Ventilator Management for the Practicing Emergency Physician

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1 Ventilator Management for the Practicing Emergency Physician Dave Caro, MD Program Director Emergency Medicine University of Florida College of Medicine-Jacksonville

2 Vent Management Why do I care? Who manages the vent in your ED?

3 Lactate > 20 ABG: 6.95/106/42 Initial vent settings PRVC 12/500/5/100% Is this an appropriate setting?

4 Vent MGMT Why do I care? Can improve or worsen the condition in your critically ill patient RT managing the vent is technically doing it under your license

5 Concerns and pitfalls Most EPs don t think about managing the ventilator Discomfort Time-intensive Ventilator physiology is complex it s critical care, for Pete s sake!

6 RT Respiratory therapist: training scope of function legal ramifications maturity and experience can make all of the difference

7 How to set up a ventilator Plugs-n-tubes Vent set up and parameters Troubleshooting

8 How to set up a ventilator 1. PLUG IN a. Electrical cord to 120-V outlet 1) Use generator outlet if available!

9 How to set up a ventilator 1. PLUG IN b. High-pressure oxygen tubing to quick-connect oxygen wall adapter 1) Chematron most popular; Puritan-Bennett, DISS systems also available 2) Ohmeda systems provides a hose-base solution 3) KNOW WHAT YOU HAVE 4) Most require that you unplug the oxygen regulator manifold we use to adjust oxygen for BVM, NRB mask, and nasal cannula

10 Ohmeda DISS Chemetron

11 Chemetron

12

13

14

15

16 Ohmeda Quick Connect

17 How to set up a ventilator 1. PLUG IN c. Flexible ventilation tubing and pressure tubing

18 How to set up a ventilator 1. Plug in d. ET tube to flexible tubing

19 How to set up a ventilator 2. Choose your settings and parameters a. Physiology b. Modes

20 Respiratory anatomy The players: Airway Dead space Ventilated space Fixed upper airway concerns Lungs Bronchioles and airflow restriction Alveoli, distention, and diffusion Elasticity/Compliance Source:

21 Modes Weaning modes Pressure support SIMV Control modes Assist control PRVC Others

22 Respiratory physiology Vital signs they re vital! Respiratory rate Oxygen saturation End-tidal CO2 VITALS (last updated: 0942) HR: 113 BP: 98/76 RR: 12 O2 Sat: 98% Temp:?

23 Ventilation parameters Timing related Volume related Pressure related Gas related Products of the above

24 Ventilation parameters Timing related Rate: breaths/minute Normal: Flow rates Normal inspiratory flow rate: 60L/min Can be increased for shorter inspiratory times I:E ratio time in inspiration (I) compared to time in expiration (E). Normally 1:2 to 1:4.

25 Ventilation parameters

26 Ventilation Parameters

27 Respiratory physiology Important parameters Tidal volume Airway pressures Peak Plateau J Pediatr (Rio J). 2007;83(2 Suppl):S100-8

28 Ventilation parameters Gas related Partial pressures FiO2 FiO2/PAO2 Other mixtures: Heliox Nitrous oxide Inhaled anesthetics

29 Ventilation parameters Physiologic products Minute ventilation = rate x tidal volume

30 Ventilation Parameters Airflow Back to physics: Potential = flow x resistance (Ohm s law) Flow = potential/resistance Potential is the gradient of pressure into the airway Resistance is provided by the bronchial tree (and what it produces) Resistance = (P atm P alv )/volumetric airflow

31 Ventilation Parameters Resistance: Size matters! Resistance INVERSELY proportional to airway radius 4 Turbulence matters! Resistance proportional to density of gas

32 Ventilation parameters The main reason we did physics in undergrad! Poiseuille s law: ΔP = 8ηlV/πr 4 (pressure in a tube) Bernoulli's theorem: In particular, deriving the Reynold s number for airflow turbulence: Re = ρvd/μ istry_physics/physics19.htm

33 Ventilation Parameters Compliance Compliance = ΔV/ΔP ΔV in liters ΔP = change in pleural pressure, in cm of H 2 O A measure of distensibility of lungs Low compliance can t distend! High compliance can t exhale!

34 Compliance who cares? YOU do when lung distensibility (compliance) decreases, the higher inflation pressures needed to deliver inflation volume are transmitted to the aveoli. This can lead to pressure-induced lung injury. Source: Marino, The ICU Book, 3 rd edition, p. 459.

35 Volume Pressure Curves

36

37

38 Modes AC (Assist Control) SIMV (Synchronized Intermittent Mandatory Ventilation) PRVC (Pressure Regulated Volume Control) Inverse Ratio Ventilation, etc.

