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Roberta Costa MD Istituto di Anestesiologia e Rianimazione Ventil@b,UCSC Rome, Italy

Patient-ventilator interaction. Roberta Costa MD Istituto di Anestesiologia e Rianimazione Ventil@b,UCSC Rome, Italy. Conflict of Interest. Medical advisor of Nihon Kohden Orangemed. GOALS of mechanical ventilation. Adequate gas exchange Ameliorate ventilatory pattern

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Roberta Costa MD Istituto di Anestesiologia e Rianimazione Ventil@b,UCSC Rome, Italy

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  1. Patient-ventilator interaction Roberta Costa MD Istituto di Anestesiologia e Rianimazione Ventil@b,UCSC Rome, Italy

  2. Conflict of Interest Medical advisor of Nihon Kohden Orangemed

  3. GOALS ofmechanicalventilation • Adequate gas exchange • Ameliorateventilatory pattern • Reduce inspiratory effort and work of • breathing (WOB)

  4. Spontaneous Assisted Controlled Ventilatory modes Assisted: pt and ventilator share the work of breathing, and cross-talk !

  5. P 0 Trigger: Start inspiration V Limit: Sustain inspiration 0 Cycling: Terminate inspiration t ime For the most effective unloading of the inspiratory muscles, the ventilator should cycle in synchrony with the activity of a patient’s own respiratory rhythm. The interplay between these two pumps is complex, and problems can arise at several points in the respiratory cycle: the onset of ventilator triggering, the rest of inspiration after triggering, the switch from inspiration to expiration, and the end of expiration.

  6. Currenttechnology Central nervous system Phrenic nerve Diaphragm excitation Diaphragm contraction Ventilator Chest wall and lung expansion Airway pressure and flow

  7. Leaks and interface characteristics during NPPV Patient’s respiratory drive Level of assistance Sedatives Trigger asynchrony Intrinsic PEEP Inspiratory trigger sensitivity (flow, pressure, neural etc) Ventilator characteristics (turbine, gas compressed, etc) Ventilator setting R.Costa

  8. Patient’s respiratory mechanics Obstructive or Restrictive Leaks and interface characteristics during NPPV Patient’s effort Sedatives Cycle asynchrony Level of Assistance Cycling off criteria (Time, volume, flow etc) Ventilator characteristics (turbine, gas compressed Expiratory valve technology, etc) Ventilator setting

  9. MINOR ASYNCHRONIES MAJOR ASYNCHRONIES Premature cycling Delayed cycling Double cycling Ineffective efforts

  10. 830 msec 860 msec 860 msec 613 msec 724 msec 660 msec 860 msec 860 msec

  11. INEFFECTIVE EFFORT CAUSES • PEEPi not counterbalanced by external PEEP • Excessive TV • Reduced neuromuscular Drive • Low Trigger sensitivity • Air leaks with pressure trigger

  12. PSV: Timepress 50 Delaytrexp 25 Delaytrinsp 130 msec Delaytrexp410 msec SwingPdi 8.55 cmH2O PTPdi 9.68 cmH2O/sec VT 740 ml Vtneu 540 ml

  13. PSV: Timepress 80 Delaytrexp 60 Delaytrinsp 75 msec Delaytrexp295 msec SwingPdi 7.67 cmH2O PTPdi 6.9 cmH2O/sec VT 750 ml Vtneu 600 ml

  14. PSV: Timepress 50 Delaytrexp 25 Delaytrinsp 285 msec Delaytrexp290 msec SwingPdi 8.13 cmH2O PTPdi 8.24 cmH2O/sec VT 810 ml Vtneu 580 ml

  15. PSV: Timepress 80 Delaytrexp 60 Delaytrinsp 165 msec Delaytrexp0 msec SwingPdi 8.16 cmH2O PTPdi 7.79 cmH2O/sec VT 780 ml Vtneu 780 ml

  16. DOUBLE CYCLING CAUSES • High respiratory drive • Too fast expiratory cycling (PSV) • Insufficient respiratory time (A/C)

  17. Pressurization ramp and Cycling off setting Patient’s respiratory mechanics Cycle Asynchrony Patient’s effort Level of pressure support

  18. Reverse trigger Diaphragmtic contraction tyriggered by a mechanical insufflation

  19. CONSEQUENCES • Continuous pliometric contraction of the diaphragm with cytochine release and fiber damage 2) Increase mucles work and oxygen consumption 3) Large Vt and higher transpulmonary pressure

  20. How we can improve patient –ventilator interaction

  21. Response of PAW to different patterns of inspiratory effort (expressed as Pmus) during AMV, PSV and PAV From Younes M : In: Tobin MJ. Principles and practice of mechanical ventilation. McGraw-Hill, 1994;

  22. PSV Delaytrinsp 605 msec, Delaytrexp 1.165 msec, Timeass 175 msec, TVneu 60 ml, TVmecc 580 ml, Pdiswing 3.21 cmH2O. PTPdi 1.74

  23. PAV+ Delaytrinsp 145 msec, Delaytrexp 190 msec, Timeass 520 msec, TVneu 360 ml, TVmecc 430 ml. Pdiswing 5.51 cmH2O, PTPdi 2.78

  24. NAVA

  25. How about sedation to improve patient- ventilator interaction?

  26. both gabaergics and morphinomimetics have side effects on neuroventilatory coupling……. Ve = TV/Ti Ti/Ttot DRIVE TIMING

  27. 13 intubated patients • Remifentanil: i.v continuous infusion at 0.03, 0.05, 0.08, 0.1, 0.15 γ/Kg/min, in random order for 25 min • At each level of sedation, PSV and NAVA trial were randomly performed for 25 min

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