Ventilator Management In Different Disease Entities

Ventilator ManagementVentilator Managementin Different Disease Entitiesin Different Disease Entities

Mechanical VentilationMechanical Ventilation

Use of sophisticated life support Use of sophisticated life support technology aimed at maintaining tissue technology aimed at maintaining tissue oxygenation and removal of carbon oxygenation and removal of carbon dioxidedioxide

Support or replace the normal ventilatory Support or replace the normal ventilatory pump in moving air into and out of the pump in moving air into and out of the lungs – inadequate or absent spontaneous lungs – inadequate or absent spontaneous breathingbreathing

Mechanical VentilationMechanical Ventilation

Not without risk – complications and Not without risk – complications and hazards an be life threateninghazards an be life threatening

Decision to initiate mechanical ventilationDecision to initiate mechanical ventilationSerious oneSerious oneSound clinical judgmentSound clinical judgmentClear understanding of the indications and Clear understanding of the indications and

associated goalsassociated goals

Indications for Mechanical Indications for Mechanical Ventilatory SupportVentilatory Support

Respiratory failure Respiratory failure An inability of the heart and lungs to provide An inability of the heart and lungs to provide

adequate tissue oxygenation or removal of adequate tissue oxygenation or removal of carbon dioxidecarbon dioxide

Acute respiratory failureAcute respiratory failurePaO2 < 60 mm HgPaO2 < 60 mm HgSpO2 < 90% SpO2 < 90% With or without PaCO2 > 45 mm HgWith or without PaCO2 > 45 mm Hg

Acute Respiratory FailureAcute Respiratory Failure

Hypoxemic respiratory failure – lung failureHypoxemic respiratory failure – lung failureHypercapnic respiratory failure – pump Hypercapnic respiratory failure – pump

failurefailureAcute ventilatory failureAcute ventilatory failure

A sudden increase in PaCO2 with a corresponding A sudden increase in PaCO2 with a corresponding decrease in pHdecrease in pH

Chronic ventilatory failureChronic ventilatory failureElevated PaCO2 with a normal or near normal pHElevated PaCO2 with a normal or near normal pH

Initial Ventilator SetupInitial Ventilator SetupKey DecisionsKey Decisions

Indications for ventilatory support presentIndications for ventilatory support present Negative pressure versus positive pressure ventilationNegative pressure versus positive pressure ventilation Non-invasive versus invasive positive pressure ventilationNon-invasive versus invasive positive pressure ventilation Type and method of establishment of an airwayType and method of establishment of an airway Pressure versus volume ventilationPressure versus volume ventilation Partial or full ventilatory supportPartial or full ventilatory support Choice of ventilatorChoice of ventilator Mode of ventilationMode of ventilation

Assist-control ventilation versus SIMV (with or without pressure Assist-control ventilation versus SIMV (with or without pressure support)support)

Pressure supportPressure support Pressure controlPressure control Mixed or dual control modesMixed or dual control modes Other newer modes of adjunctsOther newer modes of adjuncts

Indications for Mechanical Indications for Mechanical Ventilation in ARDS Ventilation in ARDS

HypoxemiaHypoxemiaApplication of PEEPApplication of PEEPDelivery of high FiO2Delivery of high FiO2

Increased work of breathingIncreased work of breathingUse of ventilator to reduce work of breathingUse of ventilator to reduce work of breathing

Impending or acute ventilatory failureImpending or acute ventilatory failureMaintenance of normal pH and/or PaCO2Maintenance of normal pH and/or PaCO2

Ventilator Settings for ALI or ARDSVentilator Settings for ALI or ARDSARDSnet ApproachARDSnet Approach

Maintaining a low tidal volume Maintaining a low tidal volume

Monitoring plateau pressureMonitoring plateau pressure

Setting PEEP based on the FiO2 Setting PEEP based on the FiO2

requirementrequirement

Lower Tidal Volume Ventilation StrategyLower Tidal Volume Ventilation StrategyNIH ARDS NetworkNIH ARDS Network

Calculate predicted body weightCalculate predicted body weight Male :Male :

PBW (kg) = 50 ± 2.3 [(height in inches)-60] PBW (kg) = 50 ± 2.3 [(height in inches)-60] = 50 ± 0.91[(height in cm) –152.4]= 50 ± 0.91[(height in cm) –152.4]

