goals
3.8 L/min
4444
• N = 2.2 ml/Kg (1 ml/pound) 150 ml in a 70 Kg (154 pound) adult• = 0.15 x 10 (f) =• Required VM = 3.8 + 1.5 =
• A larger VM is required for patients who have VD or VCO2
1.5 L/min
5.3 L
Goals, Adequate Ventilation
For VCO2 For VD
VD phys = VD ana + VD alvVD ana = conducting airways = 150 ml in a 70 Kg adultVD alv is created when non-perfused alveoli are ventilated (negligible in health, expands in disease)This 150 ml of VD ana is reduced by ETT and can be cut down to about 60% by tracheostomy
4545
• When VCO2 & VD are stable:
VM 1/ PaCO2
VM x PaCO2 = constant
• e.g., PaCO2 = 50 mmHg with VM = 5 L/min
VM to 7 L/min PaCO2 to 36 mmHg
Goals, Adequate Ventilation
V1 x P1aCO2 = V2 x P2aCO2
4646
VM =VT x f
Manipulation of VT has a different effect on the PaCO2 than does altering f.
Consider the following:A set VT of 500 ml and f of 10 b/min results in a VM of 500 × 10 = 5,000 ml/min. The same VM can be produced by a VT of 250 ml delivered at f of 20 b/min, i.e., 250 × 20 = 5,000 ml/min. If, however, the VD is taken into consideration, the implications of these two settings are vastly different.Assuming a VD phys of 150 ml, the alveolar ventilation (the effective ventilation or the ventilation that takes part in gas exchange) in the first example would be:
(500 – 150) × 10 = 3,500,and in the second example would be:
(250 – 150) × 20 = 2,000.
PaCO2 is inversely proportional not to all of the VM, but to that part of the ventilation that is independent of VD (i.e., the alveolar ventilation VA)
4747
Side effects
Goals
ITP
VR
EDV
CO
PVR RVAPPV
4848
Goals, Side Effects
PPV
ITP PA > PAP VVD
4949
All these effects mean Paw
Therefore, a goal of PPV is to mean Paw while maintaining adequate ventilation and oxygenation
Goals
5050
Effect of IFR on mean Paw
Mean Paw = area under the curve
5151
Modes (examples)Modes (examples)
Volume controlled Volume controlled IPPV (CMV)IPPV (CMV)
Pressure controlled Pressure controlled (PCV) (PLV)(PCV) (PLV)
IRVIRV
CPAPCPAP AA ACAC IMVIMV SIMVSIMV PSVPSV BIPAPBIPAP APRVAPRV Other modesOther modes
Breathing support
5252
Volume Controlled Ventilation Volume Controlled Ventilation (Controlled Mode Ventilation) (CMV) (IPPV)(Controlled Mode Ventilation) (CMV) (IPPV) Initial settings:Initial settings:
ff 10-12 /min10-12 /min VVTT 8-10 ml/Kg 8-10 ml/Kg FFIIOO22 11 I:EI:E 1:2 (1:3 in COPD)1:2 (1:3 in COPD)
AimAim pHpH 7.36 : 7.447.36 : 7.44 PaOPaO22 60: 100 mmHg60: 100 mmHg PaCOPaCO22 36: 44 mmHg36: 44 mmHg
Adjust settings (ABG, SpOAdjust settings (ABG, SpO22 > 92-94%) > 92-94%)5353
IPPVIPPV Preset f & VPreset f & VTT
No patient interaction with ventilatorNo patient interaction with ventilator Advantage: rests muscles of respirationAdvantage: rests muscles of respiration Disadvantages: requires sedation/NMB, Disadvantages: requires sedation/NMB,
potential adverse hemodynamic effects, potential adverse hemodynamic effects, muscle atrophymuscle atrophy
5454
Paw
0 t
PmaxPplat
IF E
ZEEP
IPPV
20
I EP
ause5555
Inspiratory Plateau Pressure (PInspiratory Plateau Pressure (Pplatplat))
PPawaw at end of I with no gas flow present at end of I with no gas flow present
It estimates PIt estimates PA A at end Iat end I Indirect indicator of alveolar distensionIndirect indicator of alveolar distension
5656
I:E RatioI:E Ratio
Spontaneous breathing I:E = 1:2Spontaneous breathing I:E = 1:2 TTII determinants with preset V breaths: determinants with preset V breaths:
VVTT
GFRGFR ff I pauseI pause
TTEE passively determined passively determined
5757
I:E RatioI:E Ratio
TTEE too short for exhalation too short for exhalation Breath stackingBreath stacking Auto-PEEPAuto-PEEP
