Ventilated pt.?????? I am physician /surgeon!!!!!

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Dr.Bhagyesh Shah
5/25/12

Intensivist,CIMS hospital.

My ventilated patient
Moni tor Regulate d Suction
O2 O2 Air Vac

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Ventilator

Resuscitator

Objectives of MV
l

Support pulmonary gas-exchange Reduce work of breathing Minimise lung injury

Ventilator
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Type-1 Type-2 Type-3 Type-4 hypox hypercapneic Periopera Shock emic respiratory tive respirafailure tory failure

Mechanism Etiology

QS/QT
Airspace flooding

VA

AtelectasisHypoperfusi on
1.Cardiogenic 2.Hypovolemi c 3.Septic

1.CNS drive 1.FRC 2N-M coupling 2.CV 3.Work/deadspac e

Clinical description
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1.ARDS 2.Cardiog enic pulmonar y edema 3.Pneumo

1.Overdose/CNS 1.supine/ob Myocardial injury ese/ascites, infarct peritonitis,a PE 2.Myasthenia bdominal gravis Sepsis incision 3.asthma/copd Bleed 2.age/smoki fibrosis,kyphoscol tamponade

Artificial ventilation

Invasive mechanical ventilation

Non-invasively

Pressure cycled 5/25/12

Volume cycled

Nasal prongs, masks, venturi devices, reservoir bags

Bilevel ventilation Continuous positive airway pressure

Common modes of Ventilation

Minimum rate & power for that rate: Machine

IMV

Additional rate & power for that rate: Patient

SPONTANEOUS

ASSISTED MODE

CONTROLLED ASSIST CONTROL MODE

Rate: Patient Power: Patient

Rate: Patient Power: Machine

SIMV
Minimum rate & power for that rate: Machine 5/25/12

Minimum rate: Machine Additional rate: Patient Power: Machine

Rate: Machine Power: Machine

Additional rate & power for that rate: Patient but synchronised Adapted from Prof. George

Goals of Monitoring in ventilated patient

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Ensure proper airway Ensure adequate oxygenation Ensure adequate ventilation Maintain hemodynamic stability Understanding respiratory mechanics Interpretation of

Ensure proper airway

Tube position, cut at, fixed at. (ET holder)

Clinical exam 5 point auscultation CxR EtCO2

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Cuff pressure Be alert to tube blockade, tube migration

Ensure adequate oxygenation

Clinical exam

Cyanosis Agitation Patient-ventilator asynchrony accessory muscles

Pulse oximetry ABG PO2, O2 saturation%

Remember tissue oxygenation depends on 5/25/12 cardiac output and Hb also

Basic Monitoring
Pulse Oximeter
Oxygenation

Arterial Blood Gas

Ventilation

Capnography
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Alarms
Pressure: High & Low inspiratory pressure Low PEEP Respiratory Rate: High & Low Tidal / Minute Volume: High & Low 5/25/12 Diagnose: High insp. press. High resp. rate Low Tidal volume

Asynchrony?

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Consider pharmacotherapy only if no cause has been found for the patient fighting ventilator (patient ventilator asynchrony) Pharmacotherapy Step1 Reassurance Step2 Provide pain relief

What is weaning?

It starts when clinician decides that patient may tolerate a reduction of mechanical support It includes methods used for

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a stepwise reduction in the level of support & readiness testing of

Value of Weaning Parameters

Most Weaning Indices predict weaning failure well but. do not predict successful weaning

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Weaning Trial
Brochard trial (AJRCCM 1994;150:896-903)

456 medical-surgical patients 76% passed SBT and were extubated Remaining 24% (109) randomised to T-piece trials increasing till 2 hrs tolerated SIMV with reduction of 2-4/min, twice a day PSV with reductions of 2-4 cm twice a day till 8 cm H2O tolerated PSV better than both SIMV and Tpiece (5.7+3.7 days vs 9.3+8.2 days)

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Weaning trials
Esteban trial (NEJM 1995;332:345-50)

546 medical-surgical patients 76% passed SBT and extubated 130 patients randomized to Once-a-day T-piece trial 2 or more T-piece or CPAP trials as tolerated PSV with reduction by 2-4cmH2O at least twice a day SIMV with reduction by 2-4 /min at least twice a day

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SIMV is the least effective technique Superiority of PSV or T-tube trials over one another not established Esteban trial had aggressive weaning rules produced faster weaning

Esteban or Brochard?

