Interfacing With The Ventilator€¦ · Interfacing With The Ventilator David J. Dries, MSE, MD Assistant Medical Director Surgical Care HealthPartners Medical Group Professor of

Interfacing With The

Ventilator

David J. Dries, MSE, MD

Assistant Medical Director

Surgical Care

HealthPartners Medical Group

Professor of Surgery & Anesthesiology

John F. Perry, Jr. Chair of Trauma Surgery

University of Minnesota

Regions Hospital - St. Paul, MN

The airway opens the

door to the critical care

unit…

Mechanical ventilation is

the defining event in

critical care medicine.

Spontaneous

Breathing

Extracorporeal

Pulmonary

Support

Nasal O2

Rebreather

Mask

Non-Rebreather

Mask

Mask Ventilation

Intubation and Mechanical

Ventilation

BIPAP CPAP

Continuum of Pulmonary Support

Respiratory Failure

• Intrinsic

– ARDS / ALI

• Cardiovascular

• Toxins

• Intrinsic

– Asthma / COPD

• Cardiovascular

• Anatomic

– OSA

• Neurologic

• Metabolic

Hypoxic Hypercarbic

Indications for Oral Intubation

The Gold Standard

• Emergent intubation (cardiopulmonary resuscitation, unconsciousness or apnea)

• Nasal or midfacial trauma

• Basilar skull fracture

• Epiglottitis

• Nasal obstruction

• Paranasal disease

• Bleeding diathesis

• Need for bronchoscopy

In: Critical Care Medicine: The Essentials, Fourth Edition, 2010, pp 115

Indications for Nasal Intubation

The Old Standard

• Anticipated long-term translaryngeal tube

• Cervical spine ankylosis, arthritis or trauma

• Oral or mandibular trauma, surgery or deformity

• Temporomandibular joint disease

• Awake intubation

• Gagging and vomiting

• Short (bull) neck

• Agitation


How We Do It: Steps and Timing of Rapid Sequence Intubation in a 70 kg Adult

Step Timing Action

Preparation Zero – 10 min. Prepare equipment

Assess patient

Position personnel

Select drugs

Preoxygenation Zero – 5 min. Passive administration of high flow oxygen

via bag valve mask

Premedication Zero – 2 min. Lidocaine 100 mg IVP

Vecuronium 1.0 mg IVP

Etomidate 20 mg IVP

Paralysis Zero Succinylcholine 100 mg IVP

Placement Zero + 20 s

Zero + 45 s

Zero + 1 min.

