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Respiratory Care

???????????????????. ?????????????????? (intubation) ??????????????????????????????????? ?????????????????? ??????????????????????????????????????? (humidity and aerosol therapy)?????????????????????????? (tracheobronchial suction)????????????????????????? (chest physical therapy). ??????????????

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Respiratory Care

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    1. ???????????????????????

    2. Respiratory Care 1. ??????????????????? (airway management) 2. ???????????????????? (oxygen therapy) 3. ?????????????????????? (mechanical ventilation) 4. ????????????????????? 5. ?????????????????????? 6. ?????????????????????????????????????? 7. ????????? ???? ???????? sedation, muscle relaxant

    3. ??????????????????? ?????????????????? (intubation) ??????????????????????????????????? ?????????????????? ????????????????????????? ?????????????? (humidity and aerosol therapy) ?????????????????????????? (tracheobronchial suction) ????????????????????????? (chest physical therapy)

    4. ??????????????????????????????? 1. ?????????? alveolar ventilation ??????? ???? ???????????? hypoventilation ??? RC center ????? 2. ?????????? gas exchange ??????? ???? ???????????????????????????????????? 3. ??????? work of breathing ??????????????????????????????????????????? ????????????????? 4. ??????????????????????????????????

    5. ???????????????? ??????????????????????? (negative pressure ventilation) ?????????????? ?????????????? ?????????????? ???????????????????????? (positive pressure ventilation) 1. Non-invasive positive pressure ventilation (NPPV) : CPAP, BIPAP 2. Invasive positive pressure ventilation

    6. Negative Pressure Ventilator : Iron Lung

    7. Positive Pressure Ventilator

    8. Pressure-Time curve

    9. ???????????????????????? 3 ??? 1. ??????????????????????????????????? (volume controlled ventilator) 2. ??????????????????????????????????? (pressure controlled ventilator) 3. ???????????????????????????????????????????????/??? (time controlled ventilator)

    10. Pressure limited/cycled ventilator: Bird series ????????????????? peak airway pressure ???? peak inspiratory pressure (PIP) ???????????????????????????????? ???????????????????????????? PIP ???? 20 ?? ??? ????????????????????????????? ?????????????????????????????????????????????????????????????? ????????????????????????????? PIP ?????????? ????????????????????????????????????????????????????????????????????????? ?????????????????????????????????? Vt ???????? ??????????? ??????????? lung compliance ??? airway resistance

    12. Volume limited/cycled ventilator ?????????????? set Vt ??????????????????????????????????? ?????????????????????? set Vt ????????? ???? 500 ?? ????????????????????????????? ???????????????????????????????????????????????????? set Vt ?????????????????????????????????????????????????????? ?????????????????????? ???????????????????????????????????? PIP ??? Ti ???????? ??? PIP ???????????? ??? Ti ???????????????????????? lung compliance ??? airway resistance ?????????? ?????? Bennette, Esprit

    13. Benette MA-1, MA-2

    14. Bennette 7200 Ventilator

    15. Time limited/cycled ventilator ??????????????????? inspiratory time (Ti) ??????????????????????????????????????????????????????? Ti ?????????? ???? 1 ?????? ???????????????????????????????????????????????????????????????????????????? Ti ?????????????????????????????????????????????????????? ?????????????????????? ???????????????????????????????????? Vt ????????????? ??? PIP ???????? ??? PIP ??????????????????????? lung compliance ??? airway resistance ?????????? ?????? Servo, Drager, Engstrom series

    16. Servo Ventilator

    17. Servo Ventilator

    18. Drager Ventilator

    19. New Generation Ventilators

    20. New Generation Ventilators

    21. Benette 2801 Ventilator

    22. Veolar Hamilton Ventilator

    23. ?????????????????????????????? 1. Gas inlet ???????????????????????????????? ???????????????????????????????????????????????????????? ????????????????????????????????????????????????????? 50 Psi ????????????????? ????????????? pressure cycled ventilator ????? compressed air ??????????????? ??????????????????????????????????????????????????? ??????? ?????????????????????????????? FiO2 ?????????

