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Airway and Mechanical Ventilator Skills and Knowledge

Airway and Mechanical Ventilator Skills and Knowledge. 部立雙和醫院胸腔內科 內科加護病房 陳資濤. Contents. Evaluate the patients who needs intubation Introduction of mechanical ventilation Ventilator settings Elements of ventilator settings Introduction of non-invasive ventilation (NIV).

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Airway and Mechanical Ventilator Skills and Knowledge

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  1. Airway and Mechanical Ventilator Skills and Knowledge 部立雙和醫院胸腔內科 內科加護病房 陳資濤

  2. Contents • Evaluate the patients who needs intubation • Introduction of mechanical ventilation • Ventilator settings • Elements of ventilator settings • Introduction of non-invasive ventilation (NIV)

  3. Who Needs to be intubated? • 1.供氧失敗 • 藉由脈搏血氧計(oximetry)(但容易因局部性或全身性灌流不足,嚴重貧血,與指甲油受到干擾),動脈血氧分析,或病人的發紺表現評估 • 2.通氣失敗 • 藉由鼻導管(cannula)上的二氧化碳分析儀(capnometry)(不一定總是反應真正的二氧化碳分壓,但可以提供通氣量改變的趨勢),動脈血氧分析,或病人呼吸作功的費力程度來評估. • 3.無法保護呼吸道 • 有潛在異物嗆入的風險者,如痰量變得稠又多,咳嗽反射不足,抽痰後吞嚥功能不良等.嘔吐反射(gag reflex)無法正確評估呼吸道的保護效果. • 4.神經學症狀或心肺功能惡化而需要轉送其他單位或緊急處置的病人

  4. Prediction of Difficult Intubation • L = Look (觀察) • E = Evaluate the mouth opening and airway position (評估開口程度與氣道位置) • M = Mallampati score • O = Obstruction (排除阻塞) • N = Neck mobility (評估頸部活動度)

  5. The 3-3-2 Rule • 3: The mouth opening ≧ 3 fingers • 3: Tip of the chin to the hyoid bone ≧ 3 fingers • 2: Hyoid bone to the top of the thyroid cartilage ≧ 2 fingers

  6. Mallampati Score

  7. 傳統/高階呼吸器 Bennett MA-1 Dräger Evita XL

  8. Indications for Mechanical Ventilation • Respiratory arrest • ARDS • Acute respiratory distress with accessory muscle breathing • Hypoxemia or hypercapnia with respiratory acidosis • pH <7.3, PaO2 < 60mmHg or PaCO2 >45mmHg • Severe chest contussion • General anesthesia

  9. Elements of ventilator settings • Control How the ventilator knows how much flow to deliver. • Volume Controlled (volume limited, volume targeted) and Pressure Variable • Pressure Controlled (pressure limited, pressure targeted) and Volume Variable • Dual Controlled (volume targeted (guaranteed) pressure limited)

  10. Elements of ventilator settings • Cycling How the ventilator switches from inspiration to expiration. • Time cycled – such as in pressure controlled ventilation • Flow cycled – such as in pressure support • Volume cycled – the ventilator cycles to expiration once a set tidal volume has been delivered: this occurs in volume controlled ventilation. If an inspiratory pause is added, then the breath is both volume and time cycled

  11. Elements of ventilator settings • Triggering What causes the ventilator to inspiration. • Time – the ventilator cycles at a set frequency as determined by the controlled rate. • Pressure – the ventilator senses the patient's inspiratory effort by way of a decrease in the baseline pressure. • Flow – modern ventilators deliver a constant flow around the circuit throughout the respiratory cycle (flow-by). A deflection in this flow by patient inspiration, is monitored by the ventilator and it delivers a breath. This mechanism requires less work by the patient than pressure triggering.

  12. Elements of ventilator settings • Breath pattern What causes the ventilator to cycle from inspiration. • Mandatory (controlled) - which is determined by the respiratory rate. • Assisted - as in assist control, synchronized intermittent mandatory ventilation, pressure support • Spontaneous - no additional assistance in inspiration, as in CPAP

  13. Elements of ventilator settings • Flow pattern • Sinusoidal - this is the flow pattern seen in spontaneous breathing and CPAP • Decelerating - most intensivists and respiratory therapists use this pattern in volume targeted ventilation also, as it results in a lower peak airway pressure than constant and accelerating flow, and better distribution characteristics • Constant - flow continues at a constant rate until the set tidal volume is delivered • Accelerating - flow increases progressively as the breath is delivered. This should not be used in clinical practice.

  14. Elements of ventilator settings • Mode • CMV - Conventional controlled ventilation, without allowances for spontaneous breathing. Many anesthesia ventilators operate in this way. • Assist-Control - Where assisted breaths are facsimiles of controlled breaths. • Intermittent Mandatory Ventilation - Which mixes controlled breaths and spontaneous breaths. Breaths may also be synchronized to prevent "stacking". • Pressure Support - Where the patient has control over all aspects of his/her breath except the pressure limit.

  15. CMV

  16. A/CV

  17. SIMV

  18. PSV(pressure support ventilation) Spontaneous inspiratory efforts trigger the ventilator to provide a variable flow of gas in order to attain a preset airway pressure. Can be used in adjunct with SIMV.

  19. Oxygen in  FIO2  mean alveolar pressure PEEP Re-open alveoli and  shunt Carbon dioxide out  ventilation  RR  tidal volume Main determinants

  20. 非侵入性正壓呼吸器 Mark 7 (IPPB)

  21. Evidences for Use of NPPV

  22. Contraindications to NIV

  23. Thank you very much for attention!

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