Sellick’s maneuver

Intubation

Tube confirmation

In: Trauma, Six Edition, 2008, p.194

AIRWAY/REVIEW ARTICLE

Preoxygenation and Prevention of Desaturation During

Emergency Airway Management Scott D. Weingart, MD, Richard M. Levitan, MD

Ann Emerg Med 2012; 59:165-175

• 3 minutes / high FiO2

• CPAP / PEEP

• Head up

• Rocuronium vs Succinylcholine

• 8 minutes apnea

• Apnea – high flow O2

Ann Emerg Med 2012; 59:165-175

Oxyhemoglobin Dissocation Curve

Intubation

Physiologic Responses

• Heart rate

• Blood pressure

• Medications

– etomidate

– benzodiazepines

– ketamine

– propofol

Complications

• Local trauma

• Hypoxemia

• Aspiration

• Laryngospasm

• Bronchospasm

• Mainstem intubation

Indications for Supraglottic

Airways

Oral

• Removal of retropharyngeal secretions

• Maintain patency of orophryngeal airway

• Obtunded patient without gag

• Prevention of biting


In: Trauma, Sixth Edition, 2008, p.196-197

Indications for Supraglottic

Airways

Nasal

• Removal of supraglottic secretions

• Conscious or unconscious patient

• Need for repeated cannulation of trachea

• Limited value in preventing closure of the

retropharynx


NONINVASIVE POSITIVE-PRESSURE VENTILATION VS. MECHANICAL VENTILATINO IN ACUTE RESPIRATORY FAILURE

A COMPARISON OF NONINVASIVE POSITIVE-PRESSURE VENTILATION AND

CONVENTIONAL MECHANICAL VENTILATION IN PATIETNS WITH ACUTE

RESPIRATORY FAILURE

Massimo Antonelli, MD, Giorgio Contri, MD, Monica Rocco, MD, Maurizio Bufl, MD,

Roberto Alberto De Blasi, MD, Gabriella Vivino, MD, Alessandro Gasparetto, MD,

and Gianfranco Umberto Meduri, MD

N Engl J Med 1998; 339:429-435

NONINVASIVE POSITIVE-PRESSURE VENTILATION VS. MECHANICAL VENTILATINO IN ACUTE RESPIRATORY FAILURE

A COMPARISON OF NONINVASIVE POSITIVE-PRESSURE VENTILATION AND

CONVENTIONAL MECHANICAL VENTILATION IN PATIETNS WITH ACUTE

RESPIRATORY FAILURE

Massimo Antonelli, MD, Giorgio Contri, MD, Monica Rocco, MD, Maurizio Bufl, MD,

Roberto Alberto De Blasi, MD, Gabriella Vivino, MD, Alessandro Gasparetto, MD,

and Gianfranco Umberto Meduri, MD

N Engl J Med 1998; 339:429-435

Serious Complications

and Complications

Resulting in Death

Indications for Noninvasive

Ventilation

In: Evidence-Based Practice of Critical Care, 2010, p.23

Strength of

Recommendation

Indication for

Noninvasive Ventilation

Quality of

Evidence

Strong COPD exacerbations A

Acute cardiogenic pulmonary edema A

Immunocompromised states A

Facilitating extubation in COPD A

A = multiple randomized controlled trials showing benefit with NIV.


Ventilation


Strength of

Recommendation

Indication for


Quality of

Evidence

Intermediate Postoperative respiratory failure B

Preoxygenation in hypoxemic respiratory

failure

B

Facilitation of flexible bronchoscopy B

Palliation in DNR/DNI patients B

Postextubation respiratory failure B

B = single randomized trial or nonrandomized trails showing benefit with NIV.


Ventilation


Strength of

Recommendation

Indication for


Quality of

Evidence

Weak ALI / ARDS C

Neuromuscular disease C

Pneumonia C

Status asthmaticus C

C = conflicting evidence or evidence of harm with NIV.

Desirable Characteristics of a

Mask for Noninvasive Ventilation

• Low dead space

• Transparent

• Lightweight

• Easy to secure

• Adequate seal with low facial pressure

• Disposable or easy to clean

• Nonirritating to skin (nonallergenic)

