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Non-Pulmonary Complications of Mechanical Ventilation

Non-Pulmonary Complications of Mechanical Ventilation. Complications of Mechanical Ventilation. Complications related to Intubation Mechanical complications related to presence of ETT Pulmonary complications Cardiovascular complications Biomedical complications Neurological complications

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Non-Pulmonary Complications of Mechanical Ventilation

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  1. Non-Pulmonary Complications of Mechanical Ventilation

  2. Complications of Mechanical Ventilation Complications related to Intubation Mechanical complications related to presence of ETT Pulmonary complications Cardiovascular complications Biomedical complications Neurological complications Other complications

  3. Four major concepts Know the patient Know the ventilator Put the ventilator between you and the patient Alive ill patients

  4. complications related to airways

  5. Competence Confidence • Vulnerability to complications • Fixed Full stocmach • Hypovolemia • Hypotension • Hypoxemia • Hypercarbia • Agitation • Age and sex • Unable to Open Mouth • Trismus • Small mouth • Peri-oral scarring • Fascialswealling • Trauma • Endobronchial intubation • Esophageal intubation • Severe hypoxia • Severe hypotension • Death • Unable to insert laryngoscope • Short neck • Large chest • Prominent upper incisors • Small mandible • Edema Difficult Intubation • Unable to see glottis • Fixed position of the head • Small jaw • Anterior larynx • Obstructed by blood or vomit • Environment • No skilled help • No specialized equipments • Missing of defective equipment • Poor positioning • Unable to pass tube into trachea • Fixed Unrecognizable glottis • Too small glottis or sub-glotticdiamete

  6. Injuries to Face, Lips and Oro-pharynx Trauma to the lips and cheeks from tube ties Peri-oral herpes Injuries to the tongue especially if entrapped between the endotracheal tube and the lower teeth Pressure ulcers to the palate and oropharynx

  7. Maxillary Sinus and Middle Ear Effusion • Maxillary effusion • 20% in patients intubated for > 7 days. • 47% when the gastric tube is placed nasally • 95% • Secondarily infected maxillary effusion (45-71% of effusions) • Middle ear effusion (29%) with 22% of them become infected • Hearing impairment that may contributes to the confusion and delirium in elderly population

  8. Laryngeal Injuries Some degree of glottic injury is seen in 94% of patients intubated for 4 days or longer Erosive ulcers of vocal cords (posterior commissures) Swelling and edema of the vocal cords Granulomas (7% in patients intubated for 4 days or more)

  9. Pharyngo-laryngeal Dysfunction • Post-extubation discomfort (40% regardless of the duration) • Hoarsness : edema, injury, disarticulate • 52% in short-term intubation • 70% in patients with prolonged intubation • Slowing of the reflex swallowing mechanism and risk of aspiration • 15.8% of patients who were intubated more than 4 days did not have a gag reflex • Silent aspiration: Ventilator Associated Pneumonia • 20% in young population • 36% in older population

  10. Tracheal Injuries • Cuff pressure related tracheal mucosa ischemia • Cuff pressure tracheal damage: tracheal ulceration, edema and sub-mucosal hemorrhage • Tracheal dilatation: tracheomalacia • Tracheal stenosis: • At the site of the cuff (50%) • At the site of the tracheostomy (35%) • Unclear (15%)

  11. Unplanned Extubation Self extubation (8%) and accidental extubation (1%) Longer ICU and hospital stay Increased ICU and hospital mortality

  12. Biomechanical effect Cardiovascular complications of Mechanical Ventilation

  13. Exp Insp Exp Insp CVP CVP Pressure (mmHg) Pressure (mmHg) Right atrium Right atrium Extrathoracic veins Extrathoracic veins

  14. Decreased Cardiac Output.Decreased Pressure Gradient for venous return and decrease RV preload PPV Decreased CO due to decreased RV filling Volume due to decreased venous return

  15. Decreased Cardiac OutputDecreased Right Atrial Distension -2 mm Hg 6 mm Hg PPV Decreased CO due to decreased RV filling Volume due to decrease RA compliance 5 mm Hg 2 mm Hg 3 mm Hg 8 mm Hg

  16. Decreased BPPPV vs. Spontaneous Ventilation 120 5 3 0 -3 10 0

  17. Decreased BPPPV VS. Spontaneous Ventilation 110 5 3 0 -3 8 0

  18. Hypotension following MV

  19. PPV increase CO and BP Ventricular interdependence: decrease CO during spontaneous breathing due to : increase RV filling volume with shifting the intra ventricular septum causing mechanic impedance for LV decreasing its compliance causing decrease CO and BP PPV improve the dynamic shape of the septum providing better LV compliance, better preload and thus better Stroke Volume and BP. Increase in Trans mural pressure of the great arteries in the thorax.