39 Vent mode choice for your critical patient Only mode proven to improve mortality Assist control!

40 Vent mode choice for your critical patient Basic things you ll need to address: Mode Rate Tidal Volume (TV) Fraction of Inspired Oxygen (FiO2) Pressure Support (PS) if not on AC or PRVC Positive End-Expiratory Pressure (PEEP)

41 Vent mode choice Let s start basic unresponsive, very weak/paralyzed patient _ jpg?w=500

42 Basic mode: 1. Mode: 2. Rate: 3. TV: 4. FiO2: 5. PS: 6. PEEP: AC or PRVC cc/kg 100%, titrate down Start 10 cm H2O Start 5 cm H2O

43 Vent Mode Choice Let s get more difficult a crashing asthmatic confused, struggling.

44 Bronchospastic settings Mode: Rate: TV: FiO2: PS: PEEP: PRVC 8-10 (SLOW) 6 cc/kg (LOW) 50% (if tolerated) none 5 cm H2O

45 Bronchospastic settings cont d *inspiratory flow rate HIGH (60 L/min) *I:E with I time in the second range *expect high plateau pressures (watch PEEP) *expect high peak pressures (hold on PS) *expect respiratory acidosis (allow PERMISSIVE HYPERCAPNIA) *SEDATE, SEDATE, SEDATE, SEDATE!!!!

46 Vent Mode Choice Amp it up once more: 60 year old with pneumonia and suspected ARDS.

47 High PP/Persistent Hypoxia/ARDS settings Mode: Rate: TV: FiO2: PS: PEEP: AC or PRVC cc/kg* 100% none 5 cm H2O *quickly cut back to 6cc/kg as your target

48

49

50 The crashing patient on the vent First move: DOPE Second move: Primary survey Considerations: Equipment woes Barotrauma Decrease venous return (high intrathoracic pressures)

51 DOPE D Dislodged tube O Obstruction in airway P Pneumothorax E Equipment failure

52 Ventilator Alarms Low Tidal Volume High Peak Pressure Disconnect Apnea

53 Ventilator Alarms: Low TV Low Tidal Volume Know what volumes you plan to deliver Know how to identify low TV curve Causes for this alarm: ET tube cuff leak Tube obstruction Mucous plug Pt biting or coughing Tube kinked Peak pressure too high?

54 Ventilator Alarms: Low TV Your response: Confirm ETCO2 (proper placement). Check Peak Pressure. If high, go to HIGH PP algorithm. Listen for breath sounds Air leak? Replace ETTube. (*PP should be low.) Check for PTX (before it turns into tension!) If these don t work, go to HIGH PP algorithm.

55 Ventilator Alarms: High Peak Pressures High Peak Pressures Short story: you can t drive air in Causes for this alarm: Airway resistance problem Obstruction Bronchospasm Lung expansion problem Low compliance think of things that injure the lungs: ARDS PTX

56 Ventilator Alarms: High Peak Pressures Your response: Confirm ETCO2 (proper placement) Listen for breath sounds Diminished bilaterally: immediately try to pass suction cath; suction Immediately look at the chest x-ray for PTX; ultrasound if available for PTX Wheezing: go to bronchospastic vent settings, sedation, and continuous nebs/steroids/magnesium/epi. Check Plateau Pressure (inspiratory hold pressure) Crackles or consolidation: go to ARDS vent settings.

57 Ventilator Alarms: Disconnect Disconnect We re off the vent! Causes for this alarm: We re off the vent!

58 Ventilator Alarms: Disconnect Your response: Connect the vent!

59 Ventilator Alarms: Apnea Apnea A problem only when the patient is triggering all of the breaths: pressure support vent modes Causes for this alarm: Oversedation Weakness or Paralysis pharmacologic, infectious, metabolic Hypoventilation CVA, OSA Triggers set too high (pressure triggers, flow triggers)

60 Ventilator Alarms: Apnea Your response: Stimulate the patient Stop sedation temporarily Bag ventilate if required Reset the mode to a mandatory mode

61 Summary case 1 - Youngling 18 YO female overdosed on meds. Intubated for: Vent: Mode Settings

62 Summary Case 2 - Padawan 45 YO asthmatic who deteriorates Intubated for: Vent: Mode Settings Extras

63 Summary Case 3 - Jedi 65 YO with pneumonia who deteriorates. Intubated for: Vent Mode Settings Extras

64 Summary Case 4 Jedi Master 50 YO asthmatic on vent Vent alarm goes off; pt decompensates Your response

65 Summary Vent management is necessary touch the vent! Vent management is complex approach with a strategy! Have a plan for common scenarios, and call in help when you ve got the ball rolling!

66 Summary The only vent mode that has been proven to improve mortality is assist control. (But that doesn t mean other modes don t work!) Give the patient what they need! Use sedation to your advantage. Once on the vent, use blood gas analysis to help with management. Have a plan to respond to common ventilator emergencies.

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