Optimizing Mechanical Ventilation: Initiation and Weaning, the Art And
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Airway Pressures and Volutrauma
Airway Pressures and Volutrauma Airway Pressures and Volutrauma: Is Measuring Tracheal Pressure Worth the Hassle? Monitoring airway pressures during mechanical ventilation is a standard of care.1 Sequential recording of airway pressures not only provides information regarding changes in pulmonary impedance but also allows safety parameters to be set. Safety parameters include high- and low-pressure alarms during positive pressure breaths and disconnect alarms. These standards are, of course, based on our experience with volume control ventilation in adults. During pressure control ventilation, monitoring airway pressures remains important, but volume monitoring and alarms are also required. Airway pressures and work of breathing are also important components of derived variables, including airway resistance, static compliance, dynamic compliance, and intrinsic positive end-expiratory pressure (auto-PEEP), measured at the bedside.2 The requisite pressures for these variables include peak inspiratory pressure, inspiratory plateau pressure, expiratory plateau pressure, and change in airway pressure within a breath. Plateau pressures should be measured at periods of zero flow during both volume control and pressure control ventilation. Change in airway pressure should be measured relative to change in volume delivery to the lung (pressure-volume loop) to elucidate work of breathing. See the related study on Page 1179. Evidence that mechanical ventilation can cause and exacerbate acute lung injury has been steadily mounting.3-5 While most of this evidence has originated from laboratory animal studies, recent clinical reports appear to support this concept.6,7 Traditionally, ventilator-induced lung injury brings to mind the clinical picture of tension pneumothorax. Barotrauma (from the root word baro, which means pressure) is typically associated with excessive airway pressures. -
Advanced Modes of Ventilation: Concerns for the OR
Scott, Benjamin K., MD Advanced Modes of Ventilation: Concerns for the OR WHAT I AM NOT GOING TO COVER ADVANCED MODES OF “Adaptive” Advanced Modes that focus on synchrony VENTILATION: ✪ Proportional assist CONCERNS FOR THE OR ✪ Adaptive Support ✪ Neurally Adjusted Ventilatory Assist BENJAMIN K. SCOTT, MD DEPARTMENT OF ANESTHESIOLOGY UNIVERSITY OF COLORADO SCHOOL OF MEDICINE Why? ✪ Evidence of benefit is lacking ✪ Generally interchangeable with standard intraop modes DISCLOSURES PATHOPHYSIOLOGY OF THE SICK LUNG 1. ARDS Ashbaugh and Petty: 1967 case series of 12 ICU patients ✪ Tachypnea and hypoxemia NONE ✪ Opacification on CXR ✪ Poor lung compliance ✪ Diversity of primary insult Ashbaugh DG, Bigelow DB, Petty TL et al. Acute Respiratory Distress in Adults. Lancet. 1967 LEARNING OBJECTIVES PATHOPHYSIOLOGY OF THE SICK LUNG ARDS: The Berlin Definition (c. 2011) 1. Review the pathophysiology of the diseased or injured lung 2. Understand recent strategies in mechanical ventilation, ARDS is an acute diffuse, inflammatory lung injury, leading to particularly focusing on “low‐stretch” and “open‐lung” increased pulmonary vascular permeability, increased lung weight, techniques. and loss of aerated lung tissue...[With] hypoxemia and bilateral radiographic opacities, associated with increased venous 3. Discuss strategies for OR management of patients on admixture, increased physiological dead space and decreased “advanced” vent modes lung compliance. 4. Apply these concepts to routine OR vent management The ARDS Definition Task Force*. Acute Respiratory Distress Syndrome: The Berlin Definition. JAMA. 2012;307(23):2526-2533 Scott, Benjamin K., MD Advanced Modes of Ventilation: Concerns for the OR PATHOPHYSIOLOGY OF THE SICK LUNG VENTILATING THE NON-COMPLIANT LUNG ARDS: The Berlin Definition (c. -
Noninvasive Positive Pressure Ventilation in the Home