Female : Female : PBW (kg) = 45.5 ± 2.3 [(height in inches)-60] PBW (kg) = 45.5 ± 2.3 [(height in inches)-60] = 45.5 ± 0.91[(height in cm) –152.4]= 45.5 ± 0.91[(height in cm) –152.4]

Ventilator mode : Volume assist/control Ventilator mode : Volume assist/control until weaninguntil weaning


Tidal Volume(Vt)Tidal Volume(Vt) Initial Vt : adjust Vt in steps of 1 ml/kg PBW Initial Vt : adjust Vt in steps of 1 ml/kg PBW

every 1-2 hours until Vt = 6 ml/kgevery 1-2 hours until Vt = 6 ml/kg Measure inspiratory plateau pressure (Pplat; Measure inspiratory plateau pressure (Pplat;

0.5 second inspiratory pause) every 4 hours 0.5 second inspiratory pause) every 4 hours and after each change in PEEP or Vtand after each change in PEEP or Vt

If Pplat > 30 cm H2O, decrease Vt to 5 or 4 If Pplat > 30 cm H2O, decrease Vt to 5 or 4 ml/kgml/kg

If Pplat < 25 cm H2O, and Vt,6ml/kg, increase If Pplat < 25 cm H2O, and Vt,6ml/kg, increase Vt by 1 ml/kg PBWVt by 1 ml/kg PBW


Respiratory Rate (RR)Respiratory Rate (RR)With initial change in Vt, adjust RR to With initial change in Vt, adjust RR to

maintain minute ventilationmaintain minute ventilationMake subsequent adjustments to RR to Make subsequent adjustments to RR to

maintain pH 7.30-7.45, but do not maintain pH 7.30-7.45, but do not exceed RR = 35/min and do not increase exceed RR = 35/min and do not increase set rate if PaCO2 <25 mm Hgset rate if PaCO2 <25 mm Hg

I:E ratio : Acceptable range = 1:1 – I:E ratio : Acceptable range = 1:1 – 1:3 (no inverse ratio)1:3 (no inverse ratio)


FiO2, PEEP and arterial oxygenation: Maintain PaO2 55-FiO2, PEEP and arterial oxygenation: Maintain PaO2 55-80 mm Hg or SpO2 88%-95%80 mm Hg or SpO2 88%-95%

Use only the following PEEP/FiO2 combinations:Use only the following PEEP/FiO2 combinations: FiO2 PEEP (cm H2O)FiO2 PEEP (cm H2O) 0.3-0.4 50.3-0.4 5 0.4 80.4 8 0.5 8-100.5 8-10 0.6 100.6 10 0.7 10-140.7 10-14 0.8 140.8 14 0.9 16-180.9 16-18 1 18-251 18-25


Acidosis managementAcidosis management If pH<7.30, increase RR until pH>1 7.30 or ≧If pH<7.30, increase RR until pH>1 7.30 or ≧

RR=35/minRR=35/min If pH remains <7.30 with RR = 35, consider If pH remains <7.30 with RR = 35, consider

bicarbonate infusionbicarbonate infusion If pH <7.15, Vt may be increased (Pplat may If pH <7.15, Vt may be increased (Pplat may

exceed 30 cm H2O)exceed 30 cm H2O) Alkalosis managementAlkalosis management

If pH > 7.45 and patient not triggering If pH > 7.45 and patient not triggering ventilator, decrease set RR but not below ventilator, decrease set RR but not below 6/min6/min


WeaningWeaning Initiate weaning by pressure support when all Initiate weaning by pressure support when all

of the following criteria are present:of the following criteria are present:FiO2 <0.4 and PEEP<8cm H2OFiO2 <0.4 and PEEP<8cm H2ONot receiving neuromuscular blocking agentsNot receiving neuromuscular blocking agentsInspiratory efforts are apparent (ventilator rate may Inspiratory efforts are apparent (ventilator rate may

be decreased to 50%of baseline level for up to 5 be decreased to 50%of baseline level for up to 5 minutes to detect inspiratory effort)minutes to detect inspiratory effort)

