10 mai 2009 DAC vermeidbare barotrauma JPM Das vermeidbare barotrauma technische lösungen 10 Mai...

10 mai 2009 DAC vermeidbare barotrauma JPM

Das vermeidbare Das vermeidbare barotrauma technische barotrauma technische

lösungenlösungen

10 Mai 200910 Mai 2009

J P Mulier MD PhDJ P Mulier MD PhDSint Jan Brugge-Oostende, BelgiumSint Jan Brugge-Oostende, Belgium


Announcement of Announcement of interferenceinterference

J P Mulier developed a ventilator safety J P Mulier developed a ventilator safety valvevalve

Safety frog is now on sale through Safety frog is now on sale through MedecBeneluxMedecBenelux

Receives a payment on salesReceives a payment on sales


A. Barotrauma is it possible A. Barotrauma is it possible today?today?

A. Ventilators today are relative A. Ventilators today are relative save: save:

Pressure alarms on circuitPressure alarms on circuit

Pressure limitation on ventilation Pressure limitation on ventilation modesmodes

Maximum pressure 70 CMH20Maximum pressure 70 CMH20


Barotrauma is possible today!Barotrauma is possible today!

A. Ventilators today are A. Ventilators today are notnot save save ifif: :

Anaesthesiologist not vigilant or not Anaesthesiologist not vigilant or not around around

Pressure alarms on circuitPressure alarms on circuit Alarm can be set very high !Alarm can be set very high !

Pressure limitation on ventilation modesPressure limitation on ventilation modes Limit level can be set very high !Limit level can be set very high !

Maximum pressure 70 CMH20Maximum pressure 70 CMH20 70 cmH20 gives barotrauma !70 cmH20 gives barotrauma !

Anaesthesiologist uses wrong settingsAnaesthesiologist uses wrong settings


Most common accidentMost common accidentis a human erroris a human error

Manual system is outside Manual system is outside electronic ventilator and electronic ventilator and less protectedless protected

Forgetting to switch from Forgetting to switch from manual to mechanical manual to mechanical ventilation might happenventilation might happen with a closed APL valve with a closed APL valve with a high fresh gas flowwith a high fresh gas flow

More frequent than More frequent than reported !reported !


2 and 3 liter breathing 2 and 3 liter breathing bagsbags

USUS EUREUR old old rubberrubber


Compliance of breathing Compliance of breathing bagsbags

0

20

40

60

80

100

0 5 10 15

liter

cmH

2O

35 cmH20

60 cmH2O

2L USlatex free

2 L EURlatexfree

3 L EURlatex free

2 L black rubber

3 L black rubber


ventilatorventilator

If you use large compliant balloonsIf you use large compliant balloons

No risk of barotrauma on manual No risk of barotrauma on manual or mechanical ventilationor mechanical ventilation

But is prolonged alveolar But is prolonged alveolar distension at pressure between distension at pressure between

20 and 50 cmH20 dangerous 20 and 50 cmH20 dangerous ??


Effect of 30 cmH20 during 4 x 30 Effect of 30 cmH20 during 4 x 30 secondsseconds

in rats data JPMulier 2008 2009in rats data JPMulier 2008 2009 Without safety valve Without safety valve With safety With safety

valvevalve

0 RBC


Effect of 30 cmH20 during 4 x 30 Effect of 30 cmH20 during 4 x 30 secondsseconds

in rats data JPMulier 2008in rats data JPMulier 2008

Burkitt chamber count of BALBurkitt chamber count of BAL Without safety valveWithout safety valve With safety valveWith safety valve

0 RBC11 RBC

total number of erythrocytes in BAL per ml

0

500.000

1.000.000

1.500.000

2.000.000

2.500.000

3.000.000

3.500.000

4.000.000

4.500.000

5.000.000

no safety frog with safety frog


Thoughts on the pulmonary blood-gas barrier.Thoughts on the pulmonary blood-gas barrier. West J B. Am J Physiol Lung Cell Mol Physiol. 2003 West J B. Am J Physiol Lung Cell Mol Physiol. 2003 Sep;285(3):L501-13. Sep;285(3):L501-13.

High lung volume rather than the increased alveolar High lung volume rather than the increased alveolar pressure gives the increased permeability. pressure gives the increased permeability. Hernandez LA. Hernandez LA. J Appl Physiol.J Appl Physiol. 1989;66:2364-2368. 1989;66:2364-2368.

If we increase lung volume while maintaining a If we increase lung volume while maintaining a constant capillary transmural pressure, the number constant capillary transmural pressure, the number of both endothelial and epithelial breaks is greatly of both endothelial and epithelial breaks is greatly increased. Fu Z. increased. Fu Z. J Appl Physiol.J Appl Physiol. 1992;73:123-133. 1992;73:123-133.