Technology Assessment Program Noninvasive Positive Pressure Ventilation in the Home Final Technology Assessment Project ID: PULT0717 2/4/2020 Technology Assessment Program Project ID: PULT0717 Noninvasive Positive Pressure Ventilation in the Home (with addendum) Prepared for: Agency for Healthcare Research and Quality U.S. Department of Health and Human Services 5600 Fishers Lane Rockville, MD 20857 www.ahrq.gov Contract No: HHSA290201500013I_HHSA29032004T Prepared by: Mayo Clinic Evidence-based Practice Center Rochester, MN Investigators: Michael Wilson, M.D. Zhen Wang, Ph.D. Claudia C. Dobler, M.D., Ph.D Allison S. Morrow, B.A. Bradley Beuschel, B.S.P.H. Mouaz Alsawas, M.D., M.Sc. Raed Benkhadra, M.D. Mohamed Seisa, M.D. Aniket Mittal, M.D. Manuel Sanchez, M.D. Lubna Daraz, Ph.D Steven Holets, R.R.T. M. Hassan Murad, M.D., M.P.H. Key Messages Purpose of review To evaluate home noninvasive positive pressure ventilation (NIPPV) in adults with chronic respiratory failure in terms of initiation, continuation, effectiveness, adverse events, equipment parameters and required respiratory services. Devices evaluated were home mechanical ventilators (HMV), bi-level positive airway pressure (BPAP) devices, and continuous positive airway pressure (CPAP) devices. Key messages • In patients with COPD, home NIPPV as delivered by a BPAP device (compared to no device) was associated with lower mortality, intubations, hospital admissions, but no change in quality of life (low to moderate SOE). NIPPV as delivered by a HMV device (compared individually with BPAP, CPAP, or no device) was associated with fewer hospital admissions (low SOE). In patients with thoracic restrictive diseases, HMV (compared to no device) was associated with lower mortality (low SOE). -
Management of Primary Blast Lung Injury: a Comparison of Airway Pressure Release Versus Low Tidal Volume Ventilation Timothy E
Scott et al. Intensive Care Medicine Experimental (2020) 8:26 Intensive Care Medicine https://doi.org/10.1186/s40635-020-00314-2 Experimental RESEARCH Open Access Management of primary blast lung injury: a comparison of airway pressure release versus low tidal volume ventilation Timothy E. Scott1, Anup Das2* , Mainul Haque3, Declan G. Bates2 and Jonathan G. Hardman4,5 * Correspondence: anup.das@ warwick.ac.uk Abstract 2School of Engineering, University of Warwick, Coventry CV4 7AL, UK Background: Primary blast lung injury (PBLI) presents as a syndrome of respiratory Full list of author information is distress and haemoptysis resulting from explosive shock wave exposure and is a available at the end of the article frequent cause of mortality and morbidity in both military conflicts and terrorist attacks. The optimal mode of mechanical ventilation for managing PBLI is not currently known, and clinical trials in humans are impossible due to the sporadic and violent nature of the disease. Methods: A high-fidelity multi-organ computational simulator of PBLI pathophysiology was configured to replicate data from 14 PBLI casualties from the conflict in Afghanistan. Adaptive and responsive ventilatory protocols implementing low tidal volume (LTV) ventilation and airway pressure release ventilation (APRV) were applied to each simulated patient for 24 h, allowing direct quantitative comparison of their effects on gas exchange, ventilatory parameters, haemodynamics, extravascular lung water and indices of ventilator-induced lung injury. Results: The simulated patients responded well to both ventilation strategies. Post 24-h investigation period, the APRV arm had similar PF ratios (137 mmHg vs 157 mmHg), lower sub-injury threshold levels of mechanical power (11.9 J/min vs 20.7 J/min) and lower levels of extravascular lung water (501 ml vs 600 ml) compared to conventional LTV. -
Effect of Spontaneous Breathing on Ventilator- Induced Lung Injury In
Xia et al. Critical Care 2011, 15:R244 http://ccforum.com/content/15/5/R244 RESEARCH Open Access Effect of spontaneous breathing on ventilator- induced lung injury in mechanically ventilated healthy rabbits: a randomized, controlled, experimental study Jingen Xia, Bing Sun, Hangyong He, Heng Zhang, Chunting Wang and Qingyuan Zhan* Abstract Introduction: Ventilator-induced lung injury (VILI), one of the most serious complications of mechanical ventilation (MV), can impact patients’ clinical prognoses. Compared to control ventilation, preserving spontaneous breathing can improve many physiological features in ventilated patients, such as gas distribution, cardiac performance, and ventilation-perfusion matching. However, the effect of spontaneous breathing on VILI is unknown. The goal of this study was to compare the effects of spontaneous breathing and control ventilation on lung injury in mechanically- ventilated healthy rabbits. Methods: Sixteen healthy New Zealand white rabbits were randomly placed into a spontaneous breathing group (SB Group) and a control ventilation group (CV Group). Both groups were ventilated for eight hours using biphasic positive airway pressure (BIPAP) with similar ventilator parameters: inspiration pressure (PI) resulting in a tidal volume (VT) of 10 to 15 ml/kg, inspiratory-to-expiratory ratio of 1:1, positive end-expiration pressure (PEEP) of 2 cmH2O, and FiO2 of 0.5. Inflammatory markers in blood serum, lung homogenates and bronchoalveolar lavage fluid (BALF), total protein levels in BALF, mRNA expressions of selected cytokines in lung tissue, and lung injury histopathology scores were determined. Results: Animals remained hemodynamically stable throughout the entire experiment. After eight hours of MV, compared to the CV Group, the SB Group had lower PaCO2 values and ratios of dead space to tidal volume, and higher lung compliance. -
