The Basics of Ventilator Management Overview How We Breath
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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. -
Ventilation Patterns Influence Airway Secretion Movement Marcia S Volpe, Alexander B Adams MPH RRT FAARC, Marcelo B P Amato MD, and John J Marini MD
Original Contributions Ventilation Patterns Influence Airway Secretion Movement Marcia S Volpe, Alexander B Adams MPH RRT FAARC, Marcelo B P Amato MD, and John J Marini MD BACKGROUND: Retention of airway secretions is a common and serious problem in ventilated patients. Treating or avoiding secretion retention with mucus thinning, patient-positioning, airway suctioning, or chest or airway vibration or percussion may provide short-term benefit. METHODS: In a series of laboratory experiments with a test-lung system we examined the role of ventilator settings and lung-impedance on secretion retention and expulsion. Known quantities of a synthetic dye-stained mucus simulant with clinically relevant properties were injected into a transparent tube the diameter of an adult trachea and exposed to various mechanical-ventilation conditions. Mucus- simulant movement was measured with a photodensitometric technique and examined with image- analysis software. We tested 2 mucus-simulant viscosities and various peak flows, inspiratory/ expiratory flow ratios, intrinsic positive end-expiratory pressures, ventilation waveforms, and impedance values. RESULTS: Ventilator settings that produced flow bias had a major effect on mucus movement. Expiratory flow bias associated with intrinsic positive end-expiratory pressure generated by elevated minute ventilation moved mucus toward the airway opening, whereas in- trinsic positive end-expiratory pressure generated by increased airway resistance moved the mucus toward the lungs. Inter-lung transfer of mucus simulant occurred rapidly across the “carinal divider” between interconnected test lungs set to radically different compliances; the mucus moved out of the low-compliance lung and into the high-compliance lung. CONCLUSIONS: The move- ment of mucus simulant was influenced by the ventilation pattern and lung impedance. -
COVID-19 Pneumonia: Different Respiratory Treatment for Different Phenotypes? L
Intensive Care Medicine EDITORIAL Un-edited accepted proof COVID-19 pneumonia: different respiratory treatment for different phenotypes? L. Gattinoni1, D. Chiumello2, P. Caironi3, M. Busana1, F. Romitti1, L. Brazzi4, L. Camporota5 Affiliations: 1Department of Anesthesiology and Intensive Care, Medical University of GöttinGen 4Department of Anesthesia, Intensive Care and Emergency - 'Città della Salute e della Scienza’ Hospital - Turin 5Department of Adult Critical Care, Guy’s and St Thomas’ NHS Foundation Trust, Health Centre for Human and Applied Physiological Sciences - London Corresponding author: Luciano Gattinoni Department of Anesthesiology and Intensive Care, Medical University of Göttingen, Robert-Koch Straße 40, 37075, Göttingen, Germany Conflict of interests: The authors have no conflict of interest to disclose NOTE: This article is the pre-proof author’s accepted version. The final edited version will appear soon on the website of the journal Intensive Care Medicine with the following DOI number: DOI 10.1007/s00134-020-06033-2 1 Gattinoni L. et al. COVID-19 pneumonia: different respiratory treatment for different phenotypes? (2020) Intensive Care Medicine; DOI: 10.1007/s00134-020-06033-2 Intensive Care Medicine EDITORIAL Un-edited accepted proof The Surviving Sepsis CampaiGn panel (ahead of print, DOI: 10.1007/s00134-020-06022-5) recently recommended that “mechanically ventilated patients with COVID-19 should be managed similarly to other patients with acute respiratory failure in the ICU.” Yet, COVID-19 pneumonia [1], despite falling in most of the circumstances under the Berlin definition of ARDS [2], is a specific disease, whose distinctive features are severe hypoxemia often associated with near normal respiratory system compliance (more than 50% of the 150 patients measured by the authors and further confirmed by several colleagues in Northern Italy). -
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. -
Driving Pressure for Ventilation of Patients with Acute Respiratory
LWW 02/03/20 09:38 4 Color Fig(s): F1-2 Art: ALN-D-19-00974 CLINICAL FOCUS REVIEW Jerrold H. Levy, M.D., F.A.H.A., F.C.C.M., Editor LWW Driving Pressure for Ventilation of Patients with Acute Anesthesiology Respiratory Distress Syndrome AQ1 Angela Meier, M.D., Ph.D., Rebecca E. Sell, M.D., Atul Malhotra, M.D. ALN ANET nvasive mechanical ventilation is a remarkable advance, Low Tidal Volumes Ibut the possibility of ventilator-induced lung injury exists, Low V mechanical ventilation is a well-established particularly if the ventilator settings are not optimized. The T anet method that limits ventilator-induced lung injury and best methods to avoid lung injury during mechanical ven- has been shown to improve mortality in clinical trials. An tilation, either during ventilation of healthy lungs in the original study by the ARDS Network published in 2000 operating room or during ventilation as support during aln compared a low versus high VT strategy and demonstrated critical illness, are topics of debate. In this review, we sum- a clear mortality benefit with the low V (6 ml/kg ideal marize the current evidence and review a relatively new T body weight) approach compared to a higher delivered VT ALN concept to prevent lung injury: targeting driving pressure (12 ml/kg ideal body weight).9 defined by plateau pressure minus positive end-expiratory ALN pressure (PEEP), see table 1) when setting and adjusting T1 mechanical ventilation. Positive End-Expiratory Pressure A promising single-center study looked at adjusting 0003-3022 Lung Injury PEEP settings based on measuring transpulmonary pres- sures.2 The authors used an esophageal balloon manometer Lung injury results from excess transpulmonary pressure to estimate pleural pressures in patients with ARDS. -