Specifications of VSV 3 (safety Specifications of VSV 3 (safety frog)frog)

Alarm and valve open when:Alarm and valve open when: > 75 cmH2O> 75 cmH2O > 20 CMH2O and >6 seconds> 20 CMH2O and >6 seconds

VSV offVSV off Variation less than 2 cmH2O and Variation less than 2 cmH2O and

>60 seconds>60 seconds VSV onVSV on

> 10 cmH2O > 10 cmH2O


Ventilator safety valve Ventilator safety valve (safety frog)(safety frog)

0

10

20

30

40

50

0 10 20 30 40 50

seconds

cmH

2O

Euro 2l breathingbag

Euro 2l breathingbag with VSVUSA 2l breathingbag

USA 2l breathingbag with VSV


B. Barotrauma is it possible B. Barotrauma is it possible today?today?

B. Oxygen therapy is relative B. Oxygen therapy is relative save: save: Tracheotomy mask is openTracheotomy mask is open Nasal canula is openNasal canula is open Oxygen Mask is openOxygen Mask is open

Intranasal, intra pharyngeal, Intranasal, intra pharyngeal, intratracheal canula is intratracheal canula is dangerous!dangerous!

Jet therapy with canula is Jet therapy with canula is dangerous if tip not visualiseddangerous if tip not visualised


What is the problem ?What is the problem ?

Patient is intubated with endotracheal Patient is intubated with endotracheal tube, laryngeal mask, wendeltube, tube, laryngeal mask, wendeltube, tracheocanuletracheocanule

Breathing spontaneous but Breathing spontaneous but

Patient needs oxygenPatient needs oxygen

What oxygen equipment is used?What oxygen equipment is used? What connection is used?What connection is used?


Barotrauma is possible today!Barotrauma is possible today!

B. Oxygen therapy is B. Oxygen therapy is notnot save save if: if: Oxygen Mask is used with LMAOxygen Mask is used with LMA Oxygen mask is used with OTTOxygen mask is used with OTT Oxygen mask is used with NTTOxygen mask is used with NTT Oxygen mask is used with …Oxygen mask is used with …


Oxygen Mask and LMAOxygen Mask and LMA

Different connection size Different connection size now but!!!!now but!!!!

Ideal is using a ventilatorIdeal is using a ventilator with spontaneous breathingwith spontaneous breathing With CPAP, assist,…With CPAP, assist,…

Never self constructed Never self constructed systems!systems!


Oxygen Mask and OTT NTTOxygen Mask and OTT NTT

Different size now but !!!!Different size now but !!!! Tubing might be connected Tubing might be connected

directlydirectly The inventive capacity of The inventive capacity of

anesthesiologists, anesthesia anesthesiologists, anesthesia nurses, post anesthetic nurses is nurses, post anesthetic nurses is dramatic.dramatic.


Why is Barotrauma possible Why is Barotrauma possible ??

Bottle expanders are used Bottle expanders are used to reduce 200 bar to 5 bar.to reduce 200 bar to 5 bar.

Hospital pipe line is at 5 barHospital pipe line is at 5 bar Oxygen valve reduces the Oxygen valve reduces the

pressure from 5 bar without pressure from 5 bar without reduction system!reduction system!

If oxygen mask tube is If oxygen mask tube is occluded pressure can rise occluded pressure can rise to to

5 bar! = 5000 cmH205 bar! = 5000 cmH20


O2 maskO2 mask

Used 99% on patients Used 99% on patients not intubated, no tracheacanule,..not intubated, no tracheacanule,..

Used by many different non Used by many different non anesthesia disciplinesanesthesia disciplines Not aware of barotrauma riskNot aware of barotrauma risk

Used everywhere in the hospital like Used everywhere in the hospital like emergency, intensive care, post and per emergency, intensive care, post and per operative care, pneumology, coronary care unit, operative care, pneumology, coronary care unit, neuro high care, maternity, pediatry, neuro high care, maternity, pediatry, neonatology, every ward, and outside the neonatology, every ward, and outside the hospital: pre hospital ambulance, interhospital hospital: pre hospital ambulance, interhospital transfer, helicopter service, fireman,….transfer, helicopter service, fireman,….


Why dangerous?Why dangerous?

Risk of sudden/unknown connection byRisk of sudden/unknown connection by Inexperienced health care worker who wants Inexperienced health care worker who wants

to improve O2 deliveryto improve O2 delivery patient movementpatient movement Selfmade adaptation to keep O2 mask Selfmade adaptation to keep O2 mask

connected but risk for occlusionconnected but risk for occlusion Oxygen/air supply is standard not Oxygen/air supply is standard not

protected and connect to hospital supply protected and connect to hospital supply at 5 bar.at 5 bar. 5 bar = 5 160 cmH20 !5 bar = 5 160 cmH20 !

Connections and tubing are standard not Connections and tubing are standard not protected and disrupt only above 2 barprotected and disrupt only above 2 bar 1 bar = 1 000 cmH20 !1 bar = 1 000 cmH20 !


