1 / 42

MECHANICAL VENTILATION IN ARDS / ALI

MECHANICAL VENTILATION IN ARDS / ALI. Dr. V.P.Chandrasekaran,. ARDS. Clinical syndrome of Severe dyspnea of rapid onset Hypoxemia Diffuse pulmonary infiltrates leading to respiratory failure. ALI. A less severe disorder but has the potential to evolve into ARDS. DIAGNOSING CRITERIA.

cynara
Download Presentation

MECHANICAL VENTILATION IN ARDS / ALI

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. MECHANICAL VENTILATIONINARDS / ALI Dr. V.P.Chandrasekaran,

  2. ARDS • Clinical syndrome of • Severe dyspnea of rapid onset • Hypoxemia • Diffuse pulmonary infiltrates leading to respiratory failure.

  3. ALI • A less severe disorder but has the potential to evolve into ARDS

  4. DIAGNOSING CRITERIA • Acute onset • Chest X Ray - Acute Bilateral alveolar or interstitial infiltrates • PaO2/FIO2 < 300 mmHg - ALI • PaO2/FIO2 < 200 mmHg - ARDS • PCWP < 18 mmHg or CVP < 12 mmH2O 

  5. ARDS:Pathogenesis

  6. CLINICAL COURSE

  7. NEEDS AGGRESSIVE MANAGEMENT

  8. VENTILATOR STRATEGIES • Non Invasive Ventilation • Invasive ventilation

  9. Goals of ventilation • To improve O2& CO2 gas exchange • Alveolar recruitment • To assist respiratory muscles • To improve the lung compliance

  10. SCENARIO - 1 • Mr . X , 30 year male • Fever x 5 days • Cough with expectoration x 5 days • Breathlessness Grade IV x 2 hours

  11. Chest X Ray

  12. ABG @ FiO2 0.4 Measured Data Ph -7.513 pCO2 -25.4 pO2 -66.5 Na+ -136 K+ -3.54 Cl- -101 Calculated Data • HCO3 (act)-19.9 • HCO3 (std)-23.4 • BE (ect) -3.1 • BE (B) -1.3 • ctCO2 -20.7 • AnionGap -18.8 • O2 Sat -98% ACUTE RESPIRATORY ALKALOSIS

  13. PaO2 / FiO2 = 66.5 / 0.4 =166.25 CVP 8 cm Hep Saline

  14. ARDS:Treatment • Recent decrease of mortality • Treatment of underlying cause • Better supportive ICU Care • Prevention of infections • Appropriate nutrition • GI prophylaxis • Thromboembolism prophylaxis

  15. BiPAP Pressure Support – 15 PEEP – 8 FiO2 – 0.4

  16. Apnoea Active ischemic cardiac disease Unable to handle secretion Homodynamic instability Facial trauma No respiratory drive Claustrophobia Poor cooperation Contraindications to BiPAP

  17. ADMISSION DISCHARGE

  18. SCENARIO - 2 • 40 year male • Cellulitis of Left leg • Breathlessness grade IV since morning

  19. Chest X Ray

  20. Not co operative for Bi-PaP PaO2 / FiO2 = 60.0 / 0.4 =150 CVP 7 cm Hep Saline

  21. Requires Mechanical ventilation Goals? • To improve oxygenation • Alveolar recruitment • To assist respiratory muscles • To improve the lung compliance

  22. To improve Oxygenation • More inspiratory time • Optimum PEEP • Higher FiO2 - initially

  23. Alveolar recruitment • Optimum PEEP • More inspiratory time • Low rate

  24. Protective ventilation Smaller tidal volumes • Avoid overdistention • Tolerate “permissive hypercarbia” “Open lung” ventilation with PEEP • Avoid alveolar collapse and reopening

  25. Collapse/ atelectosis/ ARDSIncreases Surface area for gas exchangeOpens the collapsed lung PEEP Collapsed alveoli After PEEP

  26. To assist respiratory muscles • Ventilator support • If needed to rest respiratory muscles with paralysis

  27. To improve the lung compliance • To keep the PEEP above the lower inflection point • Paralysis • Pressure control mode

  28. Optimal “PEEP” • Positive end-expiratory pressure should be high enough to shift the end-expiratory pressure above the lower inflection point by 2-3 cm H2O (usually 12-15 cm H2O) • Allows maximal alveolar recruitment • Decreases injury by repeated opening and closing of small airways

  29. Settings • Pressure control – to reach Vt 400ml ( 65 x 6 = 390 ml ) • Rate : 10-12/min • I:E : 1:1 • PEEP: 10-15CMH2O • FiO2 : 100% -40%

  30. Will it result in Respiratory acidosis? • Yes. But still needed…!

  31. Permissive hypercapnia pH >7.2 PCo2 <80mmHg Contraindication Hypotension Brain injury Barotrauma ARDS:Permissive Hypercapnoea

  32. Watch for • Barotrauma / pneumothorax • Hypercapnoea • Respiratory acidosis

  33. What to do if PCo2 raises above 80 mmHg or pH <7.2 • Increase Vt • Decrease PEEP • Increase rate • Decrease inspiratory time And reassess

  34. If signs of pneumothorax appears • ICD • If tension pneumothorax – needle decompression - ICD

  35. What to do if saturation does not improve? • Increase PEEP • Increase Inspiratory time (Inverse) • Increase FiO2 • Increase Vt

  36. Why should I aim for low FiO2 <60 • High FiO2 can result in oxygen toxicity and free radical injury and further precipitate ARDS and MOF

  37. Treat the cause Avoid frequent suctioning Frequent ABG assesment

  38. Adjuncts • Paralyze & Sedate • CVP guided fluids • Vasopressers • DVT prophylaxis • Stress ulcer/Bed sore prophylaxis • Nutrition

  39. ARDS Treatment ? • Prone positioning • Steroids • Anti oxidant • Nitric oxide • Surfactant • Anti-inflammatory Strategies • Prostaglandin agonist/inhibitors • Lisofylline and pentoxifylline • Anti IL-8

  40. THANK YOU

More Related