PATRICK GERARD L. MORAL, M.D.PATRICK GERARD L. MORAL, M.D.PATRICK GERARD L. MORAL, M.D.PATRICK GERARD L. MORAL, M.D.
IINTUBATIONNTUBATIONIINTUBATIONNTUBATION
• Prevention of upper airway Prevention of upper airway obstructionobstruction
• Protection against aspirationProtection against aspiration• Facilitating tracheobronchial toiletFacilitating tracheobronchial toilet• Providing a closed system for Providing a closed system for
mechanical ventilationmechanical ventilation
• Prevention of upper airway Prevention of upper airway obstructionobstruction
• Protection against aspirationProtection against aspiration• Facilitating tracheobronchial toiletFacilitating tracheobronchial toilet• Providing a closed system for Providing a closed system for
mechanical ventilationmechanical ventilation
VENTILATORY VENTILATORY FAILUREFAILURE
VENTILATORY VENTILATORY FAILUREFAILURE
REDUCED REDUCED CENTRAL DRIVECENTRAL DRIVE
REDUCED REDUCED CENTRAL DRIVECENTRAL DRIVE
IMPAIRED INSPIRATORY IMPAIRED INSPIRATORY MUSCLE PERFORMANCEMUSCLE PERFORMANCEIMPAIRED INSPIRATORY IMPAIRED INSPIRATORY MUSCLE PERFORMANCEMUSCLE PERFORMANCE
EXCESSIVE EXCESSIVE RESPIRATORY RESPIRATORY WORKLOADWORKLOAD
EXCESSIVE EXCESSIVE RESPIRATORY RESPIRATORY WORKLOADWORKLOAD
OOBJECTIVESBJECTIVESOOBJECTIVESBJECTIVES
• To support pulmonary gas To support pulmonary gas exchangeexchange– alveolar ventilationalveolar ventilation– arterial oxygenationarterial oxygenation
• To increase lung volumeTo increase lung volume• To reduce or manipulate work of To reduce or manipulate work of
breathingbreathing
• To support pulmonary gas To support pulmonary gas exchangeexchange– alveolar ventilationalveolar ventilation– arterial oxygenationarterial oxygenation
• To increase lung volumeTo increase lung volume• To reduce or manipulate work of To reduce or manipulate work of
breathingbreathing
PHYSIOLOGICAL
OOBJECTIVESBJECTIVESOOBJECTIVESBJECTIVES
• To reverse hypoxemiaTo reverse hypoxemia• To reverse acute respiratory acidosisTo reverse acute respiratory acidosis• To relieve respiratory distressTo relieve respiratory distress• To prevent / reverse atelectasisTo prevent / reverse atelectasis• To reverse ventilatory muscle fatigueTo reverse ventilatory muscle fatigue• To permit sedation / neuromuscular blockadeTo permit sedation / neuromuscular blockade• To decrease myocardial oxygen consumptionTo decrease myocardial oxygen consumption• To reduce intracranial pressureTo reduce intracranial pressure• To stabilize chest wallTo stabilize chest wall
• To reverse hypoxemiaTo reverse hypoxemia• To reverse acute respiratory acidosisTo reverse acute respiratory acidosis• To relieve respiratory distressTo relieve respiratory distress• To prevent / reverse atelectasisTo prevent / reverse atelectasis• To reverse ventilatory muscle fatigueTo reverse ventilatory muscle fatigue• To permit sedation / neuromuscular blockadeTo permit sedation / neuromuscular blockade• To decrease myocardial oxygen consumptionTo decrease myocardial oxygen consumption• To reduce intracranial pressureTo reduce intracranial pressure• To stabilize chest wallTo stabilize chest wall
CLINICAL
• 700 - 900 mL700 - 900 mL• 15 LPM (self-inflating)15 LPM (self-inflating)• augment VTaugment VT
• 700 - 900 mL700 - 900 mL• 15 LPM (self-inflating)15 LPM (self-inflating)• augment VTaugment VT
AAMBUBAG VENTILATIONMBUBAG VENTILATIONAAMBUBAG VENTILATIONMBUBAG VENTILATION
MMODESODESMMODESODES
• Assist - ControlAssist - Control• SIMVSIMV• PSVPSV• CPAPCPAP• Servo-controlled Servo-controlled
• Assist - ControlAssist - Control• SIMVSIMV• PSVPSV• CPAPCPAP• Servo-controlled Servo-controlled
BBASICASICBBASICASIC
VVAA = V = VTT - V - VDD
