DON’T VACILLATE, VENTILATE

DR JUDITH KILLEN

WAGGA WAGGA RURAL REFERRAL HOSPITAL

DON’T VACILLATE, VENTILATE

DR JUDITH KILLEN

WAGGA WAGGA RURAL REFERRAL HOSPITAL

WHY WE HAVE INTENSIVE CARE

• Intensive nursing care

• Advanced ventilatory monitoring & support

• Advanced haemodynamic monitoring and support

• Emergency renal dialysis & haemofiltration

FAILURE OF EXTUBATION

• The decision to ventilate can be thought of as a prediction of failure of extubation

• We have expanding data bases of the size of the issue from closed claim sources, studies such as NAP4, and maternal mortality analyses

AWAKE, BREATHING, PAIN FREE

GENERAL PREOPERATIVE ASSESSMENT

• Nutrition (albumin, urea, white cell count red cell morphology)

• Pre-existing disease – COPD, CCF, liver failure, neurological disease

• Age

• Obesity, OSA

DOES THE PATIENT CONSENT TO POST OPERATIVE VENTILATION?

• Hard to ask once the patient is anaesthetised.

• May not be possible to ask

• Ask about existing forward directives

• Involve family if possible

FORWARD DIRECTIVE

IS THE UPPER AIRWAY PATENT?

• Allergy

• Infection – bacterial or viral eg epiglottitis, croup, quinsy

• Burns – thermal or chemical

• Neoplasm

• Trauma including spinal cord injury

• Swelling associated with the surgical procedure

STARTING FROM THE TOP

AN OBSTRUCTED UPPER AIRWAY

PRE EXISTING UPPER AIRWAY ISSUES

• Obesity

• Obstructive sleep apnoea

• Abnormal anatomy (treacher collins etc)

• Radiotherapy

• Rheumatoid

RADIATION THERAPY

THE GLOTTIS

• Laryngospasm

• Vocal cord paralysis

• Extrinsic compression

VOCAL CORD PARALYSIS

IS THE PATIENT ABLE TO PROTECT THEIR AIRWAY?

• Vocal cord paralysis

• Cough strength

• Secretions

• Bleeding

• Residual paralysis

HAEMATOMA ANTERIOR TO CERVICAL SPINE

CHEST TRAUMA

• Rib fractures

• Pneumothorax

• Haemothorax

• Lung contusion

CHEST WALL INTEGRITY

LUNG INTEGRITY

• Chronic lung disease

• Heart failure

• Infection

• Trauma

COPD / CCF

EMPHYSEMA

BAD COMBINATIONS

• Inadequate respiratory function and thoracic or subdiaphragmatic surgery

• Neck brace plus laparotomy

• Neurological disease plus surgery

IDENTIFIED RISK FACTORS FOR FAILED EXTUBATION

• Age

• Frailty

• Obesity

• OSA

• Delerium

• Haemodynamic instability

• CCF

?AN INCREASING OR DECREASING PROBLEM

EVACUATION

• Children

• Burns

• Spinal Injuries

• For treatments unavailable in your institution such as ECMO

NOT SUITABLE FOR REGIONAL ICU!

PACKAGE YOUR PATIENT

• It may be easier to put lines in in the OR

• What lines are needed?

THANKYOU! & GOODLUCK!