• Inexpensive

Potential Advantages and Disadvantages to

Nasal vs Oronasal Masks

Oronasal

Advantages Disadvantages

Better oral leak control Increased dead space

Use for mouth breathers Difficult to maintain adequate seal

Risk of nasal and facial pressure sores

Claustrophobia

Increased aspiration risk

Increased difficulty speaking and eating

Asphyxiation with ventilator malfunction

More difficult to fit

Potential Advantages and Disadvantages to

Nasal vs Oronasal Masks

Nasal

Advantages Disadvantages

Less risk of aspiration Mouth leak

Easier secretion clearance Higher resistance through nasal passages

Less claustrophobia Less effective with nasal obstruction

Easier speech Nasal irritation and rhinorrhea

May be able to eat Mouth dryness

Easy to fit and secure Nasal bridge redness and ulceration

Less dead space

Problems Related to Masks During

NPPV

Oronasal Masks

Problem Incidence Remedy Mask discomfort 30-50% Minimize strap tension,

try different mask sizes,

or types

Claustrophobia 10-20% Reassure, switch to

different mask type

Skin rashes, nasal bridge 10-20% Same as for nasal mask

sores

Increased dead space depends on mask Insert foam rubber to

reduce dead space

Antiasphyxia valve

Aspiration/vomiting rare Quick release strap

Problems Related to Masks During

NPPV

Nasal Masks

Problem Incidence Remedy Mask discomfort 30-50% Adjust strap tension, reseat

mask, try different mask

size or type

Skin rashes 10-20% Topical steroids or

clindamycin, dermatologic

consultation

Nasal bridge sores 5-10% Minimize strap tension, use

forehead spacer, artificial

skin, switch to different

mask type

Nasal obstruction occasional Topical decongestants,

oronasal mask

Problems Related to Air Pressure and

Flow

Pressure

Problem Incidence Remedy Discomfort 20-50% Reduce inspiratory

pressure

Ear, sinus pain 10-20% Reduce inspiratory

pressure

Gastric insufflation 30-40% Reduce pressure,

simethacone, gastric suction

if ventilation impaired

Pneumothorax rare Avoid excessive inflation

pressures, consider

thoracostomy tube drainage

Problems Related to Air Pressure and

Flow

Flow

Problem Incidence Remedy Nasal/oral congestion 50% Topical steroids,

decongestants,

antihistamine/decongestant

combinations

Nasal/oral dryness 30-50% Nasal saline,

humidification, control of

air leaks

Eye irritation 33% Reduce air leakage, eye

emollients, try adjusting

strap tension, different

mask

Major Complications

Problem Occurrence Remedy Aspiration 5% Careful patient selection,

gastric drainage when

appropriate

Mucus plugging infrequent Careful patient selection,

adequate rehydration,

cough assistance,

respiratory treatments

Severe hypoxemia ** Proper patient selection,

high flow O2, increased

expiratory pressure

Hypotension infrequent Proper patient selection,

adequate hydration, lower

inspiratory pressures **Depends on etiology of respiratory failure.

Contraindications to Noninvasive

Ventilation

• Cardiopulmonary arrest, shock

• Uncontrolled cardiac ischemia or arrhythmias

• Uncooperative or agitated

• Severe upper gastrointestinal hemorrhage

• Coma, nonhypercapnic

• High aspiration risk, vomiting

• Copious secretions

• Upper airway obstruction

• Severe bulbar dysfunction

• Recent esophageal or upper airway surgery

• Multiorgan dysfunction

• Inability to fit mask due to craniofacial abnormalities


Risk Factors for Failure of


• pH <7.25

• Respiratory rate >35

• APACHE II score >29

• ALI / ARDS

• Pneumonia

• Severe hypoxemia

• Shock

• Metabolic acidosis

• Impaired mental

status


Predictors of Difficult Intubation

• Invisibility of faucial pillars, soft palate, uvula

• Mentohyoid distance less than three finger breadths

• Restricted temporomandibular joint excursion

• Restricted excursion of atlanto-occipital joint


In: Critical Care Study Guide: Text and Review, Second Edition, 2010, p.14

Mental Portion

Thyroid

Cartilage

Distance from mental portion of mandible to

the thyroid cartilage notch is known as

“thyromental distance”

Mallampati Structures Visible

Class I Class I soft palate, fauces, uvula, pillars

Class II Class II soft palate, fauces, uvula

Class III soft palate, base of uvula

Class III Class IV hard palate, soft palate not visible

Class I Class II Class III Class IV

Aids and Precautions for

Difficult Intubation

• Optimal positioning

• Availability of: – gum elastic bougies

– tracheal tubes of various sizes

– tube introducers

– varied types and sizes of laryngoscope blade

– lighted stylet

– LMA and cricothyroidotomy kit

• BURP maneuver


Distinguishing Tracheal From

Esophageal Intubation

• Conventional

– symmetrical breath sounds

– visualization of vocal cords during insertion

– ease of insufflation and recovery of tidal volume

– expiratory fogging of ET tube

– palpation of larynx

– loss of voice

– coughing of airway secretions through tube

– upper chest expansion

– absence of progressive abdominal distention


Distinguishing Tracheal From

Esophageal Intubation

• Devices and aids

– CO2 excretion color detector

– capnometry

– tidal gas recovery

– squeeze bulb syringe


CHEST Postgraduate Education Corner

CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE

Technologic Advances in Endotracheal Tube for

Prevention of Ventilator-Associated Pneumonia

Juan F., Fernandez, MD; Stephanie M. Levine, MD, FCCP; and Marcos I. Rastrepo, MD, FCCP

The two most important mechanisms implicated in

the development of VAP are microaspiration and

biofilm formation.

Chest 2012; 142:231-238

• Microaspiration

– cuff pressure control

– ultrathin cuffs

• 7 μm vs >50 μm

– channel formation

– subglottic secretion drainage

Chest 2012; 142:231-238






• Subglottic secretion drainage

– VAP rate ↓ 50%

– +/- decrease ICU LOSA

– no change mortality

– mechanical integrity

– continuous vs intermittent suction

Chest 2012; 142:231-238






Continuous Aspiration of Subglottic Secretions in

Preventing Ventilator-Associated Pneumonia Jordi Vallés, MD; Antonio Artigas, MD; Jordi Rello, MD; Natalia Bonsoms, MD;

