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Mechanical Ventilation: A Primer (How to save a life when I’m alone in the middle of the night)

Mechanical Ventilation: A Primer (How to save a life when I’m alone in the middle of the night). Nick Mohr, MD Assistant Professor Department of Emergency Medicine Division of Critical Care, Department of Anesthesia University of Iowa Carver College of Medicine. Objectives.

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Mechanical Ventilation: A Primer (How to save a life when I’m alone in the middle of the night)

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  1. Mechanical Ventilation: A Primer(How to save a life when I’m alone in the middle of the night) Nick Mohr, MD Assistant Professor Department of Emergency Medicine Division of Critical Care, Department of Anesthesia University of Iowa Carver College of Medicine

  2. Objectives • To review basic mechanical ventilation theory and terminology • To define an algorithmic approach to mechanical ventilation in the emergency department • To explore algorithms for troubleshooting ventilation and oxygenation problems • To discuss specific clinical scenarios requiring specialized ventilation strategies

  3. Conflicts of Interest • This speaker has no financial relationships to disclose. • Topics discussed in this lecture are a component of the University of Iowa Visiting Professor Program Conference Series. • The content of this lecture was developed following an extensive literature search and contains up-to-date, evidence-based information.

  4. Rescue Modes: APRV, HFOV Ventilation Adjuncts: Proning, Inhaled Vasodilators, Heliox Advanced Strategies: Triggering, PRVC/VC+ Ventilation Mechanics: Inflection Points, Loops, Synchrony % Patients Ventilated Safely 90% Basic Mechanical Ventilation Education

  5. What is the goal of mechanical ventilation?

  6. Definitions Definitions

  7. Modes of Ventilation • Assist-Control (A/C) • Volume Control (VC) • Pressure Control (PC) • Pressure Regulated Volume Control (PRVC/VC+) • Synchronized Intermittent Mandatory Ventilation (SIMV) • Pressure Support Ventilation (PSV) Definitions

  8. Ventilator Terminology • PEEP PEEP p t Definitions

  9. Ventilator Terminology peak plateau • PEEP • Tidal Volume • FiO2 • Respiratory Rate • Set vs. actual • Peak Pressure • Plateau Pressure p t Definitions

  10. Tidal Volume “Lung Protection” FiO2 Respiratory Rate PEEP “Ventilation” “Oxygenation” Definitions

  11. Determann RM. et al. Crit Care 2010;14:R1 Algorithm

  12. Mascia L. et al. JAMA 2010;304:2620-7. Algorithm

  13. Ventilation Algorithm Courtesy Scott Weingart, MD Algorithm

  14. 1. Select ventilation strategy Successful Intubation Lung Protection Strategy Obstructive Lung Disease Algorithm

  15. 1. Select ventilation strategy Successful Intubation Lung Protection Strategy Obstructive Lung Disease Algorithm

  16. 2. Calculate ideal tidal volume IBWmale (kg) = 50 + (2.3 x h(over 5 ft)(in)) IBWfemale (kg) = 45.5 + (2.3 x h(over 5 ft)(in)) Goal volume 6 mL/kg Algorithm

  17. Image courtesy JustPressPlay® Algorithm

  18. How well do we practice low tidal volume ventilation in the ED? Fuller BM. et al. AcadEmerg Med 2013;20:659-69. Algorithm

  19. 3. Select respiratory rate Try to match required minute ventilation Usually start at 14-18 breaths/minute Check a blood gas Algorithm

  20. 4. Select oxygenation parameters Start all ventilated patients at FiO2 = 100% Wean aggressively Algorithm

  21. Why add PEEP? Algorithm

  22. Volume Pressure Algorithm

  23. Volume PEEP Pressure Algorithm

  24. Volume PEEP Pressure Algorithm

  25. AIR Pulmonary artery SHUNT Pulmonary vein Bendixen HH. et al. N Engl J Med 1963;269:961-6 Algorithm

  26. Slutsky AS. et al. NEJM 2006;354:1839-41 Algorithm

  27. Why add PEEP? • Decrease shunt • Prevent atelectasis • Increase mean airway pressure Brower RG. et al. N Engl J Med 2000;342:1301-8 Algorithm