The Basics of Ventilator Management Overview How We Breath
3/23/2019 The Basics of Ventilator Management What are we really trying to do here Peter Lutz, MD Pulmonary and Critical Care Medicine Pulmonary Associates, Mobile, Al Overview • Approach to the physiology of the lung and physiological goals of mechanical Ventilation • Different Modes of Mechanical Ventilation and when they are indicated • Ventilator complications • Ventilator Weaning • Some basic trouble shooting How we breath http://people.eku.edu/ritchisong/301notes6.htm 1 3/23/2019 How a Mechanical Ventilator works • The First Ventilator- the Iron Lung – Worked by creating negative atmospheric pressure around the lung, simulating the negative pressure of inspiration How a Mechanical Ventilator works • The Modern Ventilator – The invention of the demand oxygen valve for WWII pilots if the basis for the modern ventilator https://encrypted-tbn0.gstatic.com/images?q=tbn:ANd9GcRI5v-veZULMbt92bfDmUUW32SrC6ywX1vSzY1xr40aHMdsCVyg6g How a Mechanical Ventilator works • The Modern Ventilator – How it works Inspiratory Limb Flow Sensor Ventilator Pressure Sensor Expiratory Limb 2 3/23/2019 So what are the goals of Mechanical Ventilation • What are we trying to control – Oxygenation • Amount of oxygen we are getting into the blood – Ventilation • The movement of air into and out of the lungs, mainly effects the pH and level of CO 2 in the blood stream Lab Oxygenation Ventilation Pulse Ox Saturation >88-90% Arterial Blood Gas(ABG) Po 2(75-100 mmHg) pCO 2(40mmHg) pH(~7.4) Oxygenation How do we effect Oxygenation • Fraction of Inspired Oxygen (FIO 2) – Percentage of the gas mixture given to the patient that is Oxygen • Room air is 21% • On the vent ranges from 30-100% • So if the patient’s blood oxygen levels are low, we can just increase the amount of oxygen we give them 3 3/23/2019 How do we effect Oxygenation • Positive End Expiratory Pressure (PEEP) – positive pressure that will remains in the airways at the end of the respiratory cycle (end of exhalation) that is greater than the atmospheric pressure in mechanically ventilated patients. -
Comparison Between Intermittent Mandatory Ventilation And
0021-7557/09/85-01/15 Jornal de Pediatria Copyright © 2009 by Sociedade Brasileira de Pediatria ARTIGO ORIGINAL Comparison between intermittent mandatory ventilation and synchronized intermittent mandatory ventilation with pressure support in children Comparação entre ventilação mandatória intermitente e ventilação mandatória intermitente sincronizada com pressão de suporte em crianças Marcos A. de Moraes1, Rossano C. Bonatto2, Mário F. Carpi2, Sandra M. Q. Ricchetti3, Carlos R. Padovani4, José R. Fioretto5 Resumo Abstract Objetivo: Comparar a ventilação mandatória intermitente (IMV) Objective: Tocompare intermittent mandatory ventilation (IMV) com a ventilação mandatória intermitente sincronizada com pressão with synchronized intermittent mandatory ventilation plus pressure de suporte (SIMV+PS) quanto à duração da ventilação mecânica, support (SIMV+PS) in terms of time on mechanical ventilation, desmame e tempo de internação na unidade de terapia intensiva duration of weaning and length of stay in a pediatric intensive care pediátrica (UTIP). unit (PICU). Métodos: Estudo clínico randomizado que incluiu crianças entre Methods: This was a randomized clinical trial that enrolled 28 dias e 4 anos de idade, admitidas na UTIP no período children aged 28 days to 4 years who were admitted to a PICU correspondente entre 10/2005 e 06/2007, que receberam ventilação between October of 2005 and June of 2007 and put on mechanical mecânica (VM) por mais de 48 horas. Os pacientes foram alocados, ventilation (MV) for more than 48 hours. These patients were por meio de sorteio, em dois grupos: grupo IMV (GIMV;n=35)e allocated to one of two groups by drawing lots: IMV group (IMVG; n grupo SIMV+PS (GSIMV; n = 35). -
Prevention of Ventilator Associated Complications
