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