Respiratory Mechanics in Spontaneous and Assisted Ventilation Daniel C Grinnan1 and Jonathon Dean Truwit2
Critical Care October 2005 Vol 9 No 5 Grinnan and Truwit Review Clinical review: Respiratory mechanics in spontaneous and assisted ventilation Daniel C Grinnan1 and Jonathon Dean Truwit2 1Fellow, Department of Pulmonary and Critical Care, University of Virginia Health System, Virginia, USA 2E Cato Drash Professor of Medicine, Senior Associate Dean for Clinical Affairs, Chief, Department of Pulmonary and Critical Care, University of Virginia Health System, Virginia, USA Corresponding author: Daniel C Grinnan, [email protected] Published online: 18 April 2005 Critical Care 2005, 9:472-484 (DOI 10.1186/cc3516) This article is online at http://ccforum.com/content/9/5/472 © 2005 BioMed Central Ltd Abstract mined by the following equation: C = ∆V/∆P, where C is ∆ ∆ Pulmonary disease changes the physiology of the lungs, which compliance, V is change in volume, and P is change in manifests as changes in respiratory mechanics. Therefore, measure- pressure. The inverse of compliance is elastance (E ~ 1/C). ment of respiratory mechanics allows a clinician to monitor closely Airway pressure during inflation is influenced by volume, the course of pulmonary disease. Here we review the principles of thoracic (lung and chest wall) compliance, and thoracic respiratory mechanics and their clinical applications. These resistance to flow. Resistance to flow must be eliminated if principles include compliance, elastance, resistance, impedance, compliance is to be measured accurately. This is flow, and work of breathing. We discuss these principles in normal conditions and in disease states. As the severity of pulmonary accomplished by measuring pressure and volume during a disease increases, mechanical ventilation can become necessary. -
Pathophysiology of Acid Base Balance: the Theory Practice Relationship
Intensive and Critical Care Nursing (2008) 24, 28—40 ORIGINAL ARTICLE Pathophysiology of acid base balance: The theory practice relationship Sharon L. Edwards ∗ Buckinghamshire Chilterns University College, Chalfont Campus, Newland Park, Gorelands Lane, Chalfont St. Giles, Buckinghamshire HP8 4AD, United Kingdom Accepted 13 May 2007 KEYWORDS Summary There are many disorders/diseases that lead to changes in acid base Acid base balance; balance. These conditions are not rare or uncommon in clinical practice, but every- Arterial blood gases; day occurrences on the ward or in critical care. Conditions such as asthma, chronic Acidosis; obstructive pulmonary disease (bronchitis or emphasaemia), diabetic ketoacidosis, Alkalosis renal disease or failure, any type of shock (sepsis, anaphylaxsis, neurogenic, cardio- genic, hypovolaemia), stress or anxiety which can lead to hyperventilation, and some drugs (sedatives, opoids) leading to reduced ventilation. In addition, some symptoms of disease can cause vomiting and diarrhoea, which effects acid base balance. It is imperative that critical care nurses are aware of changes that occur in relation to altered physiology, leading to an understanding of the changes in patients’ condition that are observed, and why the administration of some immediate therapies such as oxygen is imperative. © 2007 Elsevier Ltd. All rights reserved. Introduction the essential concepts of acid base physiology is necessary so that quick and correct diagnosis can The implications for practice with regards to be determined and appropriate treatment imple- acid base physiology are separated into respi- mented. ratory acidosis and alkalosis, metabolic acidosis The homeostatic imbalances of acid base are and alkalosis, observed in patients with differing examined as the body attempts to maintain pH bal- aetiologies. -
CHEM 301 Assignment #3
CHEM 301 Assignment #3 Provide solutions to the following questions in a neat and well organized manner. Clearly state assumptions and reference sources for any constants used. Due date: November 18th 1. Methane and carbon dioxide are produced under anaerobic conditions by the fermentation of organic matter, approximated by the following equation 2 {CH2O} CH4 + CO2 As gas bubbles are evolved at the sediment interface at 5 m depth and remain in contact with water at the sediment surface long enough so that equilibrium is attained. The total pressure at this depth is 148 kPa. If the pH is 8.20, calculate the total carbonate concentration in the interstitial water at 25oC. How would you expect your answer to change if these gas bubbles were present at 500 m depth? Strategy: The total pressure inside the gas bubble must be equal to the total pressure on the outside of the gas bubble (or else it would either explode or collapse). Furthermore, the total pressure inside that gas bubble is equal to the sum of the partial pressures of CH4 and CO2. We can then use the partial pressure of CO2 inside the gas bubble and the corresponding Henry’s law constant to calculate the concentration of aqueous CO2 at equilibrium. Given the pH of the solution and the expressions for Ka1 and Ka2, we can determine the concentration of HCO3- and 2- CO3 . (see textbook pgs 241-242; Chap 11, Q9) Solution: The total carbonate concentration is given by; 2- - 2- [CO3 ]T = [CO2(aq)] + [HCO3 ] + [CO3 ] From the pH speciation diagram (Fig. -
