Using Common Ventilator Graphics to Provide Optimal Ventilation

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1 Using Common Ventilator Graphics to Provide Optimal Ventilation David Vines, MHS, RRT, FAARC Associate Professor Chair / Program Director Department of Respiratory Care RUSH UNIVERSITY MEDICAL CENTER

2 Disclosure Information No disclosure information related to this topic

3 Objectives Identify clinical problems associated with mechanical ventilation using a modern ventilator and their graphic package Discuss the adjustment of settings and use of graphics in correcting common clinical problems

4 Topics Common graphics displays Pressure, flow and volume - time curves during VCV, PCV, PRVC, SIMV, PSV Pressure - volume curves Flow-volume loops Common clinical conditions Case study

5 Common Graphics Displays A. Pressure - Time curves B. Flow - Time curves C. Volume - Time curves D. Pressure -Volume curves E. Flow - Volume curves A B C D E

6 Modes of Ventilation Two parts Pattern of the Breaths Type of Breath Delivered

7 Modes of Ventilation Pattern of the Breaths Assist/Control SIMV Patient/time triggered into inspiration Patient/time triggered into inspiration Spontaneous Breathing / CPAP Patient triggered into inspiration

8 Modes of Ventilation Type of Breath Delivered Volume Ventilation Patient/ time triggered, flow/volume limited, Volume / time cycled Pressure Control Ventilation Patient/ time triggered, pressure limited, time cycled Dual Control / Pressure Regulated Volume Control (PRVC) Patient/ time triggered, pressure limited and volume targeted, time cycled Spontaneous ventilation with Pressure Support Patient triggered, pressure limited, flow cycled

9 Flow, Pressure, & Volume Time Curves during Volume Control Ventilation

10 Flow, Pressure, & Volume Time Curves during Volume Control Ventilation

11 Flow, Pressure, & Volume Time Curves during Volume Control Ventilation Assisted

12 Flow, Pressure, & Volume Time Curves during Pressure Control Ventilation

13 Flow, Pressure, & Volume Time Curves during AutoFlow (PRVC)

14 Flow, Pressure, & Volume Time Curves during SIMV- volume with CPAP + 8 cm H2O

15 Flow, Pressure, & Volume Time Curves during Spontaneous Breathing on PSV

16 Flow, Pressure, & Volume Time Curves during Spontaneous Breathing on CPAP + 5 cm H20

17 Pressure-Volume Curve during Volume Control Ventilation

18 Pressure-Volume Curve during Volume Control Ventilation Trigger work

19 Pressure-Volume Curve during Volume Control Ventilation Elastic Work

20 Pressure-Volume Curve during Volume Control Ventilation Resistance

21 Pressure-Volume Curve & Trigger Work Pressure Trigger Flow Trigger

22

23 Flow-Volume Loop during Volume Control Ventilation

24

25 Common Clinical Problems Increased Impedance Compliance and Resistance Over distension Inadequate inspiratory flows Air leak Auto PEEP and I:E Ratio Setting Rise Time or Pressure Ramp Setting Expiratory Trigger Sensitivity (ETS)

