DOCSLIB.ORG

Removal of the Endotracheal Tube (2007)

Total Page：16

File Type：pdf, Size：1020Kb

Download full-text PDF Read full-text
Removal of the Endotracheal Tube (2007) AARC GUIDELINE: REMOVAL OF THE ENDOTRACHEAL TUBE AARC Clinical Practice Guideline Removal of the Endotracheal Tube—2007 Revision & Update RET 1.0 PROCEDURE RET 3.0 ENVIRONMENT Elective removal of the endotracheal tube from The endotracheal tube should be removed in an en- adult, pediatric, and neonatal patients. vironment in which the patient can be physiologi- cally monitored and in which emergency equipment RET 2.0 DESCRIPTION/DEFINITION and appropriately trained health care providers with The decision to discontinue mechanical ventilation airway management skills are immediately avail- involves weighing the risks of prolonged mechani- able (see RET 10.0 and 11.0). cal ventilation against the possibility of extubation failure.1,2 This guideline will focus on the predictors RET 4.0 INDICATIONS/OBJECTIVES that aid the decision to extubate, the procedure re- When the airway control afforded by the endotra- ferred to as extubation, and the immediate postextu- cheal tube is deemed to be no longer necessary for bation interventions that may avoid potential rein- the continued care of the patient, the tube should be tubation. This review will not address weaning removed. Subjective or objective determination of from mechanical ventilation, accidental extubation, improvement of the underlying condition impairing nor terminal extubation. pulmonary function and/or gas exchange capacity is made prior to extubation.2 To maximize the like- 2.1 The risks of prolonged translaryngeal intu- lihood for successful extubation, the patient should bation include but are not limited to: be capable of maintaining a patent airway and gen- 2.1.1 Sinusitis3,4 erating adequate spontaneous ventilation. In gener- 2.1.2 Vocal cord injury5 al, this requires the patient to possess adequate: 2.1.3 Laryngeal injury6-8 central inspiratory drive, respiratory muscle 2.1.4 Laryngeal stenosis6,7 strength, cough strength to clear secretions, laryn- 2.1.5 Subglottic stenosis in neonates9-11 geal function, nutritional status, and clearance of and children12 sedative and neuromuscular blocking effects. 2.1.6 Tracheal injury13-16 2.1.7 Hemoptysis17 4.1 Occasionally, acute airway obstruction of 2.1.8 Aspiration18,19 the artificial airway due to mucus or mechani- 2.1.9 Pulmonary infection20-23 cal deformation mandates immediate removal 2.1.10 Endotracheal tube occlusion24-27 of the artificial airway. Reintubation or other 2.1.11 Accidental extubation necessitat- appropriate techniques for reestablishing the ing emergent reintubation25,28 airway (ie, surgical airway management) must 2.2 Extubation may result in the following be used to maintain effective gas ex- complications change.26,27,43 2.2.1 Upper airway obstruction from 4.2 Patients in whom an explicit declaration of laryngospasm29-32 the futility of further medical care is document- 2.2.2 Laryngeal edema33-37 ed may have the endotracheal tube removed de- 2.2.3 Supraglottic obstruction38 spite failure to meet the above indications.44,45 2.2.4 Pulmonary edema39-41 2.2.5 Pulmonary aspiration syndrome19,42 RET 5.0 CONTRAINDICATIONS 2.2.6 Impaired respiratory gas exchange There are no absolute contraindications to extuba- tion; however, to maintain acceptable gas exchange RESPIRATORY CARE • JANUARY 2007 VOL 52 NO 1 81 AARC GUIDELINE: REMOVAL OF THE ENDOTRACHEAL TUBE after extubation some patients may require one or Therefore, a trial of extubation may be used in more of the following: noninvasive ventilation, some marginal patients with the expectation that the continuous positive airway pressure, high inspired need for reintubation is likely. Extubation failure oxygen fraction, or reintubation. Airway protective rates