7/31/2019 patan ima 9512
1/37
Click to edit Master subtitle style
5/25/12
Ventilated pt.??????
I am physician/surgeon!!!!!
Dr.Bhagyesh ShahIntensivist,CIMS hospital.
7/31/2019 patan ima 9512
2/37
5/25/12
Monitor
Ventilator
Regulate
dSuction
O2 O2 AirVac
Resuscitator
patient
7/31/2019 patan ima 9512
3/37
5/25/12
Objectives of MV
l Support pulmonarygas-exchange
l Reduce work ofbreathing
l Minimise lung injury
Ventilator
7/31/2019 patan ima 9512
4/37
5/25/12
Type-1hypoxemicrespira
toryfailure
Type-2hypercapneic
respiratoryfailure
Type-3Perioperative
Type-4
Shock
Mechanism QS/QT VA AtelectasisHypoperfusion
Etiology Airspaceflooding1.CNS drive
2N-M coupling
3.Work/deadspace
1.FRC
2.CV
1.Cardiogenic
2.Hypovolemic
3.Septic
Clinicaldescription
1.ARDS
2.Cardiogenicpulmonar
y edema3.Pneumo
1.Overdose/CNSinjury
2.Myastheniagravis
3.asthma/copdfibrosis,kyphoscol
1.supine/obese/ascites,peritonitis,abdominal
incision2.age/smoki
Myocardialinfarct
PE
Sepsis
Bleedtamponade
7/31/2019 patan ima 9512
5/37
5/25/12
Artificial ventilation
Invasive mechanicalventilation
Non-invasively
Nasal prongs,masks, venturi
devices,reservoir bags
Pressurecycled
Volume cycledBilevel
ventilation
Continuouspositive airway
pressure
7/31/2019 patan ima 9512
6/37
5/25/12
SPONTANEOUS CONTROLLED
Rate: PatientPower: Patient Rate: MachinePower: Machine
Common modes ofVentilation
Adapted from Prof. George
ASSISTED MODE
Rate: PatientPower: Machine
ASSIST CONTROL MODE
Minimum rate:Machine
Additional rate:Patient
Power: Machine
IMV
Minimum rate & power forthat rate: Machine
Additional rate & power forthat rate: Patient
SIMVMinimum rate & power for
that rate: Machine
Additional rate & power for
that rate: Patient butsynchronised
7/31/2019 patan ima 9512
7/37
5/25/12
Goals of Monitoring inventilated patient
Ensure proper airway Ensure adequate
oxygenation Ensure adequate
ventilation Maintain hemodynamic
stability Understanding
respiratory mechanics Interpretation of
7/31/2019 patan ima 9512
8/37
5/25/12
Ensure proper airway
Tube position, cut at,fixed at. (ET holder) Clinical exam 5 point
auscultation CxR
EtCO2 Cuff pressure Be alert to tube
blockade, tube migration
7/31/2019 patan ima 9512
9/37
5/25/12
Ensure adequateoxygenation
Clinical exam Cyanosis Agitation Patient-ventilator asynchrony
accessory muscles
Pulse oximetry
ABG PO2, O2saturation%Remember tissue oxygenationdepends
on cardiac output and Hb also
7/31/2019 patan ima 9512
10/37
5/25/12
Basic
Monitoring
Oxygenation
Ventilation
Pulse Oximeter
Arterial Blood Gas
Capnography
7/31/2019 patan ima 9512
11/37
5/25/12
Alarms
Pressure:High & Lowinspiratory pressure
Low PEEP
Respiratory Rate:High & Low
Tidal / MinuteVolume:High & Low
Diagnose:
High insp.press.
High resp. rateLow Tidal
volume
7/31/2019 patan ima 9512
12/37
5/25/12
Asynchrony?
Consider pharmacotheraponly if no cause has been
found for the patientfighting ventilator(patient ventilator
asynchrony)Pharmacotherapy Step1 Reassurance
Step2 Provide pain relie
7/31/2019 patan ima 9512
13/37
5/25/12
What is weaning?
It starts when cliniciandecides that patient
may tolerate areduction of mechanicalsupport
It includes methodsused for a stepwise reduction in
the level of support & readiness testin of
7/31/2019 patan ima 9512
14/37
5/25/12
Value of Weaning
ParametersMost Weaning Indices
predict weaning failurewell
but.
do notpredictsuccessful weaning
7/31/2019 patan ima 9512
15/37
5/25/12
Weaning Trial
Brochard trial (AJRCCM1994;150:896-903)
456 medical-surgical patients 76% passed SBT and were extubated
Remaining 24% (109) randomised to T-piece trials increasing till 2 hrs
tolerated SIMV with reduction of 2-4/min,
twice a day PSV with reductions of 2-4 cm
twice a day till 8 cm H2O tolerated
PSV better than both SIMV and T-piece (5.7+3.7 days vs 9.3+8.2 days)
7/31/2019 patan ima 9512
16/37
5/25/12
Weaning trials
Esteban trial (NEJM1995;332:345-50)
546 medical-surgical patients
76% passed SBT and extubated 130 patients randomized to Once-a-day T-piece trial 2 or more T-piece or CPAP trials as
tolerated PSV with reduction by 2-4cmH2O
at least twice a day SIMV with reduction by 2-4 /min at
least twice a day
7/31/2019 patan ima 9512
17/37
5/25/12
Esteban orBrochard?
