Mechanical
description
Transcript of Mechanical
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PATRICK GERARD L. MORAL, M.D.PATRICK GERARD L. MORAL, M.D.
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IINTUBATIONNTUBATION• Prevention of upper airway Prevention of upper airway
obstructionobstruction• Protection against aspirationProtection against aspiration• Facilitating tracheobronchial toiletFacilitating tracheobronchial toilet• Providing a closed system for Providing a closed system for
mechanical ventilationmechanical ventilation
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VENTILATORY VENTILATORY
FAILUREFAILURE
REDUCED REDUCED CENTRAL DRIVECENTRAL DRIVE
IMPAIRED INSPIRATORY IMPAIRED INSPIRATORY MUSCLE PERFORMANCEMUSCLE PERFORMANCE
EXCESSIVE EXCESSIVE RESPIRATORY RESPIRATORY WORKLOADWORKLOAD
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OOBJECTIVESBJECTIVES
• To support pulmonary gas To support pulmonary gas exchangeexchange– alveolar ventilationalveolar ventilation– arterial oxygenationarterial oxygenation
• To increase lung volumeTo increase lung volume• To reduce or manipulate work of To reduce or manipulate work of
breathingbreathing
PHYSIOLOGICAL
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OOBJECTIVESBJECTIVES• To reverse hypoxemiaTo reverse hypoxemia• To reverse acute respiratory acidosisTo reverse acute respiratory acidosis• To relieve respiratory distressTo relieve respiratory distress• To prevent / reverse atelectasisTo prevent / reverse atelectasis• To reverse ventilatory muscle fatigueTo reverse ventilatory muscle fatigue• To permit sedation / neuromuscular blockadeTo permit sedation / neuromuscular blockade• To decrease myocardial oxygen consumptionTo decrease myocardial oxygen consumption• To reduce intracranial pressureTo reduce intracranial pressure• To stabilize chest wallTo stabilize chest wall
CLINICAL
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• 700 - 900 mL700 - 900 mL• 15 LPM (self-inflating)15 LPM (self-inflating)• augment VTaugment VT
AAMBUBAG VENTILATIONMBUBAG VENTILATION
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MMODESODES• Assist - ControlAssist - Control• SIMVSIMV• PSVPSV• CPAPCPAP• Servo-controlled Servo-controlled
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BBASICASIC
VVAA = V = VTT - V - VDD
VVAA = V = VEE - V - VDD VA
VT
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• Hook to mechanical ventilator with Hook to mechanical ventilator with
the following set-up:the following set-up:– mode: assist - controlmode: assist - control– VT: 500 mLVT: 500 mL– BUR: 15/ minuteBUR: 15/ minute– FiO2: 100 %FiO2: 100 %
• ABG 30 minutes after hooking to MVABG 30 minutes after hooking to MV• In-line nebulization q 6In-line nebulization q 6
OORDERSRDERS
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FiO2FiO2
• 100 %100 %• dependent on target PaO2, dependent on target PaO2,
hemodynamic status, MAP, PEEP hemodynamic status, MAP, PEEP levellevel
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OOXYGEN CONTENT XYGEN CONTENT
CaO2 =CaO2 = 1.34 mL x Hgb x SaO2 + .OO3 mL O2 x 1.34 mL x Hgb x SaO2 + .OO3 mL O2 x
PaO2PaO2
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TTIDAL VOLUMEIDAL VOLUME
• Physiologic: 5 - 7 mL / KgPhysiologic: 5 - 7 mL / Kg• MV: 10 - 15 mL / KgMV: 10 - 15 mL / Kg• alveolar distending pressure: 35 alveolar distending pressure: 35
cm Hcm H22OO
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BBASICASIC
VVAA = V = VTT - V - VDD
VVAA = V = VEE - V - VDD VA VD
mechanical
anatomic
alveolar
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CCARDIAC OUTPUTARDIAC OUTPUT
hyperinflation
Increased pulmonary vascular resistance
Increased RV afterload
Decreased RV output
Decreased LV preload
Decreased LV output
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PPV
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• 4 to 20 / minute4 to 20 / minute• 8 to 12 / minute8 to 12 / minute• dependent on:dependent on:
– delivered VTdelivered VT– metabolic ratemetabolic rate– target PaCO2target PaCO2– level of spontaneous ventilationlevel of spontaneous ventilation
RRESPIRATORY RATEESPIRATORY RATE
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• 40 to 100 L/ minute40 to 100 L/ minute• determined by level of determined by level of
spontaneous breathing effortspontaneous breathing effort
FFLOW RATELOW RATE
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• Inspiratory time: 0.8 to 1.2 sInspiratory time: 0.8 to 1.2 s• I:E 1:2 to 1:1.5I:E 1:2 to 1:1.5
IINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIO
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• Respiratory rate: 20 / minuteRespiratory rate: 20 / minute60 seconds / 20 = 3 seconds = T60 seconds / 20 = 3 seconds = Ttottot
at an I:E ratio of 1:2:at an I:E ratio of 1:2:TTII = 1 second = 1 secondTTEE = 2 seconds = 2 seconds
IINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIO
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• Respiratory rate: 30 / minuteRespiratory rate: 30 / minute60 seconds / 30 = 2 seconds = T60 seconds / 30 = 2 seconds = Ttottot
at an I:E ratio of 1:1:at an I:E ratio of 1:1:TTII = 1 second = 1 secondTTEE = 1 second = 1 second
IINSPIRATORY TIME / I:E RATIONSPIRATORY TIME / I:E RATIO
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• -0.5 to 1.5 cm H20-0.5 to 1.5 cm H20• most sensitive level that prevents most sensitive level that prevents
self-cyclingself-cycling
SSENSITIVITYENSITIVITY
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• High pressureHigh pressure• Low pressureLow pressure
PPRESSURE ALARMSRESSURE ALARMS
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• Low pressureLow pressure– check connections between tubings check connections between tubings
and patientand patient– deflated cuff deflated cuff – extubationextubation
PPRESSURE ALARMSRESSURE ALARMS
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• High pressureHigh pressure– bronchoconstrictionbronchoconstriction– airway obstructionairway obstruction– barotraumabarotrauma– right main bronchus obstructionright main bronchus obstruction– kinked endotracheal tubekinked endotracheal tube
PPRESSURE ALARMSRESSURE ALARMS
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• Cascade humidifierCascade humidifier• heats carrier gas to 37 C heats carrier gas to 37 C • holds 44 mg H20 / L gasholds 44 mg H20 / L gas• water replacementwater replacement• increases volume and decreases increases volume and decreases
viscosity of the sputumviscosity of the sputum
HHUMIDIFICATIONUMIDIFICATION
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• Chest radiographChest radiograph• Arterial blood gasArterial blood gas• OximetryOximetry• CapnographyCapnography
AANCILLARYNCILLARY
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• BarotraumaBarotrauma• Oxygen toxicityOxygen toxicity• Patient-ventilator asynchronyPatient-ventilator asynchrony• CardiovascularCardiovascular• RenalRenal• GastrointestinalGastrointestinal
CCOMPLICATIONS OMPLICATIONS
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