reported in the literature range between 1.8%- reflexes may be depressed immediately following 18.6% for adults,1,36,63-65 2.7%-22% for children,66- and for some time after extubation.18,46 Therefore, 70 and may be as high as 40%-60% for low birth- measures to prevent aspiration should be consid- weight infants.71-75 Clinical practice standards for ered. endotracheal tube removal include attentive postex- tubation monitoring, prompt identification of respi- RET 6.0 HAZARDS/COMPLICATIONS ratory distress, maintenance of a patent airway and, 6.1 Hypoxemia after extubation may result if clinically indicated, attempts to successfully es- from but is not limited to tablish an artificial airway by reintubation or surgi- 6.1.1 Failure to deliver adequate inspired cal technique. The failure and complication rates of oxygen fraction through the natural upper extubation can be used as quality monitors. airway47 6.1.2 Acute upper airway obstruction sec- RET 8.0 ASSESSMENT OF EXTUBATION ondary to laryngospasm29-32 READINESS 6.1.3 Development of post-obstruction The endotracheal tube should be removed as soon pulmonary edema39-41 as the patient no longer requires an artificial airway. 6.1.4 Bronchospasm48,49 Patients should demonstrate some evidence for the 6.1.5 Development of atelectasis, or lung reversal of the underlying cause of respiratory fail- collapse50 ure and should be capable of maintaining adequate 6.1.6 Pulmonary aspiration18,19,42 spontaneous ventilation and gas exchange. The de- 6.1.7 Hypoventilation51,52 termination of extubation readiness may be individ- 6.2 Hypercapnia after extubation may be ualized using the following guidelines. caused by but is not limited to 6.2.1 Upper airway obstruction resulting 8.1 Patients with an artificial airway to facili- from edema of the trachea, vocal cords, or tate treatment of respiratory failure should be larynx33-38 considered for extubation when they have met 6.2.2 Respiratory muscle weakness53,54 established extubation readiness criteria.64,76 6.2.3 Excessive work of breathing55-59 Examples of these criteria include but are not 6.2.4 Bronchospasm48,49 limited to 6.3 Death may occur when medical futility is 8.1.1 The capacity to maintain adequate the reason for removing the endotracheal tube. arterial partial pressure of oxygen (P /F ratio > 150-200) on inspired aO2 IO2 RET 7.0 LIMITATIONS OF METHODOLOGY/ oxygen fractions provided with simple VALIDATION OF RESULTS oxygen devices (F ≤ 0.4 to 0.5 and with IO2 Predicting extubation outcome is of significant low levels of positive airway pressure 2 clinical importance as both extubation delay and (PEEP) ≤ 5 to 8 cm H2O unsuccessful extubation are associated with poor 8.1.2 The capacity to maintain appropri- patient outcomes.1,2 However, the literature on this ate pH (pH ≥ 7.25)2 and arterial partial topic is limited by few validated objective measures pressure of carbon dioxide during sponta- to accurately predict the extubation outcome for an neous ventilation74,75 individual patient.1,2,60-63 Failed extubation, or the 8.1.3 Successful completion of 30-120 need to reinsert an artificial airway following extu- minute spontaneous breathing trial (SBT) bation, is not necessarily an indication of failed performed with a low level of CPAP (eg 5 medical practice. Patients may need reintubation cm H2O) or low level of pressure support immediately or after some interval due to inappro- eg 5-7 cm H2O) demonstrating adequate priately timed extubation, progression of underly- respiratory pattern and gas exchange, ing disease, or development of a new disorder. hemodynamic stability, and subjective 82 RESPIRATORY CARE • JANUARY 2007 VOL 52 NO 1 AARC GUIDELINE: REMOVAL OF THE ENDOTRACHEAL TUBE comfort77-81 bation, (0.65 equates to 20% successful 8.1.4 In adults, respiratory rate < 35 extubation105,106 breaths per minute