Dionisia Fontanals, PharmD; Lluis Blanch, MD; Rafael Fernández, MD; Francisco Baigorri, MD;

and Jaume Mestre, MD

Ann Intern Med 1995; 122:179-186

Diagram of continuous aspiration

of subglottic secretions.

http://www.annals.org/content/122/3/179/F1.large.jpg

Ann Intern Med 1995; 122:179-186

Proportion of Patients Remaining Without VAP

• Biofilm formation

– colonization within hours

– biofilm protective treatment

• antimicrobial coating

• silver

Chest 2012; 142:231-238






• Silver-coated tubes

– >1,500 patients studied

– VAP: silver : 4.8%; control : 7.5%

– delayed onset VAP

Chest 2012; 142:231-238






Silver-Coated Endotracheal Tubes and Incidence of

Ventilator-Associated Pneumonia

The NASCENT Randomized Trial

CARING FOR THE CRITICALLY

ILL PATIENT

Marin H. Kollef, MD

Bekele Afessa, MD Antonio

Anzueto, MD Christopher

Veremakis, MD Kim M.

Kerr, MD Benjamin D.

Margolis, MD Donald E.

Craven, MD Pamela R.

Roberts, MD Alejandro C.

Arroliga, MD Rolf D.

Hubmayr, MD Marcos I.

Restrepo, MD William R.

Auger, MD Regina

Schinner, Dipl-Stat For the

NASCENT Investigation

Group

JAMA 2008; 300:805-813

Silver-Coated Endotracheal Tubes and Incidence of

Ventilator-Associated Pneumonia

The NASCENT Randomized Trial


ILL PATIENT

Marin H. Kollef, MD

Bekele Afessa, MD Antonio

Anzueto, MD Christopher

Veremakis, MD Kim M.

Kerr, MD Benjamin D.

Margolis, MD Donald E.

Craven, MD Pamela R.

Roberts, MD Alejandro C.

Arroliga, MD Rolf D.

Hubmayr, MD Marcos I.

Restrepo, MD William R.

Auger, MD Regina

Schinner, Dipl-Stat For the

NASCENT Investigation

Group

JAMA 2008; 300:805-813

Incidence of Microbilogically Confirmed VAP

• Biofilm removal

– mucus shaver

– chlorhexidine

– gentian violet combinations

Chest 2012; 142:231-238






Acta oto-rhino-laryngologica bel., 1995, 49, 341-346

Prevention of postintubation laryngotracheal stenosis P. Ferdinande* and Dong-Ok Kim**

*Professor Department of Intensive Care Medicine, University Hospital, K.U. Leuven, Belgium;

**Assistant Professor of the Department of Anesthesiology, Kyung Hee University Hosiptal, Seoul, Korea

1. Pressure necrosis by overinflated endotracheal tube cuff

2. Endotracheal tube and cuff material, size and design

3. Duration of endotracheal intubation

4. Macrotrauma during insertion and microtrauma during maintenance

5. Technique of tracheal intubation

6. Severity of respiratory failure

7. Infection

8. Hemodynamic instability

CHEST Special Features

The Incidence of Dysphagia Following

Endotracheal Intubation

A Systematic Review

Stacey A. Skoretz, MSc; Heather L. Flowers, Med, MHSc;

and Rosemary Martino, MA, PhD

• 3-62%

• Prolonged intubation

• Effect of age

• Poor quality data

Chest 2010; 137:665-673

Translaryngeal Intubation versus Tracheostomy

Advantages

Translaryngeal Intubation Tracheostomy

Ease of placement Comfort

Inexpensive Ease of mouth care

Fewer severe complications Secretion removal

No specialized venue needed for insertion Stability

Less airway resistance

Improved communication

Ease of swallowing and enteral feeding

Reduced work of breathing

Improved mobility

Ease of reinsertion and ventilator

reconnection


Translaryngeal Intubation Tracheostomy

Discomfort Expense

Swallowing Severity of complications

Secretion clearance Swallowing impairment

Greater work of breathing Reduced cough efficiency postdecannulation

Impaired speech

Upper airway and larynx damage

Translaryngeal Intubation versus Tracheostomy

Disadvantages


ORIGINAL ARTICLE

Early Tracheostomy in Intensive Care Unit: A Retrospective Study

of 506 Cases of Video-Guided Ciaglia Blue Rhino Tracheostomies

Giovanni Zagli, MD, PhD, Manuel Linden, MD, Rosario Spina, MD, Maneula Bonizzoli, MD,