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). -
Arterial Blood Gases: Acid-Base Balance
EDUCATIONAL COMMENTARY – ARTERIAL BLOOD GASES: ACID-BASE BALANCE Educational commentary is provided through our affiliation with the American Society for Clinical Pathology (ASCP). To obtain FREE CME/CMLE credits click on Earn CE Credits under Continuing Education on the left side of the screen. **Florida licensees, please note: This exercise will appear in CE Broker under the specialty of Blood Gas Analysis. LEARNING OUTCOMES On completion of this exercise, the participant should be able to • identify the important buffering systems in the human body. • explain the Henderson-Hasselbalch equation and its relationship to the bicarbonate/carbonic acid buffer system. • explain the different acid-base disorders, causes associated with them, and compensatory measures. • evaluate acid-base status using patient pH and pCO2 and bicarbonate levels. Introduction Arterial blood gas values are an important tool for assessing oxygenation and ventilation, evaluating acid- base status, and monitoring the effectiveness of therapy. The human body produces a daily net excess of acid through normal metabolic processes: cellular metabolism produces carbonic, sulfuric, and phosphoric acids. Under normal conditions, the body buffers accumulated hydrogen ions (H+) through a variety of buffering systems, the respiratory center, and kidneys to maintain a plasma pH of between 7.35 and 7.45. This tight maintenance of blood pH is essential: even slight changes in pH can alter the functioning of enzymes, the cellular uptake and use of metabolites, and the uptake and release of oxygen. Although diagnoses are made by physicians, laboratory professionals must be able to interpret arterial blood gas values to judge the validity of the laboratory results they report. -
Relationship Between PCO 2 and Unfavorable Outcome in Infants With
nature publishing group Articles Clinical Investigation Relationship between PCO2 and unfavorable outcome in infants with moderate-to-severe hypoxic ischemic encephalopathy Krithika Lingappan1, Jeffrey R. Kaiser2, Chandra Srinivasan3, Alistair J. Gunn4; on behalf of the CoolCap Study Group BACKGROUND: Abnormal PCO2 is common in infants with term infants with HIE, both minimum and cumulative expo- hypoxic ischemic encephalopathy (HIE). The objective was to sure to hypocapnia in the first 12 h of the trial were associated determine whether hypocapnia was independently associated with death or adverse neurodevelopmental outcome (13). The with unfavorable outcome (death or severe neurodevelopmen- dose–response relationship between PCO2 and outcome for tal disability at 18 mo) in infants with moderate-to-severe HIE. infants with moderate-to-severe HIE is unknown. METHODS: This was a post hoc analysis of the CoolCap Study The risk of developing hypocapnia or hypercapnia may be in which infants were randomized to head cooling or standard affected by severity of brain injury, intensity and duration of care. Blood gases were measured at prespecified times after newborn resuscitation, timing after the primary injury, and/or randomization. PCO2 and follow-up data were available for 196 response to metabolic acidosis. Thus, in this secondary analy- of 234 infants. Analyses were performed to investigate the rela- sis of the CoolCap Study (14), we sought to confirm the obser- tionship between hypocapnia in the first 72 h after randomiza- vation that -
Neonatal Ventilation
Neonatal Ventilation Edward G. Shepherd History • Bourgeois, 1609: – “…give a small spoonfulof pure wine into the neonate’s mouth, …[to] help the infant to regain its spirits when being agitated by the labors, which sometimes make it so weak that it seems more dead than alive.” • Mauriceau, mid-1600’s: – “[The baby] should be rested on a warmed bed and brought near the fire, where the midwife having taken some wine into her mouth shall blow it into the infant’s mouth, which can be repeated several times if necessary … She should warm all the parts of the body to recall the blood and the spirits which retired during the weakness and endangered suffocation.” Neonatology 2008;94:144–149 History • Levret, 1766: – “There is one more means which sometimes works as by enchantment, it is to apply one’s mouth on that of the infant and to blow into it, taking care to pinch the tip of the nose simultaneously. This method is so effective that it is really rare that others are useful if it fails” Neonatology 2008;94:144–149 History • First ventilators: – Hunter, Chaussier, and Gorcy in the mid 1700’s • Bellows or gas attached to masks or tubes • 1800’s – Discovery of the breathing center – Determination of survival time in asphyxiated animals – First attempts at electrical resuscitation Neonatology 2008;94:144–149 History • By mid 1800’s ventilation fell out of favor – Fears of pnuemothorax, infection, and sudden death – Various positional techniques were developed • “Schultze swingings” • Arm extension and then chest compression – Stayed in practice