Auto-PEEP by Auto-PEEP by T TII
GFRGFR VVTT
ff
5858
During the expiratory phaseDuring the expiratory phase
VT
FRC
FRC
EI
FRCIA contents•Pulmonary edema•ARDS
PEEPPaO2 PaO2
5959
Paw
0 t
PEEP
IPPV + PEEP
6060
PEEPPEEP
PEEP, When?PEEP, When?PaOPaO22 < 60 mmHg (FIO < 60 mmHg (FIO22 >> 0.5) 0.5)
ActionAction
Expansion of collapsed perfused alveoliExpansion of collapsed perfused alveoli PaOPaO22
CCLL
FRCFRC Prevention of absorption atelectasisPrevention of absorption atelectasis
Improvement of V/Q QS/QT
6161
PEEP, HowPEEP, How??2.5-5 cmH2.5-5 cmH22O O incrementsincrements until PaO until PaO22 > 60 > 60
(FIO(FIO22 << 0.5) 0.5)
Goal:Goal: PEEP with maximum improvement of PaOPEEP with maximum improvement of PaO2 2
without hazardswithout hazards HazardsHazards
• COP (VR, PVR, left septal displacement)• Barotrauma (Pnx, Pnp, SC emphysema) abrupt PaO2 & COP
PEEPPEEP
6262
Best PEEP
Best PEEP
O2 transport
Static CL
Don’t give PEEP > 15 cmH2OHow to avoid COP
IVFVInotropicsPA catheter
PEEPPEEP
6363
Paw
0Sigh phase
Pmax
Int PEEP
PEEP
Intermittent PEEP(Expiratory Sigh)
t
6464
Auto-PEEPAuto-PEEP Can be measured on some ventilatorsCan be measured on some ventilators peak, plateau, and mean Pawpeak, plateau, and mean Paw Potential harmful physiologic effectsPotential harmful physiologic effects
PEEPPEEP
6565
Paw
t
Pressure-limited ventilation (PLV) (PCV)
Pmax
Pplat
0
6666
PCVPCV
Used to limit inflationary pressuresUsed to limit inflationary pressures Allows setting of TAllows setting of TII
Complexity of interacting ventilatory variablesComplexity of interacting ventilatory variables
6767
Paw
0
20
t I E
Inverse Ratio Ventilation (IRV)
Improves oxygenationNeonatesARDS
Alveolar recruitment by creating auto PEEP
No advantage over 1:1 (+PEEP) at f < 15
IRVHypoxemic RF
Optimize PEEP
FIO2 requirements > 0.6 or SaO2 < 90%
Consider IRV
VC- IRV PC- IRV
IFR I pause I:E with decelerating flows
Most effective
Indications of IRVIndications of IRV
ARDS with severe hypoxemic RF (especially ARDS with severe hypoxemic RF (especially with with FIOFIO22 requirements and PEEP) requirements and PEEP)
No uniformly accepted criteria. Proposed No uniformly accepted criteria. Proposed criteria:criteria: VC-IRV:VC-IRV:
FIOFIO22 > 0.6 or PEEP >10 cmH > 0.6 or PEEP >10 cmH22O to maintain SaOO to maintain SaO22
>90%>90% PC-IRV:PC-IRV:
Above parameters + PIP Above parameters + PIP >> 45 cmH 45 cmH22OO7070
Point of Reference:Spontaneous Breathing (SB)
Breathing Support
7171
Paw
0 t
SB
-ve
+ve
7272
Paw
0 t
CPAP
CPAP
7373
CPAP No machine breaths delivered Allows SB at elevated baseline P
Patient controls f & VT
7474
Assisted Ventilation (A)Paw
0
A
t
S
Patient f and timingHazard: hypoventilation
If or No S
No A
7575
Paw
0
A+CProvides a minimum f below which C
Assist-Control (AC)
7676
AC
Preset VPreset VTT & minimal f & minimal f
Additional patient-initiated breaths receive preset VAdditional patient-initiated breaths receive preset VTT
Advantages: Advantages: WOB; allows pt. to modify V WOB; allows pt. to modify VM
Disadvantages: potential adverse hemodynamic Disadvantages: potential adverse hemodynamic effects or inappropriate hyperventilationeffects or inappropriate hyperventilation
Preferred initial mode in most situations
7777
IMV
0
Paw
St
Preset VT and f
SB is allowedMuscle atrophy is less likely
IMV PaCOPaCO2 < apneic threshold no SB IMV = IPPV
7878
Indications of IMVIndications of IMV
Drug overdoseDrug overdose Intermittent heavy sedationIntermittent heavy sedation Unstable ventilatory driveUnstable ventilatory drive Weaning (may be combined with PSV)Weaning (may be combined with PSV)