during spontaneous 8.1.15 Airway occlusion pressure at 0.1 breathing;54 in infants and children, the seconds (P0.1) < 6 cm H2O and when nor- acceptable respiratory rate decreases in- malized for maximal inspiratory pressure versely with age and can be measured (MIP), as indicated by [P0.1/MIP], accu- with good repeatability with a stetho- rately predict successful extubation 88% scope82 and 98% of the time, respectively.107-109 8.1.5 Adequate respiratory muscle (This measurement is primarily a research strength83-85 tool.) 8.1.6 Maximum negative inspiratory pres- 8.1.16 Maximum voluntary ventilation > 86-89 twice resting minute ventilation86 sure > -30 cm H2O although current clinical practice may accept a maximum 8.1.17 In preterm infants, minute ventila- negative inspiratory pressure > -20 cm tion testing vs. standard clinical evalua- 90,91 tion resulted in shorter time to extuba- H2O 8.1.7 Vital capacity > 10 mL/kg ideal tion110 body weight92 or in neonates > 150 8.1.19 Peak expiratory flow (PEF) ≥ 60 mL/m289 L/min after 3 cough attempts measured 8.1.8 Pressure measured across the di- with an in-line spirometer111,112 aphragm during spontaneous ventilation < 8.1.20 Time to recovery of minute venti- 15% of maximum93,94 lation to pre-spontaneous breathing trial 8.1.9 In adults, spontaneous exhaled baseline levels113 minute ventilation < 10 L/min86 8.1.21 Sustained maximal inspiratory 8.1.10 In adults, a rapid shallow breathing pressures (SMIP) > 57.5 pressure time index (RSBI, respiratory rate-to-tidal-vol- units (sensitivity and specificity of 1.0) ume ratio) of ≤105 breaths/min (positive predicted extubation outcome114 predictive value (PPV) of 0.78)90; in in- 8.1.22 In neonates, total respiratory com- fants and children, variables standardized pliance (Crs, derived from VT/PIP-PEEP) by age or weight proved more useful. ≤ 0.9 mL/cm H2O was associated with ex- Modified CROP index (compliance, resis- tubation failure, whereas a value ≥ 1.3 tance, oxygenation, and ventilating pres- mL/cm H2O was associated
Load more

Recommended publications
  • Non-Invasive Ventilation Made Ridiculously Simple
    NON-INVASIVE VENTILATION MADE RIDICULOUSLY SIMPLE Jennifer Newitt, MD 3rd year Pulmonary/Critical Care Fellow Mentor: Patrick Strollo Jr, MD Myth or Fact ?!? Myth or Fact ?!? Treatment for Obstructive Sleep Apnea ■ Lifestyle Modifications – Weight loss, increased fitness – Avoid alcohol, sleep deprivation, sedatives – Lateral position, head of bed elevation ■ Surgical – Upper airway reconstruction (UPP) or tracheostomy – Upper airway stimulation ■ Positive Airway Pressure via mask ■ Oral appliance therapy Treatment for Obstructive Sleep Apnea ■ Lifestyle Modifications – Weight loss, increased fitness – Avoid alcohol, sleep deprivation, sedatives – Lateral position, head of bed elevation ■ Surgical – Upper airway reconstruction (UPP) or trach – Upper airway stimulation ■Positive Positive Airway Pressure Airway via mask Pressure via mask ■ Oral appliance therapy 3 decades later…! Continuous Positive Airway Pressure (CPAP) ■ Continuous level of positive pressure provided to overcome airway obstruction ■ Patient must inhale and exhale over continuous pressure ■ Patient initiates all breaths ■ No additional pressure above level of CPAP is provided Continuous Positive Airway Pressure (CPAP) ■ Fixed CPAP – Fixed level of pressure between 4-20 cm H20 (ex: 10 cm H20) ■ Auto-CPAP – Variable pressure according to patient needs as detected by machine – If apnea, hypopnea, flow limitation, or snoring are detected, pressure is increased until events are eliminated – If no events are detected over set time period, pressure is decreased – Set pressure
    [Show full text]
  • Sleep-Apnea-Protocol.Pdf
