Absolute Basics of Mechanical Ventilation

Absolute Basics of Mechanical Ventilation www.phwiki.com

Absolute Basics of Mechanical Ventilation

Rose, Jaimee, General Assignment Reporter has reference to this Academic Journal, PHwiki organized this Journal Absolute Basics of Mechanical Ventilation Dr David Howell Consultant in Intensive Care, Respiratory in addition to Acute Medicine Aims in addition to Objectives Define Positive Pressure Mechanical Ventilation Explain Continuous M in addition to atory Ventilation (CMV) Explain Synchronised M in addition to atory Ventilation (SIMV) Explain Pressure Support Ventilation (PSV) Explain Basic Ventilator Settings Not a Talk on Physiology of Mechanical Ventilation What you Encounter

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Positive Pressure Mechanical Ventilator Lots of Monitors in addition to Knobs to Turn Some are More Complicated than Others

Weaning Screen/st in addition to ard protocol Long Term Weaning/Individual plan Weaning Non-Invasive Ventilation Non-invasive support Tracheostomy Intubation Extubation Decannulation St in addition to ard Ventilation Advanced Ventilation Invasive support Optimising the Pt as long as weaning Prone Position Nitric Oxide Suctioning Humidification NIV is defined as ventilatory support provided via a tight fitting mask or similar interface as opposed to invasive support, which is provided via a laryngeal mask, endotracheal tube or tracheostomy tube. Tight fitting masks deliver can CPAP, BIPAP or NIV via the mechanical ventilator. NIV vs. Invasive Mechanical Ventilation The work of breathing usually accounts as long as 5% of oxygen consumption (V02). In the critically ill patient this may rise to 30%. Invasive mechanical ventilation eliminates the metabolic cost of breathing. Indications as long as Mechanical Ventilation

Inadequate oxygenation (not corrected by supplemental O2 by mask). Inadequate ventilation (increased PaCO2). Retention of pulmonary secretions (bronchial toilet). Airway protection (obtunded patient, depressed gag reflex). Indications as long as Mechanical Ventilation Intubation 1 Airway: oral Guedel airway to lift tongue off posterior pharynx to facilitate mask ventilation during pre-intubation phase. 2 Liquids: stop feed in addition to aspirate ng tube. 3 Suction: extremely important to avoid pulmonary aspiration. 4 Oxygen: preoxygenate patient in addition to ensure a source of O2 with a delivery mechanism (ambu-bag in addition to mask) is available. Bare Essentials as long as Intubation ALSOBLEED

5 Bougie: to facilitate tube insertion in more difficult airway. 6 Laryngoscope: have a long in addition to short blade available. 7 Endotracheal tube: as long as average adult, cuffed oral endotracheal tube 7.0 as long as women in addition to 8.0 as long as men. 8 End tidal CO2: to confirm correct position of tube. 9 Drugs: an induction agent, muscle relaxant, sedative are usually required. Bare Essentials as long as Intubation ALSOBLEED Principles of Mechanical Ventilation ET tube Ventilator Tubing Major Airways Alveoli PEEP Positive pressure ventilation involves delivering a mechanically generated ‘breath’ to get O2 in in addition to CO2 out. Gas is pumped in during inspiration (Ti) in addition to the patient passively expires during expiration (Te). The sum of Ti in addition to Te is the respiratory cycle or ‘breath’. Principles of Mechanical Ventilation

Flow Pressure Principles of Mechanical Ventilation Ti Te Ti Te In the fully ventilated patient, positive pressure breaths are delivered either as preset volume or pressure continuous m in addition to atory breaths (CMV) breaths. The mechanical ventilator triggers the breath in addition to switches from inspiration to expiration when the preset volume, pressure (or time) is achieved/delivered. During CMV the patient takes no spontaneous breaths. CMV is usually used in theatre in addition to in very unwell ICU patients. Principles of Mechanical Ventilation Principles of Mechanical Ventilation Volume control Tidal volume is preset Usually 500 mls Airway Pressure is Variable Pressure control Inspiratory Pressure is preset Usually 15-20 cm H20 Tidal Volume is Variable

M in addition to atory breaths are delivered during inspiration, to generate a tidal volume (Vt), at a set rate (f), the quotient of which is the minute volume (MV). Minute Volume = Tidal Volume x frequency In volume control ventilation, an inspiratory flow rate is also set. The ratio of the time spent in inspiration:expiration (I:E ratio) is usually 1:2. Principles of Mechanical Ventilation Flow Pressure Ti Te Ti Te Principles of Mechanical Ventilation Volume Control Breath Pressure Control Breath Mechanically ventilated patients usually receive positive end-expiratory pressure (PEEP), to overcome the loss of physiological PEEP provided by the larynx in addition to vocal cords. PEEP is delivered throughout the respiratory cycle in addition to is synonymous to CPAP, but in the intubated patient. St in addition to ard PEEP setting is 5 cm H20. Sedation is often required to prevent ventilator-patient asynchrony. Principles of Mechanical Ventilation

Basic Settings on the Ventilator Tidal Volume Pressure controlled breath (15-20 cm H20) Volume controlled breath (500 mls) Rate (frequency) (10-12 breaths/minute) Positive end expiratory pressure (PEEP) (5 cm H20) FiO2 (0.21-1) Peak airway pressure (PAP) Principles of Mechanical Ventilation Why is the peak airway pressure (PAP) important Ventilator Induced Lung Injury (VILI). Mechanical ventilation is injurious to the lung. Aim PAP< 35 cm H20. Flow Pressure Ti Te Ti Te Principles of Mechanical Ventilation Volume Breath Pressure Breath 35 cm H20 Rose, Jaimee Arizona Republic General Assignment Reporter www.phwiki.com

Pneumothorax Principles of Mechanical Ventilation Don’t as long as get that the peak airway pressure will also include the PEEP that is added Once stabilised on CMV, the level of ventilatory support may be reduced (weaning). This can be done by providing a mixture of synchronised intermittent m in addition to atory breaths (SIMV) in addition to spontaneously triggered pressure supported breaths (PSV). Principles of Mechanical Ventilation

Ventilator assisted breaths are synchronized with the patient’s breathing to prevent the possibility of a mechanical breath on top of a spontaneous breath. However, the patient’s attempt at a breath would not be enough to generate an adequate tidal volume on its own, hence the term ‘pressure support’. Principles of Mechanical Ventilation Pressure support is only delivered during inspiration in addition to the patient’s attempt at breathing triggers the breath rather than the ventilator. A st in addition to ard level of pressure support delivered in inspiration is 20 cm H20 Principles of Mechanical Ventilation SIMV in addition to Pressure Support Ventilation Ventilator Patient

Patient Requiring Basic Invasive Mechanical Ventilation Spontaneously Ventilating Patient Failing Conventional Therapy Escalation BIPAP Patient Position Humidification CMV (VCV or PCV) PSV PEEP/CPAP NIV on ICU BIPAP on Ward IMV (VCV or PCV) De-escalation CPAP on Ward

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