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Airways, ARDS & ventilatory strategies

Airways, ARDS & ventilatory strategies. Nov 2013. Outline. Endotracheal tubes, tracheostomies and laryngectomies ARDS Evidence based ventilation Proning, HFOV & ECMO. Airways. Oral vs nasal ETT Does size matter? Tracheostomy Insertion Care When they “fall out” TRACMAN, JAMA, 2013

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Airways, ARDS & ventilatory strategies

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  1. Airways, ARDS & ventilatory strategies Nov 2013

  2. Outline • Endotracheal tubes, tracheostomies and laryngectomies • ARDS • Evidence based ventilation • Proning, HFOV & ECMO

  3. Airways • Oral vs nasal ETT • Does size matter? • Tracheostomy • Insertion • Care • When they “fall out” • TRACMAN, JAMA, 2013 • Laryngectomy • ICU is the lair of the difficult airway

  4. Acute Respiratory Distress Syndrome • “acute diffuse, inflammatory lung injury, leading to increased pulmonary vascular permeability, increased lung weight, and loss of aerated lung tissue…[with] hypoxemia and bilateral radiographic opacities, associated with increased venous admixture, increased physiological dead space, and decreased lung compliance.” • ARDSnet, NEJM, 2000.

  5. Acute Respiratory Distress Syndrome • Within 7 days of a trigger • PaO2/FiO2 <300 (40kPa) • Bilateral CXR changes • Not solely due to cardiac failure

  6. Lung protective ventilation • 6ml/kg IBW • RR up to 35 to achieve desired MV • Plateau pressure less than 30cmH2O • I:E ratio • Permissive hypercapnia • Paralysis • High PEEP?

  7. Fixing the broken patient • Is there… • Patient-ventilator asynchrony? • Fixable contributory problems i.e. effusions, pneumothorax, bronchospasm? • Actually a problem? • Consider… • Recruitment • Paralysis • I:E ratio • PEEP • Fluid status • And then consider…

  8. Proning • Improves • Distribution of ventilation and perfusion • Recruitment • Secretion clearance • Problems • Tube/line displacement • Pressure injury • Facial oedema • Early and for prolonged periods = improved mortality? • Guerin, NEJM, 2013

  9. High Frequency Oscillatory Ventilation • RR 60-3000bpm • TV < dead space • Convection, molecular diffusion, streaming, Pendelluft & cardiogenic mixing • Now predominantly discredited • OSCAR & OSCILLATE, NEJM, 2013

  10. Extra Corporeal Membrane Oxygenation • Made famous by H1N1 • Severe, reversible, respiratory failure where conventional methods are failing • Early rather than late • Venovenousvsvenoarterial • Evidence in adults not (IMO!) conclusive • CESAR, Lancet, 2009

  11. Summary • Types of airway & what to do if they fall out • ARDS • Ventilatory strategy • Proning, HFOV and ECMO

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