  20. Cyclic BP effects is related to Volume status • Cyclic changes in Gas exchange and partial pressures Ventilation on sick individual

  21. Effect of Changing Lung Volume on Pulmonary Vascular Resistance Total pulmonary vascular resistance Pulmonary vascular Resistance Hypoxic vasoconstriction Intra-alveolar vaso-compression RV FRC TLC Lung Volume

  22. Hemodynamic effects of mechanical Insuflation Dec. LV ejection Inc. LV ejection End of inspiration Maximum of SBP, PP, Aortic velocity End of inspiration Minimum of SBP, PP, Aortic velocity .

  23. Effect of Lung Volume No effect in Normal individual with PEEP less than 10 cmH2o Major effect in patients with Dynamic Hyperinflation such as asthmatic and COPD, and in pre-existing pulmonary hypertension Small changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVR Avoid gas trapping in these patient Know the patient, Know the ventilator

  24. Alveolar pressure and Gas exchange Dead Space PaO2 Oxygen Transport

  25. Effects of PPV on hemodynamic Pleural pressure Venous Return Magnitude of Effect V/Q Matching LV afterload Work of Breathing Fully Spontaneous Partial Ventilator support Fully Controlled

  26. Bradycardia and intra-arteriolar vasodilatation Reflex Arrhythmias, Bradycardia Intra arteriolar Vasodilatation

  27. Effect of Preload on Cardiac Output Normal cardiac function Congestive heart failure Cardiac Output Left Ventricular Preload

  28. Systemic inflammatory effect Biochemical effectof Mechanical Ventilation

  29. Inflammatory Biochemical injury Local and systemic Inflammation cascade

  30. Micro vascular, Alveolar Fracture Hotchkiss et all Critical care Med, 2002 Prot for Gas and Bacteria

  31. Biochemical effect of MV Pro- Inflammatory Cytokines during PPV

  32. Psychogenic effect Neurological Functions during Mechanical Ventilation

  33. Acute Effects • Vasoconstriction secondary to hypercapnia • Decreased intra-cerebral blood volume and intracranial pressure • PEEP reduces cerebral perfusion pressure by decreasing venous return and increasing intracranial pressure • 20-25% of is transmitted to the central venous pressure in a normal compliant lung • >20% is transmitted in patients with decreased lung compliance

  34. 300 200 Non REM Stage 4 Sleep Time (minutes) Stage 3 100 Stage 2 Stage 1 0 REM 100 Age 40 MV Age 40

  35. Normal Sleep Pattern Stage 1 Stage 3 REM Stage 2 Stage 4

  36. Hyponogram for a Patient on Mechanical Ventilation Stage 1 Stage 3 REM Stage 2 Stage 4

  37. Mechanisms by which mechanical Ventilation Disrupt Sleep • Noise disruption • Ventilator alarm: • inappropriate threshold • Delayed alarm inactivation • Humidifier alarms • Disruption by nursing interventions • Airway suction • Nebulizer delivery • Ventilation-related pharmacological disruption • Benzodiazepines (↓REM, ↓deep NREM) • Oipoids (↓REM, ↓deep NREM) • Neuromuscular blocking drugs • Ventilator mode • Pressure support ventilation

  38. Systemic inflammatory and low perfusion effects Gastrointestinal Effects of Mechanical Ventilation

  39. GI Effects of PPV

  40. GI Effects of MV

  41. Esophagus, Stomach and Small Intestine • Erosive esophagitis (30-50% of patients ventilated >48 hours) • NG tube • Poor lower esophageal sphincter tone and reflux • Opiates and adrenergic agonists • Duodenogastroesophageal reflux through the action of trypsin • Upper gastrointestinal hemorrhage: • Stress • Decreased gastric mucosal protection secondary to a fall in splanchnic blood flow • Decreased motility of stomach and small intestine

  42. Liver and Gallbladder Reduction in portal venous flow secondary to the fall in cardiac output Increased hepatic arterial flow “ hepatic arterial buffer response” Normal total hepatic perfusion Hepatic engorgement Venous ischemia and elevation of serum transaminases and hyperbilirubinemia Reduction in drug clearance secondary to reduction of hepatic blood flow

  43. Large Bowel Constipation Abdominal distension

  44. Systemic inflammatory and ischemic effects Renal Functions during Mechanical Ventilation

  45. Renal Effects of MV The usual renal response to reduction of cardiac output and mean arterial pressure Reduction in urine output secondary to a fall in the transmural pressure of the right atrium that results in reduction of the secretion of atrial naturitic peptide and the activation of renin-angiotensin-aldosterone system and pituitary vasopressin secretion

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