26 Decreased Compliance during Volume Control Ventilation C=.05;R=5 C=.02;R=5

27 Decreased Compliance during Volume Control Ventilation C=.05;R=5; C=.02;R=5;

28 Decreased Compliance during Pressure Control Ventilation

29 Decreased Compliance during PRVC

30 Increased Resistance during Volume Control Ventilation C=.05;R=5 C=.05;R=20

31 Increased Resistance during Pressure Control Ventilation

32 Increased Resistance during PRVC

33 Increased Resistance C=.05;R=5 C=.05;R=20

34 Over Distention No patient effort

35 Air Leak

36 Inadequate Inspiratory Flow

37 Inadequate Inspiratory Flow

38 Auto PEEP 1:1 1.5:1 2:1

39 Auto PEEP Set rate -15 1:2 Total rate -22 1:1 Total rate -30 2:1

40 Setting Rise Time or Pressure Ramp PS- 15; Pramp 20 ms; Resistance- 20 RR- 20; Exhaled VT- 591 ml

41 Setting Rise Time or Pressure Ramp PS- 15; Pramp 50 ms; Resistance- 20 RR- 20; Exhaled VT- 580 ml

42 Setting Rise Time or Pressure Ramp PS- 15; Pramp 100 ms; resistance- 20 RR- 20; Exhaled VT- 597 ml

43 Setting Rise Time or Pressure Ramp PS- 15; Pramp 200 ms; Resistance- 20 RR- 20; Exhaled VT- 625 ml

44 Setting Expiratory Trigger Sensitivity PS- 15; Pramp 50 ms; ETS- 10% RR- 20; Exhaled VT- 700 ml

45 Setting Expiratory Trigger Sensitivity PS- 15; Pramp 50 ms; ETS- 25% RR- 20; Exhaled VT- 654 ml

46 Setting Expiratory Trigger Sensitivity PS- 15; Pramp 50 ms; ETS- 40% RR- 20; Exhaled VT- 604 ml

47 Avoid a Low ETS when Airway Resistance is High! PS- 15; Pramp 50 ms; ETS- 10%

48 Increase ETS 40%

49 Case: 38 Year Old Trauma Patient A male weighing 90 Kg (IBW) Obtunded, labored breathing 15 L/min O 2, SpO 2-85% Intubated and placed on an Avea Initial ventilator settings are Tidal volume 720 ml Rate- 12 PEEP- 10 FIO I-Time- 1.0 / Decelerating flow- 60 L/min

50

51

52

53 1. Which one of the following changes would you recommend?

54 A. Increase Flow B. Increase Rate C. Decrease Tidal Volume D. Decrease PEEP

55 A. Increase Flow B. Increase Rate C. Decrease Tidal Volume D. Decrease PEEP

56 Increase Peak Flow 70 L/min

57 Increase Peak Flow 80 L/min

58 Adjusting the Graphic Scales 70 L/min 80 L/min

59 SpO 2-92%, FIO2-.80, PEEP- 10 to 14

60 2. Which one of the following changes would you recommend?

61 A. Decrease Flow B. Decrease Rate C. Decrease Tidal Volume D. Decrease PEEP

62 A. Decrease Flow B. Decrease Rate C. Decrease Tidal Volume D. Decrease PEEP

63 Decreased Tidal Volume

64 Decreased Flow Increase I-Time

65 Turn on V-sync

66

67 Increase I-Time

68 Decreased Tidal Volume

69

70 3. Which one of the following best explains these changes?

71 A. Decrease in Airway Resistance B. Decrease in Compliance C. Increase in Airway Resistance D. Increase in Compliance

72 A. Decrease in Airway Resistance B. Decrease in Compliance C. Increase in Airway Resistance D. Increase in Compliance

73

74

75

76

77 3. Which of the following changes would you recommend?

78 A. Decrease in Time Low B. Decrease in Pressure High C. Increase in Pressure Low D. Increase in PSV

79 A. Decrease in Time Low B. Decrease in Pressure High C. Increase in Pressure Low D. Increase in PSV

80 Habashi. Crit Care Med, 2005;33(3):S228-S240

81 Habashi. Crit Care Med, 2005;33(3):S228-S240

82 Habashi. Crit Care Med, 2005;33(3):S228-S240

83

84

85 4. If his respiratory acidosis worsens, which one of the following changes would you recommend?

86 A. Increase in Pressure Low B. Increase in Pressure High C. Decrease in Time High D. Decrease in Time Low

87 A. Increase in Pressure Low B. Increase in Pressure High C. Decrease in Time High D. Decrease in Time Low

88

89 Conclusion It is important to be knowledgeable of the equipment you use and adapt it to the patient s pathophysiology.

90 Thank You RUSH UNIVERSITY MEDICAL CENTER

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