Systolic arterial pressure > 90 mm Hg without Systolic arterial pressure > 90 mm Hg without vasopressor supportvasopressor support

Traditional Tidal Volume Traditional Tidal Volume NIH ARDS NetworkNIH ARDS Network

Volume assist controlVolume assist control Tidal Volume(Vt) : 12 ml/kg predicted Tidal Volume(Vt) : 12 ml/kg predicted

body weightbody weight Plateau pressure : < 50 cm H2OPlateau pressure : < 50 cm H2O Ventilator rate setting needed to achieve Ventilator rate setting needed to achieve

a pH goal of 7.3-7.45 : 6-35 breath/mina pH goal of 7.3-7.45 : 6-35 breath/min I;E ratio : 1:1 – 1:3I;E ratio : 1:1 – 1:3

Patients Excluded in Patients Excluded in NIH ARDS Network StudyNIH ARDS Network Study

36 hours had elapsed since they met the first 36 hours had elapsed since they met the first three criteriathree criteria

Younger than 18 years of ageYounger than 18 years of age Participated in other trials within 30 days before Participated in other trials within 30 days before

the three criteria were metthe three criteria were met PregnantPregnant Neuromuscular disease that impair spontaneous Neuromuscular disease that impair spontaneous

breathingbreathing Sickle cell diseaseSickle cell disease Severe chronic respiratory diseaseSevere chronic respiratory disease

Patients Excluded in Patients Excluded in NIH ARDS Network StudyNIH ARDS Network Study

Weighed more than 1 kg per centimeter of Weighed more than 1 kg per centimeter of heightheight

Burns over more than 30 percent of their BSABurns over more than 30 percent of their BSA Other conditions with an estimated 6-month Other conditions with an estimated 6-month

mortality rate > 50%mortality rate > 50% Undergone bone marrow or lung transplantationUndergone bone marrow or lung transplantation Chronic liver disease (as defined by Child-Pugh Chronic liver disease (as defined by Child-Pugh

class C)class C) Their attending physician refused or unwilling to Their attending physician refused or unwilling to

dull life supportdull life support

Respiratory Values during the First 7 Respiratory Values during the First 7 days in NIH ARDS Network Studydays in NIH ARDS Network Study

Variable Day 1 Day 3 Day 7Variable Day 1 Day 3 Day 7

LVT TVT LVT TVT LVT TVTLVT TVT LVT TVT LVT TVT

Tidal volume 6.2±0.9 11.8±0.8 6.2±1.1 11.8±0.8 6.5±1.4 11.4±1.4Tidal volume 6.2±0.9 11.8±0.8 6.2±1.1 11.8±0.8 6.5±1.4 11.4±1.4

Plateau pressure 25±7 33±9 26±7 34±9 26±7 37±9Plateau pressure 25±7 33±9 26±7 34±9 26±7 37±9

Peak insp pressure 32±8 39±10 33±9 40±10 33±9 44±10Peak insp pressure 32±8 39±10 33±9 40±10 33±9 44±10

Mean aw pressure 17±13 17±12 17±14 19±17 17±14 20±10Mean aw pressure 17±13 17±12 17±14 19±17 17±14 20±10

RR 29±7 16±6 30±7 17±7 30±7 20±7RR 29±7 16±6 30±7 17±7 30±7 20±7

Minute ventilation 12.9±3.6 12.6±4.5 13.4±3.5 13.4±4.8 13.7±3.8 14.9±5.3Minute ventilation 12.9±3.6 12.6±4.5 13.4±3.5 13.4±4.8 13.7±3.8 14.9±5.3

PEEP 9.4±3.6 8.6±3.6 9.2±3.6 8.6±4.2 8.1±3.4 9.1±4.2PEEP 9.4±3.6 8.6±3.6 9.2±3.6 8.6±4.2 8.1±3.4 9.1±4.2

Main Outcome Variables inMain Outcome Variables inNIH ARDS Network NIH ARDS Network

