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How To Ventilate ICU Patient

How To Ventilate ICU Patient. Dr Mohammed Bahzad MBBS.FRCPC,FCCP,FCCM Head Of Critical Care Department Mubarak Alkbeer Hospital. Aims. Get oxygen in Get carbon dioxide out Minimize adverse effects Maximize patient comfort. Case A. 60 kg male

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How To Ventilate ICU Patient

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  1. How To Ventilate ICU Patient Dr Mohammed Bahzad MBBS.FRCPC,FCCP,FCCM Head Of Critical Care Department Mubarak Alkbeer Hospital

  2. Aims • Get oxygen in • Get carbon dioxide out • Minimize adverse effects • Maximize patient comfort

  3. Case A • 60 kg male • Post operative – complicated wipel procedure • No previous lung or heart disease • Still paralyzed

  4. Make the ventilator fit the patient

  5. Mode • Non-invasive • Invasive • Assist control • Pressure control • SIMV • (Pressure support) • Pick a mode you understand and are familiar with

  6. Assist control • Set tidal volume • Inspiratory-expiratory cycling • Time cycled • Time is set • Ventilator adjusts flow to deliver set tidal volume in the set time • Volume cycled

  7. Assist control • Breaths: • Ventilator initiated (control breaths) • Patient initiated (assist breaths) • Set minimum frequency • Characteristics of each inspiration are the same • Not affected by whether breath is control breath or an assist breath

  8. Assist control T 50 cmH2O Pressure 70 l/min Flow -70 700 ml Volume

  9. Assist control T 50 cmH2O Pressure 70 l/min Flow -70 700 ml Volume

  10. Assist control • Set • Minimum respiratory rate • Patient’s spontaneous respiratory rate < set rate  ventilator gives additional control breaths to make up difference • Patient’s spontaneous rate > set rate  no control breaths

  11. Volume control • Set • Minimum respiratory rate • Tidal volume

  12. Volume control • Set • Minimum respiratory rate • Tidal volume • Inspiratory time or I:E ratio • Inspiratory pause time

  13. Volume control • Longer inspiratory time • Improved oxygenation • Higher mean airway pressure • Re-distribution • Lower peak airway pressure • More time available to deliver set tidal volume • Shorter inspiratory time • Less risk of gas trapping and PEEPi • Less effect on cardiovascular system

  14. Setting I:E, inspiratory flow time, pause time • Nomenclature Volume Time

  15. Setting I:E, inspiratory flow time, pause time • Nomenclature Inspiratory flow time Volume Time

  16. Setting I:E, inspiratory flow time, pause time • Nomenclature Inspiratory pause time Volume Time

  17. Setting I:E, inspiratory flow time, pause time • Nomenclature Inspiratory time Volume Time

  18. Setting I:E, inspiratory flow time, pause time • Nomenclature Inspiratory time Expiratory time Volume Time

  19. Setting I:E, inspiratory flow time, pause time • Nomenclature Respiratory cycle time Volume Time

  20. I:E as a ratio & inspiratory pause time as a percentage 6 secs 1 2 10% Volume Time

  21. I:E as a ratio & inspiratory pause time as a percentage 3 secs 1 2  Respiratory rate 10% Volume Time

  22. Absolute inspiratory time, inspiratory flow time as a function of flow rate 6 secs 2 secs 4 secs 0.5 s Volume Time

  23. Absolute inspiratory time, inspiratory flow time as a function of flow rate 3 secs 2 secs 1 sec  Respiratory rate withoutchanging Inspiratory time orinspiratory flow 0.5 s Volume Time

  24. Absolute inspiratory time, inspiratory flow time as a function of flow rate 3 secs 2 secs 1 sec  inspiratory flow 1.5 s Volume Time

  25. Absolute inspiratory time, inspiratory flow time as a function of flow rate 3 secs 1 sec 2 sec  Absolute inspiratory time 0.5 s Volume Time

  26. Inspiratory flow time as a function of flow rate, absolute pause time 3 secs 2 secs 1 sec  Respiratory rate withoutchanging inspiratory flow orinspiratory pause time 0.5 s Volume Time

  27. Inspiratory flow time as a function of flow rate, absolute pause time 3 secs 1 sec 2 sec  inspiratory flow 0.5 s Volume Time

  28. Inspiratory flow time as a function of flow rate, absolute pause time 3 secs 0.8 sec 2.2 sec  inspiratory pause time 0.3 s Volume Time

  29. Volume control • Set • Minimum respiratory rate • Tidal volume • Inspiratory time or I:E ratio • Directly/indirectly • Inspiratory pause time • Directly/indirectly • PEEP

  30. Advantages Relatively simple to set Guaranteed minimum minute ventilation Rests muscles of respiration (if properly set) Disadvantages Not synchronized Patient may “lead” ventilator Inappropriate triggering may result in excessive minute ventilation  lung compliance  alveolar pressure with risk of barotrauma Often requires sedation to achieve synchrony. Assist control

  31. Pressure control • Pressure preset assist/control ventilation • Similar to volume control except pressure is preset

  32. PC above PEEP Pressure PEEP Time Flow Time Volume Time

  33. Normal inspiratory time Short inspiratory time PC above PEEP Pressure PEEP Time Flow Time Volume Time

  34. Advantages Relatively simple Avoids high inspiratory pressures Rests muscles of respiration Improved oxygenation Disadvantages Not synchronized Inappropriate triggering may  excessive minute ventilation Change in lung compliance or resistance  change in tidal volume Often requires sedation Pressure control

  35. Pressure support • Nomenclature • Inspiratory assist • Assisted spontaneous breathing

  36. Maximum inspiratoryflow Set % of maxinspiratory flow Pressure support PS above PEEP Pressure PEEP Flow Volume

  37. Advantages Simple to set Avoids high inspiratory pressures Better patient-ventilator synchrony Unloads respiratory muscles Disadvantages No apnoea back-up in older ventilators Change in lung compliance or resistance  change in tidal volume Pressure support

  38. Pressure support • Pressure support of 3.5-14.5 cmH2O required to overcome the additional work of breathing due to breathing through ETT and demand valve • Patients who require pressure support of < 6 cmH2O can probably be extubated

  39. SIMV (& pressure support) • SIMV almost always combined with pressure support

  40. SIMV • Patient receives a minimum number of mandatory breaths • Able to breath in between these breaths • ± pressure support breaths

  41. SIMV Mandatory breath Pressure PEEP Time Flow Time Trig Trig

  42. SIMV Pressure support breath Pressure PEEP Time Flow Time Trig Trig

  43. Mandatory breaths • Volume control breaths • Set tidal volume • Pressure control breaths • Set pressure

  44. Mandatory breaths • Synchronized with patients inspiratory efforts

  45. Triggering • Effect of triggering depends on its timing • Close to time that a mandatory breath is due (during SIMV period) • ⇒synchronized mandatory breath • Other times (during spontaneous period) • ⇒pressure support breath

  46. Spontaneous period SIMV period T T

  47. Spontaneous period SIMV period

  48. Settings • FiO2 • SIMV rate • =mandatory breath rate • SIMV period (some ventilators) • Tidal volume (or inspiratory pressure) • I:E ratio • Pressure support • PEEP

  49. Volume control • Set • Minimum respiratory rate • Tidal volume • Inspiratory time or I:E ratio • Directly/indirectly • Inspiratory pause time • Directly/indirectly • PEEP

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