7979
Paw
0 tTriggering
window
Mandatory
S
Synch. Mandatory
NO
Preset VT and fSIMV
8080
SIMV•Preset VT at a preset f
•Additional SBs at VT & f determined by patient
•Often used with PSV
•Indications:•1ry means of MV if adequate VE is delivered
•Severe respiratory alkalosis•To prevent auto PEEP•Weaning
SIMV
Potential advantagesPotential advantages Better patient-ventilator interactionBetter patient-ventilator interaction Less hemodynamic effectsLess hemodynamic effects
Potential disadvantages Potential disadvantages Higher WOB > CMV, ACHigher WOB > CMV, AC
8282
Pressure Support Ventilation (PSV)(Inspiratory Pressure Support = IPS)
(Assisted Spontaneous Breathing = ASB)
0
Paw
Spont.
PSV
Trig. Sensitivity
t
8383
Paw
0
CPAP
t
PSV
8484
PSV Pressure assist during SB (= ASB)Pressure assist during SB (= ASB) P assist continues until inspiratory effort P assist continues until inspiratory effort Delivered Delivered VVTT dependent on I effort & R/C of dependent on I effort & R/C of
lung/thoraxlung/thorax
8585
PSV
Potential advantagesPotential advantages Patient comfort Patient comfort WOB < SBWOB < SB May enhance patient-ventilator synchronyMay enhance patient-ventilator synchrony Used with SIMV to support SBUsed with SIMV to support SB
Indications:Indications: Stable patients receiving long-term MV (Stable patients receiving long-term MV (WOB)WOB) WeaningWeaning
8686
PSV
Potential disadvantages
–Variable VT if pulmonary R/C changes rapidly
–If sole mode of ventilation, apnea alarm is only backup
–Gas leak from circuit may interfere with cycling
8787
Paw
0 t
CPAP
Apnea alarm
15 s
IPPV
Apnea time
15-60 s
Apnea Ventilation
8888
Paw
0 t
Biphasic Intermittent Positive Airway Pressure
BIPAP (PCV+)
Spont.
Spont.
PCV
P1
P2
T high T low
P & T can be independently set
8989
SB superimposed on standard PCV
9090
PCV: closed
BIPAP: controlled
E valve
9191
Auto Flow
Auto flow Auto flow application of the "open application of the "open breathing system" even to Volume Controlled breathing system" even to Volume Controlled ventilation modesventilation modes
Can be used + any Volume oriented mode like Can be used + any Volume oriented mode like IPPVIPPV SIMVSIMV MMVMMV
BIPAP
9292
CPAP
SIMV-BIPAP
IPPV-BIPAP
Genuine BIPAP
No SB
SB only at P level
Continuous SB at 2 P levels
Continuous SB, both P levels are equal
Mode Contribution of SB
9393
SB possible at all times (open breathing system) Patient comfort
Patient is never locked out No fighting against the ventilator Can cough and clear his airways at any time
Sedation/MR required Improved SB Proph. & ttt of atelectasis No barotrauma or CVS Full ventilatory support, No switching between Full ventilatory support, No switching between
modes is requiredmodes is required
BIPAP
9494
Airway Pressure Release Ventilation (APRV)
P high PAO2
P low CO2
SB on 2 CPAP levels
E
MV is achieved by MV is achieved by instead of instead of Paw Paw If no SB, APRV = PC-IRVIf no SB, APRV = PC-IRV Barotrauma (Barotrauma ( Pp Pp –– Pmean) Pmean) CVSCVS Indications: (not clear)Indications: (not clear)
Mild ALIMild ALI Alveolar hypoventilation states with minimal Alveolar hypoventilation states with minimal
airflow obstructionairflow obstruction
APRV
9696
Bilevel Positive Airway Pressure (BiPAP) System
A home care device PSV to augment patient ventilation
A non-invasive alternative to traditional management in non life support applications
2 levels of PP
PCycling between the 2 levels is in response to patient F
If the patient fails to initiate P change a timed phase9797