Lower VT Traditional VT P ValueLower VT Traditional VT P ValueDeath before discharge home 31.0 39.8 0.007Death before discharge home 31.0 39.8 0.007 and breathing without and breathing without assistance (%)assistance (%)Weaning by day 28 (%) 65.7 55.0 <0.001Weaning by day 28 (%) 65.7 55.0 <0.001No. of ventilator-free days, 12 ± 11 10 ± 11 0.007No. of ventilator-free days, 12 ± 11 10 ± 11 0.007 days 1 to 28days 1 to 28Barotrauma, days 1 to 28 (%) 10 11 0.43Barotrauma, days 1 to 28 (%) 10 11 0.43No. of days without failure 15 ± 11 12 ± 11 0.006No. of days without failure 15 ± 11 12 ± 11 0.006 of non-pulmonary organsof non-pulmonary organs or systems, days 1 to 28or systems, days 1 to 28

Clinical Trials of Traditional Versus Lower Tidal Volume VentilationStrategies in Acute Lung Injury and Acute Respiratory Distress Syndrome

Number of Tidal Volumes Tidal Volumes Mortality Patients as Reported per kg PBW (%) Randomized T L T L T L Stewart et al 120 10.8+ 7.2+ 12.2 8.1 47 50

Brochard et al 116 10.3 7.1 11.3 7.8 38 47

Brower et al 52 10.2 7.3 10.2 7.3 46 50

ARDS Network 861 11.8 6.2 11.8 6.2 40 31

Evidence-Based Medicine Evidence-Based Medicine In Mechanical Ventilation in ARDSIn Mechanical Ventilation in ARDS

The ARDS network trial The ARDS network trial provided strong evidence that provided strong evidence that a lower tidal volume strategy a lower tidal volume strategy can improve clinical outcomes can improve clinical outcomes in patients with ALI or ARDSin patients with ALI or ARDS

Summary of Alternative Ventilator Summary of Alternative Ventilator Strategies for ALI/ARDSStrategies for ALI/ARDS

Ventilatory No. ofStrategy Year How Studies Patients Comments Study

Low tidal 1999 Phase III 861 Mortality was reduced by ARDS volume 22% with a 6 ml/kg Network predicted body weight tidal volume. This is the first large randomized multicenter controlled trial to show a mortality benefit from a specific therapy in ALI/ARDS

Low tidal 2002 Phase III 549 There was no mortality ARDS volume with benefit to increase levels Network high PEEP of PEEP compared with the standard ARDS Network low tidal volume strategy

Higher versus Lower Higher versus Lower Positive End-Expiratory Positive End-Expiratory

Pressures in Patients with Pressures in Patients with the Acute Respiratory the Acute Respiratory

Distress SyndromeDistress Syndrome

ARDS NetworkARDS NetworkNEJM 2002NEJM 2002

MethodsMethods

October 1999-February 2002October 1999-February 200223 hospitals of the National Heart, Lung, 23 hospitals of the National Heart, Lung,

and Blood Instituteand Blood Institute (NHLBI) ARDS Clinical (NHLBI) ARDS Clinical Trials NetworkTrials Network

PatientPatient

Intubation with MV due to Intubation with MV due to a sudden decrease in the ratio ofa sudden decrease in the ratio of the the

PaOPaO22/FiO/FiO22≦≦ 300300

a recent appearance of bilateral pulmonarya recent appearance of bilateral pulmonary

infiltrates consistent with the presence of infiltrates consistent with the presence of edemaedema

no clinicalno clinical evidence of left atrial hypertension evidence of left atrial hypertension (defined by PAWP 18 mmHg)≦(defined by PAWP 18 mmHg)≦

Criteria of exclusionCriteria of exclusion

<13 y/o<13 y/o participatedparticipated in other trials involving ALI within the in other trials involving ALI within the

precedingpreceding 30 days; 30 days; Pregnant; Pregnant; IICPIICP severe neuromuscular disease, severe neuromuscular disease, sickle cell disease,sickle cell disease,

severe chronic respiratory disease, severe chronic respiratory disease,

Criteria of exclusionCriteria of exclusion

BW>BW> 1 kg/cm, 1 kg/cm, Burns> 40 % BSA, Burns> 40 % BSA, Severe chronic liver disease, Severe chronic liver disease, VasculitisVasculitis with diffuse alveolar hemorrhage, with diffuse alveolar hemorrhage, A coexisting conditionA coexisting condition associated with an associated with an

estimated 6-month mortality rate >50 %; estimated 6-month mortality rate >50 %; Post- BMT or lung transplant;Post- BMT or lung transplant;

Their attending physician refused to allow Their attending physician refused to allow enrollment. enrollment.

Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.

Evidence-Based Medicine Evidence-Based Medicine In Mechanical Ventilation in ARDSIn Mechanical Ventilation in ARDS

with Higher PEEPwith Higher PEEP

The ARDS Network higher versus The ARDS Network higher versus lower PEEP trial provided strong lower PEEP trial provided strong evidence that there was no evidence that there was no mortality benefit to increase levels mortality benefit to increase levels of PEEP compared with the of PEEP compared with the standard ARDS Network low tidal standard ARDS Network low tidal volume strategyvolume strategy

Algorithm for ventilator management of ARDS using the ARDSnet protocolCalculate predicted body weight

CMV (A/C). VCV. Set initial volume to 8 mL/kg, then 7 mL/kg after 1 hr, then 6 mL/kg after next hr. increase respiratory rate to maintain minute ventilation. I:E ratio 1:2. PEEP and FiO2 per FiO2/PEEP table

Pplat <30 cm H2O

Adjust FiO2 or PEEPper FiO2/PEEP table

↑rate

↑VT by 1 mL/kg

↑VT to 7-8 mL/kg

↓VT to 4 mL/kg

↓rate↑rateConsider HCO3 ↑VT

Evaluate for weaning

VT 4 mL/kg

Pplat <25 cm H2O

VT < 6 mL/kg

Severe dyspnea

PaO2 55-80SpO2 88-95

FiO2 0.4≦PEEP=8

pHpH<7.15

START

no no

nono

no

no

no

no yes

yes

yes

yes

yes

yes

yes

yes

7.30-7.45

>7.45<7.30

ARDS Network N Engl J Med 2000; 342:1301

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Chronic Pulmonary DiseasePatients with Chronic Pulmonary Disease

Acute on chronic ventilatory failure and Acute on chronic ventilatory failure and hypoxemiahypoxemia Elevated PaCO2 and resulting hypoxemiaElevated PaCO2 and resulting hypoxemia

Unloading work-of-breathingUnloading work-of-breathing Increased work-of-breathing due to increased resistanceIncreased work-of-breathing due to increased resistance

Resting ventilatory musclesResting ventilatory muscles Exhausted musclesExhausted muscles

Improving bronchial hygieneImproving bronchial hygiene Increased airway secretionsIncreased airway secretions

Ventilator Strategy in Chronic Ventilator Strategy in Chronic Pulmonary Obstructive DiseasePulmonary Obstructive Disease

Primary concern : patient-ventilator Primary concern : patient-ventilator synchronysynchronyTo avoid unnecessary work of breathingTo avoid unnecessary work of breathingTo reduce anxietyTo reduce anxietyTo decrease ventilatory driveTo decrease ventilatory driveTo minimize auto-PEEPTo minimize auto-PEEP

Algorithm for the ventilator management of the patient with COPD

(A/C), PCV or VCV, VT 8-10 mL/kg, Pplat < 30 cm H2O, rate 10/min, Ti 0.6-1.2 s, PEEP 5 cm H2O, FiO2 for SpO2 90-95%

Clear secretionsAdminister bronchodilators

↑PEEP if missed trigger efforts↓VT or rate

↓ FiO2↑ FiO2

↑rate↑VT

NPPVContinue

NPPV

CandidateFor

NPPV

Patienttolerates

Clinicallyimproved

PaO2mmHg

pHPplat <

25 cm H2OPplat >

30 cm H2O

↓rate ↓VT

Auto-PEEP

Auto-PEEP

START

yes yes yes yes

yes

yes

no

no

yes

no

yes

no

>75

55-75 mmHg

<55

7.30-7.45

<7.30>7.45

intubate

intubate intubate

Fumeaux T et al Intensive Care Med 2001;27:1868Gladwin MT et al Intensive Care Med 1998;24:898Nava S et al Ann Intern Med 1998; 128:721

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Chest TraumaPatients with Chest Trauma

Flail chest with paradoxical chest movement, Flail chest with paradoxical chest movement, tachypnea, hypoxemia, hypercarbiatachypnea, hypoxemia, hypercarbia