    Evidence-based Practice Center Systematic Review Protocol Project Title: Continuous Positive Airway Pressure Treatment for Obstructive Sleep Apnea in Medicare Eligible Patients I. Background Sleep apnea is a common disorder that affects people of all ages. It is characterized by periods of airflow cessation (apnea) or reduced airflow (hypopnea) during sleep. Sleep apnea may be caused by mechanical obstruction of the airways resulting in disturbed airflow patterns, by a central loss of respiratory drive, or a combination of the two (mixed). Obstructive sleep apnea- hypopnea syndrome, more commonly called obstructive sleep apnea (OSA), is the most common type of sleep apnea.1 Definition and severity of obstructive sleep apnea Sleep apnea is primarily diagnosed with sleep tests that measure sleep time (and often other sleep measures) and respiratory events. OSA is distinguished from central sleep apnea by the presence of respiratory effort during episodes of apnea and hypopnea (in contrast with central sleep apnea where respiratory effort is lacking). The severity of OSA is typically quantified by the sum of the number of apneas and hypopneas per hour of sleep, a quantity that has been termed the apnea-hypopnea index (AHI). AHI is often used as part of both diagnosis (and, thus, study inclusion criteria) and as a surrogate measure for health outcomes (also called an intermediate outcome) in studies. The American Academy of Sleep Medicine (AASM) publishes scoring manuals for AHI and other physiological events to characterize OSA. In the United States, AASM is the predominant accrediting institution for sleep laboratories. AASM first published its scoring manual in 1999 (known as the “Chicago” Criteria).2 They have amended their definitions of breathing events, sleep time, and how these are measured multiple times since their first set of criteria, with major revisions in 2007,3 and in 2012.4 Minor revisions have been made almost annually since (the current version is v2.6,5 released in 2020).
    [Show full text]
  • The Laryngeal Mask Airway: Potential Applications in Neonates
    F485 Arch Dis Child Fetal Neonatal Ed: first published as 10.1136/adc.2003.038430 on 21 October 2004. Downloaded from PERSONAL PRACTICE The laryngeal mask airway: potential applications in neonates D Trevisanuto, M Micaglio, P Ferrarese, V Zanardo ............................................................................................................................... Arch Dis Child Fetal Neonatal Ed 2004;89:F485–F489. doi: 10.1136/adc.2003.038430 The laryngeal mask airway is a safe and reliable airway 2.5–5 kg.11 It has been postulated that a smaller size (0.5) could be useful in preterm management device. This review describes the insertion newborns. However, there are reports of techniques, advantages, limitations, and potential successful use of size 1 in preterm neonates applications of the laryngeal mask airway in neonates. weighing 0.8–1.5 kg.12–15 ........................................................................... (2) Fully deflate the cuff as described in the manual, and lubricate the back of the mask tip (for neonates in the labour ward, he ability to maintain a patent airway and lubrication may not be necessary, as oral provide effective positive pressure ventilation and pharyngeal secretions may reproduce T(PPV) is the main objective of neonatal this function). resuscitation and all anaesthesiological proce- (3) Press (flatten) the tip of the LMA against the dures.1–6 This is currently achieved with the use hard palate. During this manoeuvre, the of a face mask or an endotracheal tube. Both of these devices have major limitations from a operator should grasp the LMA like a pen strictly anatomical point of view and require with the index finger at the junction adequate operator skills. In certain situations, between the mask and the distal end of the both face mask ventilation and tracheal intuba- airway tube.