4-fold reintubation rate compared to Brochard

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Weaning protocols improve weaning (Ely et al. NEJM 1996;335:1864-69)

What are the final lessons?

Weanable patients should undergo a 30 minute T-piece trial (not in infants). [PS (7 cm H20) is acceptable] IMV should NOT be used in patients who

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Tracheostomy

When it becomes apparent that patient will require prolonged ventilator assistance Patients who benefit from early tracheotomy; those-

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Requiring high levels of sedation to tolerate ET tubes Marginal respiratory mechanics - in whom a tracheostomy tube having lower resistance reduce risk of muscle overload Psychological benefit from ability to eat orally, communicate by articulated speech, and experience enhanced

Tracheostomy: Timing
Early tracheostomy (1-7 days) may benefit patients expected to need prolonged ventilation Early tracheostomy: Does not affect survival Does not affect rates of VAP Reduces duration of ventilatory support Reduces duration of ICU stay But, prediction of need for prolonged (> 2 weeks) ventilation is still to be refined 5/25/12

Ventilator Care Bundle

Hand Hygiene Head up 45 degree Oral care with chlorhexidine mouthwash qds. Endotracheal tube with Subglotic suction,cuff pressure monitoring. Daily sedation vacation Early tracheostomy Early mobilization,kinetic bed,position change HME(change every 72 hrs or 5/25/12

HME

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Heated humidifier

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Feeding
Ryles tube feeding to be started as soon as the pt. can tolerate. Naso-jejunal tube is prefered if possible. Calorie and protein intake is to be optimised. Role of iv glutamine + or oral is established in cases of ARDS. Watch every 4 hrly for RTA. Parentral only in certain 5/25/12

Analgesia

Combine it with sedation if sedatives being used. Short acting iv/oral/transdermal preparations. Avoid NSAID in icu. Use synergy of PCM and Opioids.

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Sedation-paralytics
Know the difference between sedatives and paralytics. Never use paralytics alone. Try to avoid paralytics for long term to avoid icu induced myoneuropathy. Infusions are always better than short boluses. Daily sedation vacation is must. 5/25/12

Titrate sedation to effect; use objective scale Use a protocol for sedation

Ideally maintain sedation Level 3 5/25/12

In mech. ventilated pt. daily interuption of sedation decreases duration of mechanical ventilator and icu stay. In case of midazolam it reduces use of midazolam by almost half. Less pt. in daily wake up group required Neuro imaging to check mentation. Rate of complications same even when woken up. A trend towards mortality benefit seen but not statistically significant.
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Thromboprophylaxis

DVT prophylaxis is must. Mechanical Medical Combined

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PPI Sucralfate Frequent change of position Air bed Specialized dressing Chlorhexidine bath Head up most of the time
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Stress ulcer and pressure sore prophylaxis

Glycemic control

Target RBS 150-180 If abnormal correct with insulin Hypoglycemia must be avoided.

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Bowel-bladder care

Hourly monitoring of urine Daily bowel movt. to be ensured. Use of silicon catheter in long term pts. High threshold for use of antibiotic or antifungal.

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Daily drugs to be deescalated

Antibiotics Anti epileptics Sedatives Analgesics Supplements Antiplatelets/heparins

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rParalyze the patient to calm him down. rGet routine daily Chest X-rays rPut bicarbonate or other poisons down the ET tube rGive chest physiotherapy to mobilize secretions rChange ET or tracheostomy tubes routinely rChange reusable ventilator tubing > 48 hrs rChange single-use ventilator tubing at all & r DO NOT administer prophylactic antibiotics
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DO NOT do this to your patient

Feeding Analgesia Wish your Sedation patient FAST HUG BID Thromboprophylaxis Head up Ulcer prophylaxis Glycemic control Bowel and Bladder Invasive lines and tubes De-escalate

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Thank you

Dr.Bhagyesh Shah

(9099068938) CIMS Critical Care and Emergency Medicine Consultant

5/25/12 09/05/2012 Email-drbhagyeshshah@gmail.com