Ventilator Use and Weaning

1. Ventilator Use and Weaning 台大醫院 外科加護病房 柯文哲醫師

2. Indication of Intubation • airway obstruction • airway protection • bronchial hygiene • ventilator use

3. History of Ventilator • 1952 ~ 1953 : • Europe polio epidemics • 1 ~ 2 % respiratory failure

4. Ventilator Type 1. negative pressure e.g. iron lung 2. positive pressure endotracheal intubation

5. Iron lung

6. How to understand ventilator ? 1. time cycle begin 2. pressure trigger ↗ 3. flow trigger inspiration ↘ terminate 1. time controlled 2. volume controlled 3. pressure controlled 4. flow controlled expiration : passive process

7. ventilator v pt

8. Noun Explanation • Inspiration time • I/E ratio • respiration rate (RR) • tidal volume (VT) • oxygen fraction (FiO2) • flow rate

9. flow pattern decelerating accelerating horizontal

10. PEEPautoPEEP Ventilator v V pt

11. sensitivity • pressure trigger P ventilator V pt P time >

12. sensitivity • flow trigger F F Base flow: 10 L/min Trigger flow: 3 L/min V pt

13. disadvantage of pressure trigger 1. autotrigger 2. effort P V pt

14. peak airway pressure • mean airway pressure PAP P ---------------------------------------------------------------- MAP Time

15. plateau time , pressure • end-inspiratory pause , inflation hold P time pt v

17. Restrictive lung disease Vs Obstructive lung disease P t

18. Ventilator Mode • CMV • ACMV • SIMV + PS • PC • PS • CPAP

19. ACMV (assisted controlled mandatory ventilation )

20. PC ( pressure control )

21. PS ( pressure support )

22. SIMV + PS

23. The Board on Ventilator • setting part : what you set • demonstration part : the actual condition • warning part : beyond the limit value

24. Care of the Intubated Patients • 1. check position of the tube • too deep → one lung • too shallow → balloon above or • on the cord • 2. sputum suction

25. Cough Mechanism • 1. deep inspiration • 2. close the glottis • 3. abd. wall contract • 4. suddenly open glottis

26. intubated patients can not cough effectively

27. Complication of Ventilator Use • barotrauma • infection • hemodynamic effect • discomfort

28. Ventilator Fighting • disconnect & ambu bagging • save life then diagnosis

29. Ventilator weaning

30. Components of Normal Ventilation • CNS • spinal cord • phrenic n. • intercostal n. • neuromuscular junction • muscle • thoracic cage • airway • lung

31. CNS 1. structural lesion : CVA head injury infection degeneration 2. dysfunction : drug , anesthesia , alcohol metabolic factor

32. Spinal Cord • cervical spinal cord injury • infarction • inflammation

33. phrenic n. (75%) intercostal n. (25%) • iatrogenic • Guillain-Barre syndrome

34. Neuromuscular Junction • myasthenia gravis • m. relaxant drugs • depolarizing : succinylcholine • non-depolarizing : pavulon • tetanus • botulism

35. Muscle • cardiac output • hypoxia • anemia • nutrition • m. mass

36. Thoracic Cage • deformity : • scoliosis , thoracoplasty , funnel chest • space occupying lesion : • hemothorax , pneumothorax , etc....

37. Airway • asthma • spasm (hyper-reactive airway ) • foreign body

38. Lung Parenchyma • ARDS • pneumonia • atelectasis • lobectomy, pneumonectomy • embolism

39. Q : how to wean the ventilator ? A : Why to ventilate this patient ? Are there new problems during the ventilator use ?

41. WEANS NOW

42. WEANS NOW weaning parameter : PI max ＞-25 mmHg TV ＞5 ml/kg VC ＞10 - 15 ml/kg RR ＜30/min MV ＜10 L/min MMV＞2 MV PE max.＞35 mmHg

43. WEANS NOW • endotracheal tube • too small ? • obstruction ? • esp. in large patients with hyperventilation

44. WEANS NOW • alkalosis • PaCO2＜32 mmHg → apnea • But in sepsis , head injury , anxiety

45. WEANS NOW nutrition

46. WEANS NOW secretion respiration Vs cough

47. WEANS NOW neuromuscular disease

48. WEANS NOW obstruction asthma, bronchospasm hyper-reactive airway

49. WEANS NOW • wait

50. Continuous Flow Vs Demand Flow