    26. ?????????????????????????????? (???) 2. Machine ?????????????? ????????????????????????????????????????? ???????????? ?????????????????????????????????????????????????? FiO2 ????????????? ???????????????????????????????????????? gas outlet ??????????? ??????????? ????????????? ????????????????????

    27. ?????????????????????????????? (???) 3. ????????????????? (nebulizer or humidifier) ?????????????????????????????????????????????? ??????????????????????????????????? ?????????????????? 2 ???? ??? 1. Simple jet nebulizer ??????????????????????? aerosol ????? ???????????????????????????????????????????? ???? ??????? Bird 2. Heated humidifier ????????????????????????????????? ????????????? ??????????? ???? Bennette

    32. ?????????????????????????????? (???) 4. Inspiratory pathway ??????????????????????????????????????????????????????????? 5. Expiratory pathway ????????????????????????????????????????????????? 6. Expiratory valve ???????????????????????????????????????????????????????????? expiratory pathway ??????????????????????????????????????????????????????????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????????

    35. Mode of ventilation 1. Continuous mandatory ventilation (CMV) - Controlled mode – Assisted mode – Assisted/control mode 2. Synchronized intermittent mandatory ventilation (SIMV) 3. Pressure support ventilation (PSV) 4. Continuous positive airway pressure (CPAP) and Positive end expiratory pressure (PEEP)

    36. Tidal Volume (Vt) ???????????????????????????????????????????????????????????????????? ??????????? ???? ???? ???? ???????????????????????????????????????????????????? (set Vt) ?????????????????????????????????? (exhaled Vt) ???????????? Bird ??????????????????????? Vt ??? ?????????????? respirometer ???????????????????????? exhalation valve ?????????? Bird ??????? Vt ????????????????? 7-10 ?????????.

    37. Inspiratory flow rate ????????????????????????????????????????????????????????? ?????????????????????? (liter per min = LPM) ???????????????????? pressure cycled ???????????????????????????????????????????????????????????????????????????????????????????????????? (pressure dependent flow) ??????????????????????????????? ???????????????????????? ???????????? (volume cycled) ???????????????????????????????????????????????????? ???? constant flow, decelerating flow ???????? peak inspiratory flow (PIF) 35-45 LPM

    38. Inspiratory time (Ti) ?????????????????????????????????????????????? ?????????????????????????? ??????? ?????????? Inspiratory time (Te) ??????????????????????????????????????????? ????????????????????????? ??????? ?????????? I:E ratio ????????????????????????????????????????????????????????????????????????? ?????????????????? 1:3

    39. Respiratory rate (RR) ???????????????????? ??????????????????????????-??????????? 1 ???? ???????????????????????? 12-25 ???????????? Minute volume (ventilation)=MV ?????????????????????????-?????????????????????? 1 ???? ??????????? ??????????? (LPM) ???????????????????????????????????????????????????????? ???????? MV ??????? Vt ?????? RR ?????????????????????????????????????????????????????? MV ????? ???????????????????????????????? Tv ???????? ?????????? exhaled Vt ???????? 1 ????????????????? MV ???? 8-10 LPM

    40. Airway pressure (Paw) ?????????????????????????????????????????????????????????????????????????????? ??????????????????????????????????????????????????? ??????????? ???????????? (cmH2O) ??????????????????????????????????????????????????? 0 ??????????????????????? ???????????????????????????????????????????????? Paw ?????? negative pressure Peak Paw (PIP) ????????????????????????????????????????????????????????????????????????? ?????????????? 40 ??.???

