7/31/2019 patan ima 9512

1/37

Click to edit Master subtitle style

5/25/12

Ventilated pt.??????

I am physician/surgeon!!!!!

Dr.Bhagyesh ShahIntensivist,CIMS hospital.

7/31/2019 patan ima 9512

2/37

5/25/12

Monitor

Ventilator

Regulate

dSuction

O2 O2 AirVac

Resuscitator

patient

7/31/2019 patan ima 9512

3/37

5/25/12

Objectives of MV

l Support pulmonarygas-exchange

l Reduce work ofbreathing

l Minimise lung injury

Ventilator

7/31/2019 patan ima 9512

4/37

5/25/12

Type-1hypoxemicrespira

toryfailure

Type-2hypercapneic

respiratoryfailure

Type-3Perioperative

Type-4

Shock

Mechanism QS/QT VA AtelectasisHypoperfusion

Etiology Airspaceflooding1.CNS drive

2N-M coupling

3.Work/deadspace

1.FRC

2.CV

1.Cardiogenic

2.Hypovolemic

3.Septic

Clinicaldescription

1.ARDS

2.Cardiogenicpulmonar

y edema3.Pneumo

1.Overdose/CNSinjury

2.Myastheniagravis

3.asthma/copdfibrosis,kyphoscol

1.supine/obese/ascites,peritonitis,abdominal

incision2.age/smoki

Myocardialinfarct

PE

Sepsis

Bleedtamponade

7/31/2019 patan ima 9512

5/37

5/25/12

Artificial ventilation

Invasive mechanicalventilation

Non-invasively

Nasal prongs,masks, venturi

devices,reservoir bags

Pressurecycled

Volume cycledBilevel

ventilation

Continuouspositive airway

pressure

7/31/2019 patan ima 9512

6/37

5/25/12

SPONTANEOUS CONTROLLED

Rate: PatientPower: Patient Rate: MachinePower: Machine

Common modes ofVentilation

Adapted from Prof. George

ASSISTED MODE

Rate: PatientPower: Machine

ASSIST CONTROL MODE

Minimum rate:Machine

Additional rate:Patient

Power: Machine

IMV

Minimum rate & power forthat rate: Machine

Additional rate & power forthat rate: Patient

SIMVMinimum rate & power for

that rate: Machine

Additional rate & power for

that rate: Patient butsynchronised

7/31/2019 patan ima 9512

7/37

5/25/12

Goals of Monitoring inventilated patient

Ensure proper airway Ensure adequate

oxygenation Ensure adequate

ventilation Maintain hemodynamic

stability Understanding

respiratory mechanics Interpretation of

7/31/2019 patan ima 9512

8/37

5/25/12

Ensure proper airway

Tube position, cut at,fixed at. (ET holder) Clinical exam 5 point

auscultation CxR

EtCO2 Cuff pressure Be alert to tube

blockade, tube migration

7/31/2019 patan ima 9512

9/37

5/25/12

Ensure adequateoxygenation

Clinical exam Cyanosis Agitation Patient-ventilator asynchrony

accessory muscles

Pulse oximetry

ABG PO2, O2saturation%Remember tissue oxygenationdepends

on cardiac output and Hb also

7/31/2019 patan ima 9512

10/37

5/25/12

Basic

Monitoring

Oxygenation

Ventilation

Pulse Oximeter

Arterial Blood Gas

Capnography

7/31/2019 patan ima 9512

11/37

5/25/12

Alarms

Pressure:High & Lowinspiratory pressure

Low PEEP

Respiratory Rate:High & Low

Tidal / MinuteVolume:High & Low

Diagnose:

High insp.press.

High resp. rateLow Tidal

volume

7/31/2019 patan ima 9512

12/37

5/25/12

Asynchrony?

Consider pharmacotheraponly if no cause has been

found for the patientfighting ventilator(patient ventilator

asynchrony)Pharmacotherapy Step1 Reassurance

Step2 Provide pain relie

7/31/2019 patan ima 9512

13/37

5/25/12

What is weaning?

It starts when cliniciandecides that patient

may tolerate areduction of mechanicalsupport

It includes methodsused for a stepwise reduction in

the level of support & readiness testin of

7/31/2019 patan ima 9512

14/37

5/25/12

Value of Weaning

ParametersMost Weaning Indices

predict weaning failurewell

but.

do notpredictsuccessful weaning

7/31/2019 patan ima 9512

15/37

5/25/12

Weaning Trial

Brochard trial (AJRCCM1994;150:896-903)

456 medical-surgical patients 76% passed SBT and were extubated

Remaining 24% (109) randomised to T-piece trials increasing till 2 hrs

tolerated SIMV with reduction of 2-4/min,

twice a day PSV with reductions of 2-4 cm

twice a day till 8 cm H2O tolerated

PSV better than both SIMV and T-piece (5.7+3.7 days vs 9.3+8.2 days)

7/31/2019 patan ima 9512

16/37

5/25/12

Weaning trials

Esteban trial (NEJM1995;332:345-50)

546 medical-surgical patients

76% passed SBT and extubated 130 patients randomized to Once-a-day T-piece trial 2 or more T-piece or CPAP trials as

tolerated PSV with reduction by 2-4cmH2O

at least twice a day SIMV with reduction by 2-4 /min at

least twice a day

7/31/2019 patan ima 9512

17/37

5/25/12

Esteban orBrochard?