VVAA = V = VEE - V - VDD
VVAA = V = VTT - V - VDD
VVAA = V = VEE - V - VDD VAVA
VTVT
• Hook to mechanical ventilator with Hook to mechanical ventilator with the following set-up:the following set-up:– mode: assist - controlmode: assist - control– VT: 500 mLVT: 500 mL– BUR: 15/ minuteBUR: 15/ minute– FiO2: 100 %FiO2: 100 %
• ABG 30 minutes after hooking to MVABG 30 minutes after hooking to MV• In-line nebulization q 6In-line nebulization q 6
• Hook to mechanical ventilator with Hook to mechanical ventilator with the following set-up:the following set-up:– mode: assist - controlmode: assist - control– VT: 500 mLVT: 500 mL– BUR: 15/ minuteBUR: 15/ minute– FiO2: 100 %FiO2: 100 %
• ABG 30 minutes after hooking to MVABG 30 minutes after hooking to MV• In-line nebulization q 6In-line nebulization q 6
OORDERSRDERSOORDERSRDERS
FiO2FiO2FiO2FiO2
• 100 %100 %• dependent on target PaO2, dependent on target PaO2,
hemodynamic status, MAP, PEEP hemodynamic status, MAP, PEEP levellevel
• 100 %100 %• dependent on target PaO2, dependent on target PaO2,
hemodynamic status, MAP, PEEP hemodynamic status, MAP, PEEP levellevel
OOXYGEN CONTENT XYGEN CONTENT OOXYGEN CONTENT XYGEN CONTENT
CaO2 =CaO2 =
1.34 mL x Hgb x SaO2 + .OO3 mL O2 x 1.34 mL x Hgb x SaO2 + .OO3 mL O2 x PaO2PaO2
CaO2 =CaO2 =
1.34 mL x Hgb x SaO2 + .OO3 mL O2 x 1.34 mL x Hgb x SaO2 + .OO3 mL O2 x PaO2PaO2
TTIDAL VOLUMEIDAL VOLUMETTIDAL VOLUMEIDAL VOLUME
• Physiologic: 5 - 7 mL / KgPhysiologic: 5 - 7 mL / Kg• MV: 10 - 15 mL / KgMV: 10 - 15 mL / Kg• alveolar distending pressure: 35 alveolar distending pressure: 35
cm Hcm H22OO
• Physiologic: 5 - 7 mL / KgPhysiologic: 5 - 7 mL / Kg• MV: 10 - 15 mL / KgMV: 10 - 15 mL / Kg• alveolar distending pressure: 35 alveolar distending pressure: 35
cm Hcm H22OO
BBASICASICBBASICASIC
VVAA = V = VTT - V - VDD
VVAA = V = VEE - V - VDD
VVAA = V = VTT - V - VDD
VVAA = V = VEE - V - VDD VAVA VDVD
mechanical
anatomic
alveolar
CCARDIAC OUTPUTARDIAC OUTPUTCCARDIAC OUTPUTARDIAC OUTPUT
hyperinflation
Increased pulmonary vascular resistance
Increased RV afterload
Decreased RV output
Decreased LV preload
Decreased LV output
PPV
• 4 to 20 / minute4 to 20 / minute• 8 to 12 / minute8 to 12 / minute• dependent on:dependent on:
– delivered VTdelivered VT– metabolic ratemetabolic rate– target PaCO2target PaCO2– level of spontaneous ventilationlevel of spontaneous ventilation
• 4 to 20 / minute4 to 20 / minute• 8 to 12 / minute8 to 12 / minute• dependent on:dependent on:
– delivered VTdelivered VT– metabolic ratemetabolic rate– target PaCO2target PaCO2– level of spontaneous ventilationlevel of spontaneous ventilation
RRESPIRATORY RATEESPIRATORY RATERRESPIRATORY RATEESPIRATORY RATE
• 40 to 100 L/ minute40 to 100 L/ minute• determined by level of determined by level of
spontaneous breathing effortspontaneous breathing effort
• 40 to 100 L/ minute40 to 100 L/ minute• determined by level of determined by level of
spontaneous breathing effortspontaneous breathing effort
FFLOW RATELOW RATEFFLOW RATELOW RATE
• Inspiratory time: 0.8 to 1.2 sInspiratory time: 0.8 to 1.2 s• I:E 1:2 to 1:1.5I:E 1:2 to 1:1.5
• Inspiratory time: 0.8 to 1.2 sInspiratory time: 0.8 to 1.2 s• I:E 1:2 to 1:1.5I:E 1:2 to 1:1.5
IINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIOIINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIO
• Respiratory rate: 20 / minuteRespiratory rate: 20 / minute
60 seconds / 20 = 3 seconds 60 seconds / 20 = 3 seconds = T= Ttottot
at an I:E ratio of 1:2:at an I:E ratio of 1:2:
TTII = 1 second = 1 second
TTEE = 2 seconds = 2 seconds
• Respiratory rate: 20 / minuteRespiratory rate: 20 / minute