    41. Sensitivity ??????????????????????? ????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????????? (assisted ventilation) ???????????????????????? ???????? 2 ???? ??? 1. Pressure sensing ???? pressure triggering ????????????????????????????????????????????????? ????????? ????? ???????????????????? –2 ??.??? 2. Flow sensing ???? flow triggering ???????????????????????????????????????????????? ????????? ?????????????

    42. Fractional inspired oxygen concentration (FiO2) ????????????????????????????????????????????????????????? ??????????????????????????????????????? 50% ???? 100% ???????? FiO2 ??????? 0.5 ??? 1 ???????? ??????????????????????????????????? FiO2 ????????? ?????????? ?????????????????????????????? SaO2 > 90% ??? FiO2 ??????? 0.3-0.4

    43. ??????????????? Bird Ventilator 1. Off

    44. ??????????????? Bird Ventilator 2. Start

    45. ??????????????? Bird Ventilator 3. Inhalation

    46. ??????????????? Bird Ventilator 4. Exhalation

    47. Center Part of Bird : ???????????????????????

    48. ????????????????????????????????? ??????????????????????????????????????????????????? (mortality) ???????????????????????????????????????????????????????? (length of stay) ??????????????????????????????????? (complications and morbidities)

    49. ?????????????????????????????????

    50. ???????????????????????????? ????????????????????????????????????????????????????????????????????????? LOS ?????????? ?????? low tidal volume (lung protective strategies) ?????????????????? ARDS ??????????????????????????????????????????????? ventilator associated pneumonia (VAP) ?????? non-invasive mechanical ventilator ?????????????????????? (COPD, weaning) ?????? protocol directed weaning

    51. ????????????????????????????? ??????????????????????????????????? ?????????? plateau pressure ?????????? 35 ??.??? ???????????? barotrauma ????????????? tidal volume 8-10 ??/?? ??????????????? volutrauma ????????????????????????? (FiO2) ??????? 50-60 % ?????????? SaO2 ?????? 90% (PaO2 60 ??????) ???? RR = 12-16 /min, I:E ratio = 1:3

    52. ??????????????????????????????????????? ??????????????????????? ???????????????????????????????????????????????????????? Normal lung: neuromuscular weakness Obstructive lung: COPD, asthma Restrictive lung: ARDS Unilateral lung disease: severe pneumonia, bronchopleural fistula

    53. ?????????????????????????????????????????? Mode : CMV ???? SIMV Tidal volume 10 ml/kg Respiratory rate 12-16 / min ????? PaCO2 40 ?????? Peak inspiratory flow rate 60-80 L/min I:E ratio = 1:3 FiO2 0.3-0.5 ????? PaO2 > 60-80 ??????

    54. ??????????????????????????????????????? Obstructive lung disease ?????????????? airway obstruction (COPD, asthma) ?????????????? prolonged exhaled time (?? RR, i-Time) ?????????? high peak airway pressure (PAP) ??? plateau pressure ??????????????? Adequate sedation Aggressive bronchodilator

    55. ?????????????????????????????????????????????????????? ???????? airway resistance ??? dynamic hyperinflation (auto PEEP) Mode : CMV, SIMV with PS 5-10 cmH2O TV 8-10 ml/kg Peak inspiratory flow rate 80-100 L/m RR 10-16 /min PEEP 80% of estimated auto PEEP Volume cycled preferred

    56. ??????????????????????????????????????? Restrictive lung disease ???? ???????????? ARDS ??? small tidal volume ( 6-8 cc/Kg ) ??? PEEP ?????????? hypoxemia ????? respiratory rate Accept permissive hypercapnea ????????? PEEP effect ???? suction

    57. ????????????????????????????????????????? Restrictive ???????? compliance ???????????? Pplat ??? Mode CMV, SIMV TV 6-8 ml/kg RR 15-25 /min Peak inspiratory flow rate 60-80 L/m PEEP 8-10 cmH2O

    58. Ventilator Parameters

    59. Ventilator Waveforms

    66. Complication of mechanical ventilation 1. Barotrauma – pneumothorax ???????????????????????????? ??????????????? PIP < 40 cmH2O, Plateau P< 35 cmH2O 2. Volutrauma ??????????? Vt ????????? ?????????????? Vt ??????? 10 ?????????. 3. Oxygen toxicity ??????? FiO2 ????????? ?????????????? 0.6 4. Ventilator associated pneumonia ?????????? aseptic technique, ??????????