What is safe?What is safe?

Nasal tips are fixed on tubing.Nasal tips are fixed on tubing. Safe as not connectable to other Safe as not connectable to other

equipment.equipment.

tube fixed at connector open at endtube fixed at connector open at end

Oxygen mask sometimes Oxygen mask sometimes deconnectabledeconnectable

Tubing used for other oxygen Tubing used for other oxygen applications!applications!


Who is responsible?Who is responsible?

Oxygen supply installer ?Oxygen supply installer ? Not mentioned to use it in this wayNot mentioned to use it in this way

Oxygen therapy equipment?Oxygen therapy equipment? Only made for open systems, not Only made for open systems, not

for intubated patientsfor intubated patients Physician requiring O2 therapy or Physician requiring O2 therapy or

nurse using equipment in the nurse using equipment in the wrong waywrong way

Patient gets the traumaPatient gets the trauma


pressure flow relation through oxygen mask tubing

0

2040

60

80

100120

140

160

0 5 10 15 20 25

Flow L/min

Pre

ssu

re m

bar

Can we put a pressure relief Can we put a pressure relief valve on the oxygen supply? valve on the oxygen supply?


Equipment Equipment

Does equipment exists for oxygen Does equipment exists for oxygen therapy in intubated patients?therapy in intubated patients? Yes oxygen cap for trachea canuleYes oxygen cap for trachea canule Yes ventilators but not mentioned for Yes ventilators but not mentioned for

spontaneous breathing without assistspontaneous breathing without assist The spontaneous breathing circuit of The spontaneous breathing circuit of

anesthesia ventilator is not protected either!anesthesia ventilator is not protected either! Ventilator too expensive not to use as pure Ventilator too expensive not to use as pure

oxygen supplyoxygen supply Self made equipmentSelf made equipment

Self made safety protection?Self made safety protection? No special equipment available.No special equipment available.


Special equipment to Special equipment to develop?develop?

To use only on intubated patients, To use only on intubated patients, tracheo canule, LM ,… patients?tracheo canule, LM ,… patients? Risk remains when classical mask is usedRisk remains when classical mask is used

Protect every oxygen supply?Protect every oxygen supply? Pressure to high ? For high flowPressure to high ? For high flow

Protect every standard O2 line from Protect every standard O2 line from O2 mask, tracheo masks,…at the endO2 mask, tracheo masks,…at the end Will every company use this protection?Will every company use this protection?


New developed barotrauma New developed barotrauma valvevalve

Protects every oxygen supplyProtects every oxygen supply Should be build inShould be build in Use regular tube for flow up to 10 l/minUse regular tube for flow up to 10 l/min Use larger size tube for flow up to 20 l/minUse larger size tube for flow up to 20 l/min


Pressure flow relation with Pressure flow relation with new barotrauma valvenew barotrauma valve

O2 supply protected and tubing occluded

01020304050

0 5 10 15 20

flow L/min

Pre

ss

ure

cm

H2

0 No barotraumaNo barotrauma Risk volutrauma remain !Risk volutrauma remain !


Conclusion: How to protectConclusion: How to protect Protect all oxygen supply with a low Protect all oxygen supply with a low

pressure sensitive devicepressure sensitive device Keeps pressure below 40 cm H20Keeps pressure below 40 cm H20 Signals problems with alarmSignals problems with alarm

Use max 6 l oxygen / minuteUse max 6 l oxygen / minute More is lost trhough barotrauma valveMore is lost trhough barotrauma valve

Use large tubing for higher flowUse large tubing for higher flow Ambu, masks with reservoir,…Ambu, masks with reservoir,…

Or use small inexpensive safety frog Or use small inexpensive safety frog also for oxygen supply ?also for oxygen supply ?


ConclusionConclusion

VentilatorVentilator Barotrauma nicht möglichBarotrauma nicht möglich

Aber Aber volutraumavolutrauma ist möglich ist möglich Brauchen sie ein ventilator safety Brauchen sie ein ventilator safety

valve: safety frogvalve: safety frog

O2 TherapyO2 Therapy Barotrauma ist ein risikoBarotrauma ist ein risiko

Brauche sie ein Brauche sie ein baroprotectorbaroprotector oder oder ein ein voluprotectorvoluprotector on jeden O2 punkt on jeden O2 punkt


More informationMore information

[email protected]@azbrugge.be

www.publicationslist.org/jan.muliwww.publicationslist.org/jan.mulierer

European society for peri European society for peri operative care of the obese operative care of the obese patient patient www.espcop.orgwww.espcop.org

http://www.publicationslist.org/jan.mulier

http://www.publicationslist.org/jan.mulier

http://www.espcop.org/


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10 mai 2009 DAC vermeidbare barotrauma JPM Das vermeidbare barotrauma technische lösungen 10 Mai...

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