Useful in (home care):Useful in (home care): Obstructive sleep apneaObstructive sleep apnea COPDCOPD Musculoskeletal disordersMusculoskeletal disorders
BiPAP
9898
BIPAP = PCV + SB at all timesBIPAP = PCV + SB at all times APRV = similar + extended times at higher PsAPRV = similar + extended times at higher Ps BiPAP system = a non continuous form of BiPAP system = a non continuous form of
breathing support breathing support
9999
Advantages of different modesCMVCMVRests muscles of respirationRests muscles of respiration
ACACPatient determines amount of ventilatory supportPatient determines amount of ventilatory supportWOBWOB
SIMVSIMVImproved patient-ventilator interactionImproved patient-ventilator interactionInterference with normal CV functionInterference with normal CV function
PSVPSVPatient comfortPatient comfortImproved patient-ventilator interactionImproved patient-ventilator interactionWOBWOB
PCVPCVAllows limitation of PIPAllows limitation of PIPControl of I:EControl of I:E
100100
Disadvantages of different modesCMVCMVNo patient-ventilator interactionNo patient-ventilator interaction
Requires sedation/NMBRequires sedation/NMBMuscle atrophyMuscle atrophyPotential adverse hemodynamic effectsPotential adverse hemodynamic effects
ACACPotential adverse hemodynamic effectsPotential adverse hemodynamic effectsMay lead to inappropriate hyperventilationMay lead to inappropriate hyperventilation
SIMVSIMVWOB compared to ACWOB compared to AC
PSVPSVApnea alarm is only backupApnea alarm is only backupVariable effect on patient toleranceVariable effect on patient tolerance
PCVPCVPotential hyper- or hypoventilation with R/C Potential hyper- or hypoventilation with R/C changeschanges
High Frequency Ventilation (HFV) What is it? What is it? VVT T (1-3 ml/kg)(1-3 ml/kg) , , ff Types:Types:
Applied to chest wall:Applied to chest wall:
HF body surface oscillationsHF body surface oscillations Applied at air openings:Applied at air openings:
HFPPVHFPPV 60-110 b/min60-110 b/min (60-100)(60-100) HFJVHFJV 110-400 b/min110-400 b/min (100-600)(100-600) HFOHFO 400-2400 b/min400-2400 b/min (300-3000)(300-3000)
102102
AdvantagesAdvantages:: Raw and CRaw and CLL don don’’t affect efficacy of t affect efficacy of
ventilationventilation Paw Paw no no COP, no barotrauma COP, no barotrauma Reflex suppression of SB Reflex suppression of SB no need for no need for
sedatives/MRsedatives/MR
HFV
103103
IndicationsIndications BP fistulaBP fistula Bronchoscopy, upper AW proceduresBronchoscopy, upper AW procedures ARDSARDS Patients at Patients at risk for barotrauma (stiff L + risk for barotrauma (stiff L + Paw)Paw) Patients who cannot be intubatedPatients who cannot be intubated ICPICP ShockShock Thoracic surgery (e.g., descending A. Aneurysm)Thoracic surgery (e.g., descending A. Aneurysm) LithotripsyLithotripsy
HFV
104104
Permissive Hypercapnia
Acceptance of Acceptance of Pa PaCOCO22, e.g., , e.g., V VTT to to peak peak
PawPaw
Contraindicated with Contraindicated with ICP ICP
Consider in severe asthma and ARDS Consider in severe asthma and ARDS
105105
Pediatric Considerations
Infants (< 5 kg)
–Time-cycled, PLV
–PIP initiated at 18–20 cm H2O
–Adjust to adequate chest movement or exhaled VT 10–15 mL/kg
–Low level of PEEP (2–4 cm H2O) to prevent alveolar collapse
106106
ChildrenChildren SIMV modeSIMV mode VVTT 10 mL/kg 10 mL/kg
Flow rate adjusted to yield desired TFlow rate adjusted to yield desired TII
Infants 0.6Infants 0.6––0.7 secs0.7 secs Toddlers 0.8 secsToddlers 0.8 secs Older 0.9Older 0.9––1.0 secs1.0 secs
f <18-20 /minf <18-20 /min PEEP 2-4 cm HPEEP 2-4 cm H22OO 107107
108108