Presentation Overview. Monitoring Strategies for the Mechanically Ventilated Patient. Early Monitoring Strategies. Early Attempts To Monitor WOB

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Marylou Jennifer Snow
5 years ago
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1 Monitoring Strategies for the Mechanically entilated Patient Presentation Overview A look back into the future What works and what may work What s all the hype about the WOB? Are ventilator graphics really useful? Has the era of non- invasive monitoring finally arrived? How It All Got Started Early Monitoring Strategies William Withering 17 Stephen Hales Early Perfusion Monitor Early Attempts To Monitor WOB Work: A Basic Feature In All Interactions Work 1

2 Work of Breathing Components Physiologic Components of Work Patient physiologic entilatory pattern Underlying disease Mechanical imposed Circuit/airway Mode of ventilation Non-elastic work to overcome airway resistance Elastic work to inflate the lungs Elastic work to expand the thorax Diaphragmatic Function Crural fibers Costal fibers 2

Physical Assessment for WOB Checking for Paradox

Function and Expansion The Influence Of Rate &

this data Restrictive disease favors fast rates

with lower rates and larger volumes Clinical

ml/kg/ibw Endurance RR 24-38 br/min T 5-7 ml/kg

LT, Raw, C RSBI, NIF, P 100 Graphics P and F

index and indicator of fatigue Pdi trans-

3 Physical Assessment for WOB Checking for Paradox and Asynchrony Determining Respiratory Muscle Function and Expansion The Influence Of Rate & Tidal On The WOB Titrate Rise Time and Esens with this data Restrictive disease favors fast rates with smaller volumes COPD patients have less WOB with lower rates and larger volumes Clinical Assessment Strength NIF > - 20 to 30 C ml/kg/ibw Endurance RR br/min T 5-7 ml/kg IBW RSBI < 105 br/l E 200 ml/kg IBW Patient Comfort Measuring the WOB Calculations Airway/esophageal Oxygen consumption Indirect C LT, Raw, C RSBI, NIF, P 100 Graphics P and F loops Esophageal Monitoring TTdi tension time index and indicator of fatigue Pdi trans- diaphragmatic to measure work Independent measurements of lung and chest wall mechanics 3

Severe Moderate Fatigue Zone Now It s Time to Let the Patient

Atrophy Zone 0 1 2 3 4 5 Respiratory Work Units Where is your

A Picture Is Worth - Curves Graphics The essentials

4 Severe Moderate Fatigue Zone Now It s Time to Let the Patient Do Their Share of the WOB Increasing Energy Demands Normal Atrophy Zone Respiratory Work Units Where is your patient? A Picture Is Worth - Curves Graphics The essentials Evaluating lung mechanics Determining ventilator settings How often are they really used? A Two Dimensional iew Curve Curve 4

5 Curve Spontaneous Positive E I Normal Compliance Decreased Compliance 0 ml 0 20 cm H 2 O 30 C = volume pressure = 0 20 = 30 ml/cmh 2 O C = volume pressure = 0 30 = 20 ml/cm H 2 O Airways Resistance Increased Inspiratory Resistance Expiratory Resistance Inspiratory Resistance 5

over-distention 10 P 04 06 04 B T 02 Paw cmh 2 O - -40-20 A 0 20 40 Paw cmh 2 O - 40 20 0 10 20 40 Alveolar collapse Increased Trigger Effort

6 Increased Expiratory Resistance Inflection Points: What Do They Represent? Overshoot 15 Maximizing PIP Levels Upper And Lower Inflection Points A = 400/20 = 20 ml/cwp B = 0/40 = 15 ml/cwp T LITERS T LITERS 06 Alveolar over-distention 10 P B T 02 Paw cmh 2 O A Paw cmh 2 O Alveolar collapse Increased Trigger Effort AutoPEEP Paw cmh 2 O - 40 Increased Trigger Effort 20 T LITERS Measures trapped air not reflected by Paw or PEEP Influences WOB, hemodynamics and lung mechanics Often essential in some modes of ventilation 6

Detecting Auto-PEEP Detecting Auto-PEEP 120 120 1 2 3 4 5 6 SEC 1 2 3 4 5 6 SEC -120 Zero flow at end exhalation indicates equilibration of lung and circuit pressure 120 The transition from

7 Detecting Auto-PEEP Detecting Auto-PEEP SEC SEC -120 Zero flow at end exhalation indicates equilibration of lung and circuit pressure 120 The transition from expiratory to inspiratory occurs without the expiratory flow returning to zero Note: There can still be pressure in the lung behind airways that are completely obstructed Auto-PEEP AutoPEEP Case Study A 1 2 B 1 2 C Mrs KT suffered a CHI following an automobile accident While being ventilated in C, using AC, she showed erratic exhaled volumes, changes in BP, and required frequent sedation ABG s showed moderated hypoxemia, with mild hypercapnia Pulse oximetry was unstable and periods of desaturation were noted when the patient s exhaled T s became erratic The following represents a typical flow-time tracing during a desaturation episode This patient was generating AutoPEEP leading to decreased S P O 2 and erratic exhaled T Getting Ready For The Future, or Is It Already Here? Metabolic gas measurements: One more time! Transcutaneous CO 2 monitoring What s next? Monitoring entilation Invasive gold standard but what about cost and safety? PetCO 2 not reliable for NI or with unstable /Q TcCO 2, do we really want to go back there? Transcutaneous end-tidal ABG 7

Recipient Dead layer Epidermis Living layer

Phonocardiography and ECG So, What s Next?

Combining pulmonary and cardiovascular data

8 Transcutaneous CO2 Monitoring Improved response time Less frequent site changes Fewer membrane issues Cardiovascular Technologies Non-Invasive Cardiac Output Recipient Dead layer Epidermis Living layer Capillary layer TcCO 2 PaCO2 Integrated Phonocardiography and ECG So, What s Next? Integration of patient data with real- time physiologic data? Moving towards 3 dimensional graphics? Combining pulmonary and cardiovascular data in a closed- loop system? Comments and Questions Help Save The Wetlands wwwridingtherimcom 8

Mechanical Ventilation. Mechanical Ventilation is a Drug!!! is a drug. MV: Indications for use. MV as a Drug: Outline. MV: Indications for use

Mechanical Ventilation. Mechanical Ventilation is a Drug!!! is a drug. MV: Indications for use. MV as a Drug: Outline. MV: Indications for use Mechanical Ventilation is a Drug!!! Mechanical Ventilation is a drug I am an employee of Philips Healthcare Hospital Respiratory Care Group and they help me pay for my kids education Jim Laging, RRT, RCP