SIMV is the least effective technique

Superiority of PSV or T-tube trialsover one another not established

Esteban trial had aggressiveweaning rules produced fasterweaning

4-fold reintubation rate compared toBrochard

Weaning protocols improve weaning

(Ely et al. NEJM 1996;335:1864-69)

7/31/2019 patan ima 9512

18/37

5/25/12

What are the final

lessons? Weanable patients

should undergo a 30

minute T-piece trial (notin infants).

[PS (7 cm H20) is

acceptable]

IMV should NOT be

used in patients who- -

7/31/2019 patan ima 9512

19/37

5/25/12

Tracheostomy When it becomes apparent that

patient will require prolongedventilator assistance

Patients who benefit from earlytracheotomy; those--

Requiring high levels of sedation totolerate ET tubes

Marginal respiratory mechanics - in

whom a tracheostomy tube havinglower resistance reduce risk of muscleoverload

Psychological benefit from ability toeat orally, communicate by articulated

speech, and experience enhanced

7/31/2019 patan ima 9512

20/37

5/25/12

Tracheostomy: TimingEarly tracheostomy (1-7 days) may

benefit patientsexpected to need prolongedventilationEarly tracheostomy:

Doesnot

affect survivalDoes notaffect rates of VAP

Reduces duration of ventilatory support

Reduces duration of ICU stay

But, prediction of need for prolonged (> 2weeks)ventilation is still to be refined

il dl

7/31/2019 patan ima 9512

21/37

5/25/12

Ventilator Care Bundle Hand Hygiene

Head up 45 degree Oral care with chlorhexidine mouthwash

qds.

Endotracheal tube with Subgloticsuction,cuff pressure monitoring. Daily sedation vacation

Early tracheostomy Early mobilization,kinetic bed,position

change

HME(change every 72 hrs or

7/31/2019 patan ima 9512

22/37

5/25/12

HME

7/31/2019 patan ima 9512

23/37

5/25/12

Heated humidifier

7/31/2019 patan ima 9512

24/37

5/25/12

7/31/2019 patan ima 9512

25/37

5/25/12

Feeding

Ryles tube feeding to be startedas soon as the pt. can tolerate.

Naso-jejunal tube is prefered if

possible. Calorie and protein intake is to be

optimised.

Role of iv glutamine + or oral isestablished in cases of ARDS. Watch every 4 hrly for RTA.

Parentral only in certain

7/31/2019 patan ima 9512

26/37

5/25/12

Analgesia

Combine it with sedation ifsedatives being used.

Short acting iv/oral/transdermalpreparations. Avoid NSAID in icu.

Use synergy of PCM and Opioids.

7/31/2019 patan ima 9512

27/37

5/25/12

Sedation-paralytics

Know the difference betweensedatives and paralytics.

Never use paralytics alone. Try to avoid paralytics for long

term to avoid icu inducedmyoneuropathy.

Infusions are always better thanshort boluses.

Daily sedation vacation is must.

7/31/2019 patan ima 9512

28/37

5/25/12

Titrate sedation to effect; use

objective scaleUse a protocol for sedation

Ideally maintain

sedation Level 3

7/31/2019 patan ima 9512

29/37

5/25/12

In mech. ventilated pt. daily interuption ofsedation decreases duration of mechanicalventilator and icu stay.

In case of midazolam it reduces use of

midazolam by almost half. Less pt. in daily wake up group requiredNeuro imaging to check mentation.

Rate of complications same even when

woken up. A trend towards mortality benefit seen

but not statistically significant.

7/31/2019 patan ima 9512

30/37

5/25/12

Thromboprophylaxis

DVT prophylaxis is must. Mechanical

Medical Combined

Stress ulcer and

7/31/2019 patan ima 9512

31/37

5/25/12

Stress ulcer andpressure sore

prophylaxis PPI Sucralfate

Frequent change of position Air bed Specialized dressing

Chlorhexidine bath Head up most of the time

7/31/2019 patan ima 9512

32/37

5/25/12

Glycemic control

Target RBS 150-180 If abnormal correct with insulin

Hypoglycemia must be avoided.

7/31/2019 patan ima 9512

33/37

5/25/12

Bowel-bladder care

Hourly monitoring of urine Daily bowel movt. to be ensured.

Use of silicon catheter in long termpts. High threshold for use of antibiotic

or antifungal.

7/31/2019 patan ima 9512

34/37

5/25/12

Daily drugs to bedeescalated

Antibiotics Anti epileptics

Sedatives Analgesics Supplements

Antiplatelets/heparins

DO NOT do

7/31/2019 patan ima 9512

35/37

5/25/12

DO NOTdo

this to yourpatientrParalyze the patient to calm him down.r

Get routine daily Chest X-raysrPut bicarbonate or other poisons down the ET tuberGive chest physiotherapy to mobilize secretionsrChange ET or tracheostomy tubes routinelyrChange reusable ventilator tubing > 48 hrs

rChange single-use ventilator tubing at all&r DO NOT administer prophylactic antibiotics

7/31/2019 patan ima 9512

36/37

5/25/12

Wish yourpatient

FAST HUG BID

Feeding Analgesia

Sedation Thromboprophylaxis Head up

Ulcer prophylaxis Glycemic control Bowel and Bladder Invasive lines and tubes De-escalate

7/31/2019 patan ima 9512

37/37

5/25/12

Thank you

Dr.Bhagyesh Shah

(9099068938)CIMS Critical Care and EmergencMedicine Consultant

09/05/2012

mailto:Email-drbhagyeshshah@gmail.commailto:Email-drbhagyeshshah@gmail.commailto:Email-drbhagyeshshah@gmail.commailto:Email-drbhagyeshshah@gmail.commailto:Email-drbhagyeshshah@gmail.com