Prevention of Ventilator associated complications Authors: Dr Aparna Chandrasekaran* & Dr Ashok Deorari From: Department of Pediatrics , WHO CC AIIMS , New Delhi-110029 & * Neonatologist , Childs Trust Medical Research Foundation and Kanchi Kamakoti Childs Trust Hospital, Chennai -600034. Word count Text: 4890 (excluding tables and references) Figures: 1; Panels: 2 Key words: Ventilator associated complications, bronchopulmonary dysplasia Abbreviations: VAP- Ventilator associated pneumonia , BPD- Bronchopulmonary dysplasia, ELBW- Extremely low birth weight, VLBW- Very low birth weight, ROP- Retinopathy of prematurity, CPAP- Continuous positive airway pressure, I.M.- intramuscular, CI- Confidence intervals, PPROM- Preterm prelabour rupture of membranes, RCT- Randomised control trial, RR- Relative risk, PEEP- Peak end expiratory pressure Background: The last two decades have witnessed a dramatic reduction in neonatal mortality from 4.4 million newborn deaths annually in 1990 to 2.9 million deaths yearly in the year 2012, a reduction by 35%. In India, neonatal mortality has decreased by 42% during the same period. (1) With the increasing survival and therapeutic advances, the new paradigm is now on providing best quality of care and preventing complications related to therapy. Assisted ventilation dates back to 1879, when the Aerophone Pulmonaire, the world’s earliest ventilator was developed. This was essentially a simple tube connected to a rubber bulb. The tube was placed in the infant’s airway and the bulb was alternately compressed and released to produce inspiration and expiration. (2) With better understanding of pulmonary physiology and mechanics , lung protective strategies have evolved in the last two decades, with new resuscitation devices that limit pressure (T-piece resuscitator), non-invasive ventilation, microprocessors that allow synchronised breaths and regulate volume and high frequency oscillators/ jet ventilators. -
Mechanical Ventilation Page 1 of 5
UTMB RESPIRATORY CARE SERVICES Policy 7.3.53 PROCEDURE - Mechanical Ventilation Page 1 of 5 Mechanical Ventilation Effective: 10/26/95 Formulated: 11/78 Revised: 04/11/18 Mechanical Ventilation Purpose Mechanical Artificial Ventilation refers to any methods to deliver volumes of gas into a patient's lungs over an extended period of time to remove metabolically produced carbon dioxide. It is used to provide the pulmonary system with the mechanical power to maintain physiologic ventilation, to manipulate the ventilatory pattern and airway pressures for purposes of improving the efficiency of ventilation and/or oxygenation, and to decrease myocardial work by decreasing the work of breathing. Scope Outlines the procedure of instituting mechanical ventilation and monitoring. Accountability • Mechanical Ventilation may be instituted by a qualified licensed Respirator Care Practitioner (RCP). • To be qualified the practitioner must complete a competency based check off on the ventilator to be used. • The RCP will have an understanding of the age specific requirements of the patient. Physician's Initial orders for therapy must include a mode (i.e. mandatory Order Ventilation/Assist/Control, pressure control etc., a Rate, a Tidal Volume, and an Oxygen concentration and should include a desired level of Positive End Expiratory Pressure, and Pressure Support if applicable. Pressure modes will include inspiratory time and level of pressure control. In the absence of a complete follow up order reflecting new ventilator changes, the original ventilator settings will be maintained in compliance with last order until physician is contacted and the order is clarified. Indications Mechanical Ventilation is generally indicated in cases of acute alveolar hypoventilation due to any cause, acute respiratory failure due to any cause, and as a prophylactic post-op in certain patients. -
Biomarkers of Acute Lung Injury: Worth Their Salt? Alastair G Proudfoot1,2†, Matthew Hind1,2† and Mark JD Griffiths1,2*†
Proudfoot et al. BMC Medicine 2011, 9:132 http://www.biomedcentral.com/1741-7015/9/132 Clinical Biomarkers OPINION Open Access Biomarkers of acute lung injury: worth their salt? Alastair G Proudfoot1,2†, Matthew Hind1,2† and Mark JD Griffiths1,2*† Abstract The validation of biomarkers has become a key goal of translational biomedical research. The purpose of this article is to discuss the role of biomarkers in the management of acute lung injury (ALI) and related research. Biomarkers should be sensitive and specific indicators of clinically important processes and should change in a relevant timeframe to affect recruitment to trials or clinical management. We do not believe that they necessarily need to reflect pathogenic processes. We critically examined current strategies used to identify biomarkers and which, owing to expedience, have been dominated by reanalysis of blood derived markers from