  28. 5. Limit plateau pressure P peak plateau P ventilator alveoli Algorithm

  29. 6. Check blood gas, reassess Check ABG/VBG at 15-30 minutes Correlate with EtCO2 Algorithm

  30. Lung Protective Ventilation Plateau Pressure ≤ 30 cm H20 Minimize FiO2 Tidal volume 6 – 8 mL/kg Volume PEEP set to limit atelectasis and shunt (PEEP table) Pressure Algorithm

  31. Goal-Directed Ventilation Comfort Sedation Pain Control MAP ≥ 65 pH ≥ 7.15 FiO2 ≤ 60% VT < 8 mL/kg pplateau < 30 pO2 ≥ 60 Algorithm

  32. Lung Protective Ventilation • Start with A/C (VC), sedation/pain control • Set tidal volume (6 – 8 mL/kg IBW) • Adjust respiratory rate for ventilation • Set FiO2 at 100% and wean aggressively • Titrate PEEP to necessary FiO2 (table) • Check plateau pressure (goal < 30) • Check blood gas and titrate Algorithm

  33. How does ventilation differ in patients with obstructive lung disease? Algorithm

  34. Obstructive Lung Disease Normal lungs Peak pressure rises “Air trapping” P Flow Flow does not return to zero Algorithm

  35. Marini. et al. Critical Care Medicine: The Essentials, 1997 Algorithm

  36. Normal Abnormal Flow “Rest” “No Silence” Algorithm

  37. Protection Tidal Volume “Lung Protection” FiO2 Respiratory Rate PEEP “Ventilation” “Oxygenation” Algorithm

  38. 1. Select ventilation strategy Successful Intubation Lung Protection Strategy Obstructive Lung Disease Algorithm

  39. 2. Calculate ideal tidal volume IBWmale (kg) = 50 + (2.3 x h(over 5 ft)(in)) IBWfemale (kg) = 45.5 + (2.3 x h(over 5 ft)(in)) Goal volume 8 mL/kg Algorithm

  40. 3. Select respiratory rate Try to meet ventilatory demands Start at 8 breaths per minute Reassess at bedside – look at flow loop This is the most effective way to kill a severe asthmatic with the ventilator Algorithm

  41. 4. Select oxygenation parameters Start all ventilated patients at FiO2 = 100% Wean aggressively These patients probably will not require high FiO2 levels Algorithm

  42. 5. Set PEEP Start low (PEEP 0 okay) Keep it low Algorithm

  43. 6. Limit plateau pressure P peak plateau P ventilator Recheck frequently alveoli Algorithm

  44. 7. Check blood gas, reassess Check ABG/VBG at 15-30 minutes Correlate with EtCO2 pH ≥ 7.10 – 7.15 is good enough in most circumstances Algorithm

  45. Goal-Directed Ventilation Comfort Sedation Pain Control MAP ≥ 65 pH ≥ 7.15 FiO2 ≤ 60% VT < 8 mL/kg pplateau < 30 pO2 ≥ 60 Algorithm

  46. Obstructive Lung Disease Ventilation • Start with A/C (VC), sedation/pain control (deep) • Set tidal volume (8 mL/kg IBW), higher for ventilation • Keep respiratory rate low • Set FiO2 at 100% and wean aggressively • Use PEEP 0 - 5 • Check plateau pressure (goal < 30), no air trapping • Check blood gas and titrate Algorithm

  47. Troubleshooting the Ventilator Troubleshooting

  48. Failures of Mechanical Ventilation Hypoxia Hemodynamic Instability Troubleshooting

  49. Hypoxia on the Ventilator D O P E islodgement EtCO2 Direct Visualization Fiberoptic Bronchoscopy Troubleshooting

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