Giovanni Cianchi, MD, Valentina Anichini, MD, Stefania Matano, MD,

Silvia Benemei, MD, Paola Nicoletti, MD, and Adriano Peris, MD

Kaplan-Meier curves of duration of MV days Kaplan-Meier curves of LOS days in the ICU

J Trauma 2010; 68:367-372

Duration of

MV

ICU LOS

clinical investigations in critical care

A Meta-analysis of Prospective Trials

Comparing Percutaneous and Surgical

Tracheostomy in Critically Ill Patients Bradley D. Freeman, MD; Karen Isabella, RN; Natatia Lin, BS; and Timothy G. Buchman, PhD, MD

Chest 2000; 118:1412-1418

ORs with 95% CIs

(represented by arrowheads and horizontal bars,

respectively) for operative and postoperative complications comparing SCT and PDT.

The effect of tracheostomy timing during critical illness on

long-term survival

Damon C. Scales, MD, PhD, FRCPC; Deva Thiruchelvam, MSc: Alexander Kiss, PhD; Donald

A. Redelmeier, MD, MSHSR, FRCPC, FACP

Crit Care Med 2008; 36:2547-2557

• 10 day threshold

• 10,927 patients

• Early tracheostomy – less mortality

– 1.008 x/day mortality

Survival of tracheostomized patients after initiation

of mechanical ventilation

Crit Care Med 2008; 36:2547-2557

The effect of tracheostomy timing during critical illness on

long-term survival

Damon C. Scales, MD, PhD, FRCPC; Deva Thiruchelvam, MSc: Alexander Kiss, PhD; Donald

A. Redelmeier, MD, MSHSR, FRCPC, FACP

Time from mechanical ventilation (day 1)

to death (months)

Time from mechanical ventilation (day 1)

to death (months)

Early vs Late Tracheotomy for Prevention of

Pneumonia in Mechanically Ventilated Adult

ICU Patients A Randomized Controlled Trial


ILL PATIENT

Pier Paolo Terragni, MD

Massimo Antonelli, MD

Roberto Fumagalli, MD

Chiara Faggiano, MD

Mauizio Berardino, MD

Franco Bobbio Pallavicini, MD

Antonio Miletto, MD

Salvatore Magione, MD

Angelo U. Sinardi, MD

Mauro Pastorelli, MD

Nicoletta Vivaldi, MD

Alberto Pasetto, MD

Giorgio Della Rocca, MD

Rosario Urbino, MD

Claudia Filippini, PhD

Eva Pagano, PhD

Andrea Evangelista, PhD

Gianni Ciocone, MD

Luciana Mascia, MD, PhD

V. Marco Ranieri, MD JAMA 2010; 303:1483-1489

Development of VAP

according to whether

patients received an

early or late

tracheotomy

Cricothyroidotomy

• Technique

– landmarks

• thyroid / cricoid cartilage

• 2 cm below cords

– open approach

• vertical incision

• transverse opening (membrane)

– percutaneous

The Bottom Line…

• Mechanical ventilation defines critical care

• Airway choices reflect disease process and

affect outcomes

• Multitude of new technologies have

changed practice patterns and will

continue to change practice patterns

Source Complication SCT PDT

Friedman, et al. Parathracheal insertion 0 4

Transient hypotension 11 15

Transient hypoxia 11 0

Subcutaneous emphysema 4 0

Minor bleeding (25-100 mL) 11 13

Loss of airway (>20 s) 4 0

Other 0 4

Holdgaard, et al. Minor bleeding 80 20

Major bleeding 7 0

Cuff puncture 0 17

Resistance to insertion 0 27

Porter and Loss of airway/death 0 8

Ivatury Hypoxia 8 25

Hypotension 0 0

Blood loss >100 mL 0 0

Chest 2000; 118:1412-1418

Description and

Frequencies of

Operative

Complications

Crit Care Med 2008; 36:2547-2557

Relative reduction in risk

of death at 90 days.

Relative risk of death for

patients receiving early

tracheostomy compared to

patients receiving late

tracheostomy.

Documents

Interfacing With The Ventilator€¦ · Interfacing With The Ventilator David J. Dries, MSE, MD Assistant Medical Director Surgical Care HealthPartners Medical Group Professor of