    [Show full text]
  • Intravenous Alfaxalone Anaesthesia in Two Squamate Species: Eublepharis Macularius and Morelia Spilota Cheynei
    INTRAVENOUS ALFAXALONE ANAESTHESIA IN TWO SQUAMATE SPECIES: EUBLEPHARIS MACULARIUS AND MORELIA SPILOTA CHEYNEI Tesi per il XXIX Ciclo del Dottorato in Scienze Veterinarie, Curriculum Scienze Cliniche Veterinarie Dipartimento di Scienze Veterinarie, Universita’ degli Studi di Messina Tutor: Prof. Filippo Spadola Cotutor: Prof. Zdenek Knotek Dr. Manuel Morici Sommario L’anestesia negli Squamati è una costante sfida della medicina e chirurgia dei rettili. Le differenze morfo-fisiologiche di questi taxa, rendono difficilmente applicabile i comuni concetti di anestesiologia veterinaria usati con successo negli altri animali da compagnia. Diversi protocolli anestetici sono stati utilizzati, sia per l’induzione che per il mantenimento, sia negli ofidi che nei sauri, ma con risultati variabili. Di fatti la maggior parte dei protocolli risultano in induzione o recuperi troppo brevi o troppo lunghi. L’obbiettivo di questa tesi dottorale è di valutare l’efficacia di un anestetico steroideo (alfaxalone), somministrato per via endovenosa in due specie di squamati usati come modello: il geco leopardo (Eublepharis macularius) e il pitone tappeto (Morelia spilota cheynei). Due metodi di somministrazione endovenosa (vena giugulare nei gechi e vena caudale nei serpenti) sono stati analizzati e descritti, usando un dosaggio di anestetico di 5 mg/kg in 20 gechi leopardo, e di 10 mg/kg in 10 pitoni tappeto. Nei gechi il tempo di induzione, il tempo di perdita del tono mandibolare, l’intervallo di anestesia chirurgica e il recupero completo sono stati rispettivamente di 27.5 ± 30.7 secondi, 1.3 ± 1.4 minuti, 12.5 ± 2.2 minuti and 18.8 ± 12.1 minuti. Nei pitoni tappeto, il tempo di induzione, la perdita di sensazione, il tempo di inserimento del tubo endotracheale, l’intervallo di anestesia chirurgica e il recupero sono stati rispettivamente di 3.1±0.8 minuti, 5.6±0.7 minuti, 6.9±0.9 minuti, 18.8±4.7 minuti, e 36.7±11.4 minuti.
    [Show full text]
  • Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing
    AAAAI Work Group Report Role of the Allergist-Immunologist and Upper Airway Allergy in Sleep-Disordered Breathing Dennis Shusterman, MD, MPHa, Fuad M. Baroody, MDb, Timothy Craig, DOc, Samuel Friedlander, MDd, Talal Nsouli, MDe, and Bernard Silverman, MD, MPHf; on behalf of the American Academy of Allergy, Asthma & Immunology’s Rhinitis, Rhinosinusitis and Ocular Allergy Committee Work Group on Rhinitis and Sleep-disordered Breathing San Francisco, Calif; Chicago, Ill; Hershey, Pa; Solon, Ohio; Washington, DC; and Brooklyn, NY BACKGROUND: Sleep-disordered breathing in general and RESULTS: Survey results were returned by 339 of 4881 active obstructive sleep apnea in particular are commonly encountered members (7%). More than two-third of respondents routinely conditions in allergy practice. Physiologically, nasal (or asked about sleep problems, believed that sleep-disordered nasopharyngeal) obstruction from rhinitis, nasal polyposis, or breathing was a problem for at least a “substantial minority” adenotonsillar hypertrophy are credible contributors to snoring (10%-30%) of their adult patients, and believed that medical and nocturnal respiratory obstructive events. Nevertheless, therapy for upper airway inflammatory conditions could existing practice parameters largely relegate the role of the potentially help ameliorate sleep-related complaints. Literature allergist to adjunctive treatment in cases of continuous positive review supported the connection between high-grade nasal airway pressure intolerance. congestion/adenotonsillar hypertrophy and obstructive sleep OBJECTIVES: To survey active American Academy of Allergy, apnea, and at least in the case of pediatric patients, supported the Asthma & Immunology members regarding their perceptions use of anti-inflammatory medication in the initial management and practices concerning sleep-disordered breathing in adult and of obstructive sleep apnea of mild-to-moderate severity.