SIMV is the least effective technique
Superiority of PSV or T-tube trialsover one another not established
Esteban trial had aggressiveweaning rules produced fasterweaning
4-fold reintubation rate compared toBrochard
Weaning protocols improve weaning
(Ely et al. NEJM 1996;335:1864-69)
7/31/2019 patan ima 9512
18/37
5/25/12
What are the final
lessons? Weanable patients
should undergo a 30
minute T-piece trial (notin infants).
[PS (7 cm H20) is
acceptable]
IMV should NOT be
used in patients who- -
7/31/2019 patan ima 9512
19/37
5/25/12
Tracheostomy When it becomes apparent that
patient will require prolongedventilator assistance
Patients who benefit from earlytracheotomy; those--
Requiring high levels of sedation totolerate ET tubes
Marginal respiratory mechanics - in
whom a tracheostomy tube havinglower resistance reduce risk of muscleoverload
Psychological benefit from ability toeat orally, communicate by articulated
speech, and experience enhanced
7/31/2019 patan ima 9512
20/37
5/25/12
Tracheostomy: TimingEarly tracheostomy (1-7 days) may
benefit patientsexpected to need prolongedventilationEarly tracheostomy:
Doesnot
affect survivalDoes notaffect rates of VAP
Reduces duration of ventilatory support
Reduces duration of ICU stay
But, prediction of need for prolonged (> 2weeks)ventilation is still to be refined
il dl
7/31/2019 patan ima 9512
21/37
5/25/12
Ventilator Care Bundle Hand Hygiene
Head up 45 degree Oral care with chlorhexidine mouthwash
qds.
Endotracheal tube with Subgloticsuction,cuff pressure monitoring. Daily sedation vacation
Early tracheostomy Early mobilization,kinetic bed,position
change
HME(change every 72 hrs or
7/31/2019 patan ima 9512
22/37
5/25/12
HME
7/31/2019 patan ima 9512
23/37
5/25/12
Heated humidifier
7/31/2019 patan ima 9512
24/37
5/25/12
7/31/2019 patan ima 9512
25/37
5/25/12
Feeding
Ryles tube feeding to be startedas soon as the pt. can tolerate.
Naso-jejunal tube is prefered if
possible. Calorie and protein intake is to be
optimised.
Role of iv glutamine + or oral isestablished in cases of ARDS. Watch every 4 hrly for RTA.
Parentral only in certain
7/31/2019 patan ima 9512
26/37
5/25/12
Analgesia
Combine it with sedation ifsedatives being used.
Short acting iv/oral/transdermalpreparations. Avoid NSAID in icu.
Use synergy of PCM and Opioids.
7/31/2019 patan ima 9512
27/37
5/25/12
Sedation-paralytics
Know the difference betweensedatives and paralytics.
Never use paralytics alone. Try to avoid paralytics for long
term to avoid icu inducedmyoneuropathy.
Infusions are always better thanshort boluses.
Daily sedation vacation is must.
7/31/2019 patan ima 9512
28/37
5/25/12
Titrate sedation to effect; use
objective scaleUse a protocol for sedation
Ideally maintain
sedation Level 3
7/31/2019 patan ima 9512
29/37
5/25/12
In mech. ventilated pt. daily interuption ofsedation decreases duration of mechanicalventilator and icu stay.
In case of midazolam it reduces use of
midazolam by almost half. Less pt. in daily wake up group requiredNeuro imaging to check mentation.
Rate of complications same even when
woken up. A trend towards mortality benefit seen
but not statistically significant.
7/31/2019 patan ima 9512
30/37
5/25/12
Thromboprophylaxis
DVT prophylaxis is must. Mechanical
Medical Combined
Stress ulcer and
7/31/2019 patan ima 9512
31/37
5/25/12
Stress ulcer andpressure sore
prophylaxis PPI Sucralfate
Frequent change of position Air bed Specialized dressing
Chlorhexidine bath Head up most of the time
7/31/2019 patan ima 9512
32/37
5/25/12
Glycemic control
Target RBS 150-180 If abnormal correct with insulin
Hypoglycemia must be avoided.
7/31/2019 patan ima 9512
33/37
5/25/12
Bowel-bladder care
Hourly monitoring of urine Daily bowel movt. to be ensured.
Use of silicon catheter in long termpts. High threshold for use of antibiotic
or antifungal.
7/31/2019 patan ima 9512
34/37
5/25/12
Daily drugs to bedeescalated
Antibiotics Anti epileptics
Sedatives Analgesics Supplements
Antiplatelets/heparins
DO NOT do
7/31/2019 patan ima 9512
35/37
5/25/12
DO NOTdo
this to yourpatientrParalyze the patient to calm him down.r
Get routine daily Chest X-raysrPut bicarbonate or other poisons down the ET tuberGive chest physiotherapy to mobilize secretionsrChange ET or tracheostomy tubes routinelyrChange reusable ventilator tubing > 48 hrs
rChange single-use ventilator tubing at all&r DO NOT administer prophylactic antibiotics
7/31/2019 patan ima 9512
36/37
5/25/12
Wish yourpatient
FAST HUG BID
Feeding Analgesia
Sedation Thromboprophylaxis Head up
Ulcer prophylaxis Glycemic control Bowel and Bladder Invasive lines and tubes De-escalate
7/31/2019 patan ima 9512
37/37
5/25/12
Thank you
Dr.Bhagyesh Shah
(9099068938)CIMS Critical Care and EmergencMedicine Consultant
09/05/2012
mailto:[email protected]:[email protected]:[email protected]:[email protected]:[email protected]Top Related