    67. Common problems during mechanical ventilation

    68. Common problems during mechanical ventilation

    69. Tracheal Cuff Inflation

    70. VAP: Preventive strategies

    71. Subglottic suction ETT

    72. ??????????????????????????

    73. Position of Ventilated patient

    74. Bronchodilator treatment by MDI

    75. ????????????????????????? ventilator Increased risk of pneumonia Impaired cardiac performance Neuromuscular problems related to sedation and N-M blocking agents Cause lung damages (ventilator induced lung injuries, VILI)

    76. Ventilator Induced Lung Injuries Pulmonary edema Morphologic changes Inflammatory reaction (neutrophil, cytokines) Fibroproliferative changes Mimic ards

    77. ARDS

    78. ??????????????????????????

    79. Common problems during mechanical ventilation

    80. Hypotension

    81. High Airways Pressure

    82. High Airways Pressure

    83. Non Invasive Mechanical ventilation ?????? non-invasive mechanical ventilation ??????????????????? ??????????????????????????????

    84. Non invasive mechanical ventilation

    85. ??????????????????????? ?????????????????????????????????????????????????????????????? ?????????????????????????????????????????????????????????????????????????????????????????????????????? ????????????????????????????????????????????????????????????????????????????? ??????????????????????????

    86. ?????????????????????????????? ????????????????????????????????????????? ?????? shock, vital sign ???????? Cardiovascular instability, cardiac arrthymia, acute MI Multiple organ dysfunction ?????????????????? sedation ???????? ??????? severe hypercatabolic state : sepsis

    87. ????????????????????????????????????????? RR > 35-40 /min PR > 140 /min Hypo / hypertension (systolic < 90 >180) SaO2 < 90% TV < 0.25 L Agitation, diaphoresis, anxiety, somnolence

    88. ????????????????????????????? 1. ???????????????? CMV ?????????????? SIMV with pressure support and CPAP ???? 2. ????? spontaneous breathing ???? T-piece ???? weaning trial 3. ??????????????????????????????????? 4. ??????????????????????? ???????? ??????????? ???????????????? 5. ?????????????????????? 10% 6. Monitoring ??????????????????? ???????????????????????????????? 7. ????????????????????????? 2 ??????????????????????????????????

    89. ???????????????????????????????????? Respiratory drive ?????????????? Respiratory muscle ?????????? hypoK Gas exchange ???? pneumonia Increased work load ???? sepsis, brochospasm Cardiovascular instability ???? CHF Others : malnutrition

    90. Weaning process

    91. Patient’s Position

    92. ?????????????? ICU ????? wean ??????????????????????????????????????? wean ??????? wean ?????????????????? protocol directed ?????? physician directed ??????????????????? ?????????????????? wean ?? wean ???????, ??? parameter ?????? ????????????? wean

    93. ?????????????? ICU ????? wean ??????????????????? wean vital signs unstable: hypotension, extreme tachycardia acute cardiac event: ischemia, arrhythmia need for muscles relaxant high FiO2 high PEEP on ventilator setting ??????????????? contraindication ?????? T-piece trial ???????

    94. ?????????????? ICU ????? wean ????????????????????, ????????????? monitor EKG, HR, O2 saturation ??????????? T-piece ???? CPAP PS 5 cmH2O ??? RR, tidal volume ????????????? 15 ???? ???????????? agitation, tachycardia, hypoxemia, RR>35 ???? wean ???????????????????????????????????? T-piece trial

    96. Thank you for your attention

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