    [Show full text]
  • Tracheal Intubation
    //Tracheal Intubation http://www.expertconsultbook.com/expertconsult/b/book.do?m... Tracheal Intubation Technique As previously discussed, because of differences in anatomy, there are differences in techniques for intubating the trachea of infants and children compared with adults.[1–4,17–19,99,114,115] Because of the smaller dimensions of the pediatric airway there is increased risk of obstruction with trauma to the airway structures. A technique to be avoided is that in which the blade is advanced into the esophagus and then laryngeal visualization is achieved during withdrawal of the blade. This maneuver may result in laryngeal trauma when the tip of the blade scrapes the arytenoids and aryepiglottic folds. There are several approaches to exposing the glottis in infants with a Miller blade. One philosophy consists of advancing the laryngoscope blade under constant vision along the surface of the tongue, placing the tip of the blade directly in the vallecula and then using this location to pivot or rotate the blade to the right to sweep the tongue to the left and adequately lift the tongue to expose the glottic opening. This avoids trauma to the arytenoid cartilages. One can thus lift the base of the tongue, which in turn lifts the epiglottis, exposing the glottic opening. If this technique is unsuccessful, one may then directly lift the epiglottis with the tip of the blade (see Video Clip 12-1, Coming Soon). Another approach is to insert the Miller blade into the mouth at the right commissure over the lateral bicuspids/incisors (paraglossal approach). The blade is advanced down the right gutter of the mouth aiming the blade tip toward the midline while sweeping the tongue to the left.
    [Show full text]
  • Policies & Procedures Title: CPAP/Bipap-Non Invasive Ventilation
    Policies & Procedures Title: CPAP/BiPAP-Non Invasive Ventilation (NIV) - Care and Monitoring of the Patient • Post-operative care • Acute respiratory failure Number: 1114 Authorization: Source: Nursing Date Effective: January 2016 [X] SHR Nursing Practice Committee Scope: SHR Acute Urban Any PRINTED version of this document is only accurate up to the date of printing 30-May-16. Saskatoon Health Region (SHR) cannot guarantee the currency or accuracy of any printed policy. Always refer to the Policies and Procedures site for the most current versions of documents in effect. SHR accepts no responsibility for use of this material by any person or organization not associated with SHR. No part of this document may be reproduced in any form for publication without permission of SHR. Overview The following policy applies only to the use of NIV for adult patients with acute respiratory failure (see appendix A, post-operative patients and dyspnea in palliative care patients. It does not apply to the treatment of sleep disordered breathing, chronic, stable respiratory failure or pediatric patients. Definitions: Non-Invasive Ventilation is the provision of ventilatory support through the patient’s upper airway using a mask or similar device. For the purposes of this policy, both continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP) will be generically referred to as non- invasive ventilation (NIV). Note: See SHR policy 7311-60-024 https://www.saskatoonhealthregion.ca/about/RWPolicies/7311-60- 024.pdf for the application of non-invasive ventilation for acute respiratory failure. Continuous Positive Airway Pressure (CPAP) is a continuous positive airway pressure that is used to provide a patent airway during periods of sleep apnea.
