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Respiratory Management: Initial Setup and Ventilation Adjustment

Learn how to position mask, connect to ventilator, comfort patient, and adjust ventilatory parameters for optimal care. Understand NPPV discontinuation criteria and benefits of early intervention in mechanical ventilation.

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Respiratory Management: Initial Setup and Ventilation Adjustment

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  1. Initial Setup • Position • Mask • Initial ventilatory setting • Comfort • Nasogastric tube placement

  2. Mask • Positionhead of the bed at a 45° angle • Select the correct size mask

  3. Mask • Connect the mask to the ventilator

  4. Comfort • Explain the modality and provide reassurance • Hold the mask in place until patient is • comfortable • in synchrony with the ventilator • Secure the mask avoiding a tight fit • Skin patch to minimize abrasion and necrosis • nasal bridge and chin

  5. Mask • Hold the mask until the patient is • Comfortable and • In synchrony with the ventilator

  6. Mask • Secure the mask and avoid a tight fit

  7. Mask • Allow passage of two fingers beneath head straps • Allow small air leaks if exhaled Vt is adequate

  8. Nasogastric Tube • Avoid nasogastric tube placement • resting upper esophageal sphincter pressure = 33 ± 12 mmHg • aerophagia is rare with peak mask pressure < 25 cmH2O • Monitor forabdominal distention

  9. Ventilatory Parameters • Adjust to patient needs • increase CPAP to ≥ 5 cmH2O* • increase PSV to • – VT > 7ml/kg and RR < 25 bpm • – relaxation of sternocleidomastoid muscle (palpation) • – highest exhaled Vt without significant air leak • Adjust to patient comfort • avoid contraction of transversus abdominal m. • ask what setting is the most comfortable • * CPAP offsets PEEPi and recruits alveoli but may worsen air leakage

  10. Ventilatory Parameters • CPAP ≥ 5 cmH2O • PSV to Vt > 7 ml/kg and RR < 25 bpm • Reset alarms and apnea backup

  11. Delivery of Mechanical Ventilation • Continuous until resolution of ARF • intermittent 5-15 m breaks, Q 3-4 has tolerated • – stable patients with CPAP < 5cm H2O • – once stable, after 4-6 h of continuous NPPV • – remove face mask, providing adequate FiO2 for: • oral intake (liquid diet, medications) or expectoration • – 6-12 hours/day for several days

  12. Thorax 2002; 57: 192-211.

  13. Changes in PaCO2 and pHHypercapnic respiratory failure Chest 1996; 109: 179

  14. Changes in PaO2:FiO2 over time Forty patients with hypoxemic ARF - ABG correction in 31 (78%) Chest 1996; 109:179

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  16. Criteria to Discontinue NPPV • Need for endotracheal intubation to •  protect airways •  clear copious amounts of secretions • Cardiovascular instability •  hypotension or significant arrhythmia • Inability to improve •  gas exchange •  mental status •  dyspnea • Intolerance to NPPV

  17. Mask Mask ET ET Resolving ARF Evolving ARF Respiratory failure Duration of Mechanical Ventilation UT experience with 203 patients: mean duration of MV 25 hours • earlier intervention • avoiding sedation and paralysis • reduced incidence of MV-induced respiratory muscle atrophy 1 • eliminating the imposed work by the endotracheal tube • lower rate of complications, especially infections 2-6 • earlier removal 1. Le Bourdelles et al. AJRCCM 1994;149:1539-1544. 2. Brochard et al. NEJOM 1995; 333: 817-822. 3. Antonelli et al. NEJOM 1998; 339: 429-435. 4. Guerin et al. Intensive Care Med. 1998; 24: 27. 5. Nourdine et al. Intensive Care Med. 1999; 25:567-573. 6. Girou et al. JAMA 2000; 284: 2361-2367.

  18. Conventional MV with ETI Early Established Resolving Post-extubation 1 2 4 3 Timing of NPPV Application • 1. Early: to prevent intubation • 2. Established: as alternative to intubation • 3. Resolving: to wean from ventilation • 4. Post-extubation: to prevent re-intubation

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