CPAP  Boussignac  peri  extuba4on!  

Mulier  J  P.  AZ  Sint-­‐Jan  Brugge-­‐Oostende  AV,    Belgium  32  nd  int  symp  Intensive  Care  and  Emergency  Med.  

 Silver  Hall    17:30  

1 32 int symp Int Care Emerg Med 2012

Gastric tube and stomach aspiration before extubation

to prevent post extubation aspiration

Treat if new red blood detected Empty stomach pouch and oral cavity to prevent post

extubation aspiration

CPAP for the obese J P Mulier 27 6 2011

A deLeon Acta Anesth Scand 2010 Body position and esophageal sphincter pressures in obese patients during anesthesia

Laying flat higher risk of aspiration

Barrier pressure (between stomach and pharynx) before and during anesthesia decreased to same level in all positions:

3 IFSO Hamburg 2011 Anaesthesia induction

Pharynx dysfunction increases the aspiration risk be sure to be fully decurarised

0 50

100 150

Control TOF 0.6 TOF 0.7 TOF 0.8 TOF 0.9

Upper oesophagal Sfincter resting tone

(mm Hg)

Neuromusculair block Eriksson LI et al Anesthesiology 1997; 87: 1035

Partial NMB Volunteers No sedation

CPAP for the obese J P Mulier 27 6 2011

Prevention  of  Atelectasis  in  Morbidly  Obese  Patients  during  General  Anesthesia  and  Paralysis:  PEEP  and  LRM  

Reinius et al. Anesthesiology 2009

Extubation same problem

  Use positive pressure, CPAP during extubation and recruit after extubation with a mask.

  No suctioning while extubating

  If you need to clear the airways before extubation do it under high flow CPAP, small tube size, short intermittent time

32 int symp Int Care Emerg Med 2012 7

Tracheal pressures during aspiration

CPAP for the obese J P Mulier 27 6 2011

closed ventilation

6 6,5 7 7,5 8 8,5 Closed aspiration no peep

blue 8 Ch -8 -6 -7 black 10 Ch -22 -18 -17 whit 12 Ch -48 -24 -20 green 14 Ch -144 -36 -25 orange 16 Ch -350 -59 -32

ETT open to air 6 6,5 7 7,5 8 8,5 Open

aspiration blue 8 Ch -1 -0,5 0 0 0 0 safe black 10 Ch -4 -3 -2 -1 -0,5 -0,5 dangerous whit 12 Ch -24 -11 -6 -4 -3 -2 not done? green 14 Ch -99 -32 -17 -11 -6 -4 orange 16 Ch -300 -90 -38 -23 -13 -8

CPAP 10 Vygon 6 6,5 7 7,5 8 8,5 CPAP 10 blue 8 Ch 8 9 10 10 10 10 black 10 Ch 4 6 7 8 9 9 whit 12 Ch -16 -2 2 4 6 7 green 14 Ch -86 -26 -10 -2 2 4 orange 16 Ch -300 -90 -30 -14 -3 1

ETT size 6 – 8,5

CPAP – PEEP always

From before intubation till after extubation

Keeps the lungs open

LRM lung Recruitment Maneuver when

Low sat, Loss of peep

Re-open the lungs

IFSO Hamburg 2011 Anaesthesia induction 9

But you not always have an intensive care ventilator with CPAP

  In the PACU, Older ventilators on ICU

  In the operating room even pressure support ventilators have no CPAP in spontaneous breathing mode (except ZEUS)

  No CPAP at induction and manual ventilation

  No CPAP at extubation

  No cpap after extubation

  Use of Boussignac mask is not possible during induction

32 int symp Int Care Emerg Med 2012 10

New: boussignac CPAP connected to ventilator through one way valve and T piece

32 int symp Int Care Emerg Med 2012 11

APL peep Boussignac CPAP

32 int symp Int Care Emerg Med 2012 12

Peep set at 10 cmH20 with APL only Fresh gas flow never sufficient

Peep set at 10 cmH20 with APL and Boussignac

32 int symp Int Care Emerg Med 2012 13

0

2

4

6

8

10

12

0 10 20 30 40 50 60 70

Boussignac 5 CPAP Vygon valve

Boussignac 5 CPAP Intersurgical valve

Boussignac10 CPAP Vygon valve

Boussignac 10 CPAP Intersurgical valve

Conclusion 1.  Change every ventilator to a CPAP ventilator with a

Boussignac CPAP air amplifier.

1.  Simple easy and cheap and also usefull for intensive care

2.  Keep CPAP and PEEP during induction of anesthesia

3.  Keep CPAP and PEEP during extubation and after extubation

4.  During laparoscopy just peep to keep lungs open? How much?

32 int symp Int Care Emerg Med 2012 15

How much PEEP needed during Pneumoperitoneum ?   PEEP 5 tot 10 maximum 15 cmH20 during ventilation of

normal lungs.

  Pneumoperitoneum 10 to 15 max 20 mmHg

  You need 14 to 19 max 26 cmH20 to equal pressures and 5 more to expand the lungs and avoid atelectasis?

  This is never done. Sometimes no PEEP is even used without saturation change but having atelectasis.

32 int symp Int Care Emerg Med 2012 16

EIT could help us to see atelectasis during laparoscopy?

Too high Right place?

32 int symp Int Care Emerg Med 2012 17

PEEP vs Pneumoperitoneum !

Peep 0 5 10 15 cmH20 before pneumoperitoneum

PEEP 5 cmH20 Pneumoperitoneum 0 5 10 15 mmHg

Morbid obese patients with WHR < 1, pear shaped body

JPM 18 05 2010 Anesthesie voor bariatrische heelk 18

Pneumoperitoneum can be handled with normal, PEEP ranges