    [Show full text]
  • Effect of Continuous Positive Airway Pressure Versus Supplemental Oxygen on Sleep
    1 Effect of Continuous Positive Airway Pressure versus Supplemental Oxygen on Sleep 2 Quality in Obstructive Sleep Apnea: A placebo-CPAP controlled study 3 4 5 José S. Loredo, MD,a Sonia Ancoli-Israel PhD,b Eui-Joong Kim, MD,c,b 6 Weon Jeong Lim, MD,d,b And Joel E. Dimsdale MDb 7 8 9 From the Department of Medicine,a and the Department of Psychiatry,b University of California, 10 San Diego, the Department of Psychiatry, Eulji University, Daejeon, Korea,c Department of 11 Psychiatry, Ewha Womans University, Seoul, Korea d 12 13 This work was performed at the University of California San Diego 14 15 This work was supported in part by NIH grants HL44915, AG08415, M01 RR00827, HL36005 16 and K23 HL04056 17 18 The authors did not receive any financial support from or were involved with organization(s) 19 with financial interest in the subject matter 20 21 Address correspondence and requests for reprints to Dr. José S. Loredo, UCSD Medical Center 22 Dept. of Medicine, 200 West Arbor Drive, San Diego, CA 92103-0804. 23 Phone: (619) 543-5593. Fax: (619) 543-7519. E-mail: [email protected] 1 24 ABSTRACT 25 Study Objectives: We investigated the short term effectiveness of CPAP and O2 in improving 26 sleep quality in patients with OSA. 27 Design: Randomized, double blinded, placebo-CPAP controlled, parallel study. 28 Setting: General Clinical Research Center at a University Hospital 29 Patients: Seventy-six untreated OSA patients 30 Interventions: Patients were randomized to one of three treatments (CPAP, placebo-CPAP, 31 nocturnal O2 at 3 L/min) for 2-weeks.
    [Show full text]
  • The Effect of Continuous Positive Airway Pressures on Lung Volumes
    Paraplegia (1996) 34, 54- 58 © 1996 International Medical Society of Paraplegia All rights reserved 0031-1758/96 $12.00 The effect of continuous positive airway pressures on lung volumes in tetraplegic patients 2 LA Harveyl and ER Ellis 2 1 Physiotherapy Department, The Prince Henry Hospital, Sydney; School of Physiotherapy, Faculty of Health Sciences, The University of Sydney, Sydney, Australia Continuous positive airway pressure (CPAP) is widely advocated for the treatment of respiratory complications. However the effects of CPAP on the respiratory function of tetraplegic patients have not yet been investigated. The purpose of this study was to examine the effects of breathing with different levels of CPAP on the relationship between closing volume (CV) and functional residual capacity (FRC) in ten recently injured, but otherwise healthy tetraplegic patients with lesions between the fourth and eighth cervical segments. Lung volumes were measured before, during and after 32 min of zero end-expiratory pressure and 5 and 10 cm H20 of CPAP. FRC was measured by the open-circuit nitrogen washout method and CV was measured by the single breath nitrogen washout method. FRC was unaffected by zero end-expiratory pressure, but both 5 cm H20 and 10 cm H20 of CPAP caused significant increases in FRC. FRC returned to pre-CPAP values by the first minute after removal of 5 and 10 cm H20 of CPAP. We were unable to measure CVs in any subjects. It was concluded that 5 and 10 cm H20 of CPAP increase FRC in healthy tetraplegic individuals, but that these increases are rapidly lost with the subsequent removal of CPAP.
    [Show full text]
  • Practice Parameters for the Use of Continuous and Bilevel Positive
    PRACTICE PARAMETER Practice Parameters for the Use of Continuous and Bilevel Positive Airway Pressure Devices to Treat Adult Patients With Sleep-Related Breathing Disorders An American Academy of Sleep Medicine Report Clete A. Kushida, MD, PhD1; Michael R. Littner, MD2; Max Hirshkowitz, PhD3; Timothy I. Morgenthaler, MD4; Cathy A. Alessi, MD5; Dennis Bailey, DDS6; Brian Boehlecke, MD, MSPH7; Terry M. Brown, DO8; Jack Coleman, Jr., MD9; Leah Friedman, PhD10; Sheldon Kapen, MD11; Vishesh K. Kapur, MD, MPH12; Milton Kramer, MD13; Teofilo Lee-Chiong, MD14; Judith Owens, MD15; Jeffrey P. Pancer, DDS16; Todd J. Swick, MD17; Merrill S. Wise, MD18 1Stanford University Center of Excellence for Sleep Disorders, Stanford, CA; 2VA Greater Los Angeles Healthcare System and David Geffen School of Medicine at UCLA, Sepulveda, CA; 3Baylor College of Medicine and VA Medical Center, Houston, TX; 4Mayo Sleep Disorders Center, Mayo Clinic, Rochester, MN; 5UCLA/Greater Los Angeles Healthcare System, Sepulveda, CA; 6Englewood, Colorado; 7University of North Carolina, Chapel Hill, NC; 8St. Joseph Memorial Hospital, Murphysboro, IL; 9Middle Tennessee ENT, Murfreesboro, TN; 10Stanford University School of Medicine, Stan- ford, CA; 11VA Medical Center and Wayne State University, Detroit, MI; 12University of Washington Sleep Disorder Center, Seattle, WA; 13Maimoides Medical Center, Psychiatry Department, Brooklyn, NY and New York University School of Medicine, New York, NY; 14National Jewish Medical and Research Center, Sleep Clinic, Denver, CO; 15Department of Pediatrics, Rhode Island Hospital, Providence, RI; 16Toronto, Ontario, CN; 17Houston, TX; 18Houston, TX Summary: Positive airway pressure (PAP) devices are used to treat pa- studies are usually adequate. 4) CPAP usage should be monitored objec- tients with sleep related breathing disorders (SRBD) including obstructive tively to help assure utilization.