large multicenter Phase 3 studies. Combining new and existing validated biomarkers with physiological and other data may add predictive power and facilitate the development of important aids to research and therapy. Introduction The natural history of acute lung injury Thesyndromeacutelunginjury(ALI)anditsmore Regardless of the wide variety of insults that cause or severe counterpart acute respiratory distress syndrome contribute to the development of ALI, the response of (ARDS) are defined by radiographic and physiological the lung is largely stereotypic. A combination of tissue changes that characterize patients with acute lung fail- injury and inflammation affecting the gas exchange sur- ure (Table 1) [1]. All age groups may be affected, face of the lung, the alveolar-capillary membrane, causes although the syndrome has a higher incidence and mor- high permeability pulmonary edema. -
The Future of Mechanical Ventilation: Lessons from the Present and the Past Luciano Gattinoni1*, John J
Gattinoni et al. Critical Care (2017) 21:183 DOI 10.1186/s13054-017-1750-x REVIEW Open Access The future of mechanical ventilation: lessons from the present and the past Luciano Gattinoni1*, John J. Marini2, Francesca Collino1, Giorgia Maiolo1, Francesca Rapetti1, Tommaso Tonetti1, Francesco Vasques1 and Michael Quintel1 Abstract The adverse effects of mechanical ventilation in acute respiratory distress syndrome (ARDS) arise from two main causes: unphysiological increases of transpulmonary pressure and unphysiological increases/decreases of pleural pressure during positive or negative pressure ventilation. The transpulmonary pressure-related side effects primarily account for ventilator-induced lung injury (VILI) while the pleural pressure-related side effects primarily account for hemodynamic alterations. The changes of transpulmonary pressure and pleural pressure resulting from a given applied driving pressure depend on the relative elastances of the lung and chest wall. The term ‘volutrauma’ should refer to excessive strain, while ‘barotrauma’ should refer to excessive stress. Strains exceeding 1.5, corresponding to a stress above ~20 cmH2O in humans, are severely damaging in experimental animals. Apart from high tidal volumes and high transpulmonary pressures, the respiratory rate and inspiratory flow may also play roles in the genesis of VILI. We do not know which fraction of mortality is attributable to VILI with ventilation comparable to that reported in recent clinical practice surveys (tidal volume ~7.5 ml/kg, positive end-expiratory pressure (PEEP) ~8 cmH2O, rate ~20 bpm, associated mortality ~35%). Therefore, a more complete and individually personalized understanding of ARDS lung mechanics and its interaction with the ventilator is needed to improve future care. -
Date 10/15/2018 Page 1 of 12 Protocol Version-I
Feasibility and Impact of Volume Targeted Ventilation for preterm infants born < 32 weeks gestational age with need for invasive Positive Pressure Ventilation in the Delivery Room in reducing neonatal pulmonary morbidities Phase I: Feasibility of Measuring Tidal Volume in the Delivery Room Phase II: Feasibility of providing Volume Targeted Ventilation in the Delivery Room Primary Investigator: Ruben Vaidya, MD Co-Investigators: Paul Visintainer, PhD, Rachana Singh, MD Research Coordinator: TBD Address: Division of Newborn Medicine Department of Pediatrics UMMS-Baystate, Springfield, MA 01199 Phone: 413-794-2400 Email: [email protected] Date 10/15/2018 Page 1 of 12 Protocol Version-I SPECIFIC AIMS AND HYPOTHESIS Bronchopulmonary dysplasia (BPD) continues to be one of the most common long-term pulmonary complications associated with preterm birth. Despite significant decreases in preterm mortality, BPD rates in infants born < 28 weeks gestational age have remained unchanged at approximately 40% i ii iii. This probably is due to the multifactorial pathogenesis of BPD, with lung injury to the immature pulmonary tissue secondary to exposures including but not limited to antenatal/postnatal infection, free oxygen radical toxicity, and/or mechanical ventilation all leading to lung inflammation. Delivery room (DR) practices of preterm infant during initial resuscitation can have a significant impact on occurrence and severity BPD. Current delivery room resuscitation for intubated preterm infants focuses on pressure limited ventilation (PLV), however, rapidly changing pulmonary compliance during the early newborn transition phase results in significant variability in the tidal volume provided to the infant, which in turn can lead to volutrauma, barotrauma and/or atelactetotrauma.