60 seconds / 20 = 3 seconds 60 seconds / 20 = 3 seconds = T= Ttottot
at an I:E ratio of 1:2:at an I:E ratio of 1:2:
TTII = 1 second = 1 second
TTEE = 2 seconds = 2 seconds
IINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIOIINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIO
• Respiratory rate: 30 / minuteRespiratory rate: 30 / minute
60 seconds / 30 = 2 seconds 60 seconds / 30 = 2 seconds = T= Ttottot
at an I:E ratio of 1:1:at an I:E ratio of 1:1:
TTII = 1 second = 1 second
TTEE = 1 second = 1 second
• Respiratory rate: 30 / minuteRespiratory rate: 30 / minute
60 seconds / 30 = 2 seconds 60 seconds / 30 = 2 seconds = T= Ttottot
at an I:E ratio of 1:1:at an I:E ratio of 1:1:
TTII = 1 second = 1 second
TTEE = 1 second = 1 second
IINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIOIINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIO
• -0.5 to 1.5 cm H20-0.5 to 1.5 cm H20• most sensitive level that prevents most sensitive level that prevents
self-cyclingself-cycling
• -0.5 to 1.5 cm H20-0.5 to 1.5 cm H20• most sensitive level that prevents most sensitive level that prevents
self-cyclingself-cycling
SSENSITIVITYENSITIVITYSSENSITIVITYENSITIVITY
• High pressureHigh pressure• Low pressureLow pressure
• High pressureHigh pressure• Low pressureLow pressure
PPRESSURE ALARMSRESSURE ALARMSPPRESSURE ALARMSRESSURE ALARMS
• Low pressureLow pressure– check connections between tubings check connections between tubings
and patientand patient– deflated cuff deflated cuff – extubationextubation
• Low pressureLow pressure– check connections between tubings check connections between tubings
and patientand patient– deflated cuff deflated cuff – extubationextubation
PPRESSURE ALARMSRESSURE ALARMSPPRESSURE ALARMSRESSURE ALARMS
• High pressureHigh pressure– bronchoconstrictionbronchoconstriction– airway obstructionairway obstruction– barotraumabarotrauma– right main bronchus obstructionright main bronchus obstruction– kinked endotracheal tubekinked endotracheal tube
• High pressureHigh pressure– bronchoconstrictionbronchoconstriction– airway obstructionairway obstruction– barotraumabarotrauma– right main bronchus obstructionright main bronchus obstruction– kinked endotracheal tubekinked endotracheal tube
PPRESSURE ALARMSRESSURE ALARMSPPRESSURE ALARMSRESSURE ALARMS
• Cascade humidifierCascade humidifier• heats carrier gas to 37 C heats carrier gas to 37 C • holds 44 mg H20 / L gasholds 44 mg H20 / L gas• water replacementwater replacement• increases volume and decreases increases volume and decreases
viscosity of the sputumviscosity of the sputum
• Cascade humidifierCascade humidifier• heats carrier gas to 37 C heats carrier gas to 37 C • holds 44 mg H20 / L gasholds 44 mg H20 / L gas• water replacementwater replacement• increases volume and decreases increases volume and decreases
viscosity of the sputumviscosity of the sputum
HHUMIDIFICATIONUMIDIFICATIONHHUMIDIFICATIONUMIDIFICATION
• Chest radiographChest radiograph• Arterial blood gasArterial blood gas• OximetryOximetry• CapnographyCapnography
• Chest radiographChest radiograph• Arterial blood gasArterial blood gas• OximetryOximetry• CapnographyCapnography
AANCILLARYNCILLARYAANCILLARYNCILLARY
• BarotraumaBarotrauma• Oxygen toxicityOxygen toxicity• Patient-ventilator asynchronyPatient-ventilator asynchrony• CardiovascularCardiovascular• RenalRenal• GastrointestinalGastrointestinal
• BarotraumaBarotrauma• Oxygen toxicityOxygen toxicity• Patient-ventilator asynchronyPatient-ventilator asynchrony• CardiovascularCardiovascular• RenalRenal• GastrointestinalGastrointestinal
CCOMPLICATIONS OMPLICATIONS CCOMPLICATIONS OMPLICATIONS
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