    [Show full text]
  • 1. Ventilator Management
    1. Ventilator Management Indications for Mechanical Ventilation Apnea Ventilatory insufficiency Increase in PaCo2 and decrease in ph Refractory hypoxemia Complications Associated with Mechanical Ventilation Hypotension Increased intrathoracic pressure decreases venous return to the heart Increased risk of ventilator associated pneumonia (VAP) Keep HOB at > 30 Maintain frequent, good oral care Problems with endotracheal tube Mucous plugging Tube my become dislodged Kinking or biting of tube Cuff rupture Pneumothorax Initial Ventilator Settings—parameters to be clarified Type of ventilation Mode of ventilation Tidal volume or peak inspiratory setting Respiratory rate FiO2 PEEP (Positive End Expiratory Pressure) Types of Ventilation Volume Cycled Ventilation(VCV) A pre-selected tidal volume is delivered at the pressure required. Tidal volume guaranteed. Peak inspiratory pressure will vary depending on airway resistance and lung compliance. Pressure Control Time-Cycled Ventilation (PCV) Operator selects inspiratory pressure and inspiratory time Breath is terminated when inspiratory time is reached Inspiratory pressure is guaranteed; tidal volume is dependant on airway resistance and lung compliance Pressure Support (PSV) Requires intact respiratory drive Operator selects inspiratory pressure Patient initiates breath, pressure quickly rises to set pressure and is maintained throughout the inspiratory phase Tidal volume determined by lung compliance and inspiratory effort Modes of Ventilation Assist/Control
    [Show full text]
  • Mechanical Ventilation
    Fundamentals of MMeecchhaanniiccaall VVeennttiillaattiioonn A short course on the theory and application of mechanical ventilators Robert L. Chatburn, BS, RRT-NPS, FAARC Director Respiratory Care Department University Hospitals of Cleveland Associate Professor Department of Pediatrics Case Western Reserve University Cleveland, Ohio Mandu Press Ltd. Cleveland Heights, Ohio Published by: Mandu Press Ltd. PO Box 18284 Cleveland Heights, OH 44118-0284 All rights reserved. This book, or any parts thereof, may not be used or reproduced by any means, electronic or mechanical, including photocopying, recording or by any information storage and retrieval system, without written permission from the publisher, except for the inclusion of brief quotations in a review. First Edition Copyright 2003 by Robert L. Chatburn Library of Congress Control Number: 2003103281 ISBN, printed edition: 0-9729438-2-X ISBN, PDF edition: 0-9729438-3-8 First printing: 2003 Care has been taken to confirm the accuracy of the information presented and to describe generally accepted practices. However, the author and publisher are not responsible for errors or omissions or for any consequences from application of the information in this book and make no warranty, express or implied, with respect to the contents of the publication. Table of Contents 1. INTRODUCTION TO VENTILATION..............................1 Self Assessment Questions.......................................................... 4 Definitions................................................................................
    [Show full text]