Pulmonary contusion with tachypnea and severe Pulmonary contusion with tachypnea and severe hypoxemia (PaO2< 60 mmHg) breathing 100% O2hypoxemia (PaO2< 60 mmHg) breathing 100% O2

Rib fracture with chest pain requiring large dose of Rib fracture with chest pain requiring large dose of narcotics for pain controlnarcotics for pain control

Post-operative thoracotomyPost-operative thoracotomy Hemodynamic instability, particularly with marginal Hemodynamic instability, particularly with marginal

respiratory reserve (hypoxemia and tachypnea)respiratory reserve (hypoxemia and tachypnea) Severe associated injuries ( head injury)Severe associated injuries ( head injury)

Ventilator Strategy in PatientsVentilator Strategy in Patientswith Chest Traumawith Chest Trauma

Full ventilatory support initiallyFull ventilatory support initiallySedation, or paralysis may be necessary Sedation, or paralysis may be necessary

initiallyinitiallyBarotrauma is commonBarotrauma is commonTidal volumeTidal volume

8-10 ml/kg with satisfactory lung compliance8-10 ml/kg with satisfactory lung compliance4-8 ml/kg with pulmonary contusion and 4-8 ml/kg with pulmonary contusion and

ARDSARDS

Algorithm for Mechanical Ventilation of the Patient with Chest TraumaSTART

CMV (A/C), VT 6 to 10 mL/kg, FiO2 1.0.rate 15/min, Ti 1 s, VCV or PCV, PEEP 5 cm H2O

Titrate FiO2 toSpO2 92-95%

Good lung down

↑PEEP

↓VT and↑rate

↑FiO2

MaintainCurrent settings

↓rate ↑rate

↑VT or↑rate

FiO2<0.6

Broncho-Pleuralfistula

ICP>20

Unilateraldisease

Pplat>30 cm H2O

PplatpH

no no no

no

yes

yesyes

yes

yes

Unilateraldisease

no

>25

≦25

>7.45

7.30-7,45

<7.30

Calhoon JH et al Chest Surg Clin N Am 1997;7:199Ferguson M et al 1996 2:449Gentilello LM et al Am J Respir Crit Care Med 2001 163:604

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Acute Head InjuryPatients with Acute Head Injury

Depression due to primary neurologic Depression due to primary neurologic injuryinjury

Associated injuries to the spine, chest Associated injuries to the spine, chest and abdomenand abdomen

Neurogenic pulmonary edemaNeurogenic pulmonary edemaTreatment with respiratory suppressant Treatment with respiratory suppressant

medications (barbiturate, sedatives, medications (barbiturate, sedatives, paralysis)paralysis)

Algorithm for Mechanical Ventilation of the Patient with Head Injury

Unilateral lungdisease

CMV (A/C), PCV or VCV,VT 4 t0 8 mL/kg.FiO2 1.0,rate 20/min, Ti 1 s, PEEP 5 cm H2O

CMV (A/C), PCV or VCV,VT 8 t0 12 mL/kg.FiO2 1.0,rate 20/min, Ti 1 s, PEEP 5 cm H2O

Titrate FiO2 for SpO2 92%≧

PaCO2 Pplat ＞ 30

PaO2

FiO2>0.6

ICP ICP

ICP<20

FiO2>0.6

Maintainventilator settings

More aggressiveMedical therapy

Slowly ↓rate to initialsetting

↑rate ↓rate

↓VT

↑rate

↓FiO2

↑FiO2

↑PEEP

START

yes

yesno

no

no

yes<35>45

35 - 45

>100

70 - 100

<70nono

yes

>20

<20

>20<20

no

Berrouschot J et al Crit Care Med 2000 28:2956

yes

Management of Intracranial PressureManagement of Intracranial Pressure

Hyperventilation : PaCO2 of 25- 30 mmHgHyperventilation : PaCO2 of 25- 30 mmHg Mean airway pressure : kept as low as possibleMean airway pressure : kept as low as possible Positioning : 30Positioning : 30° elevation of the head° elevation of the head Dehydration and osmotherapy : manitol and lasixDehydration and osmotherapy : manitol and lasix Sedation and paralysis : agitation, coughSedation and paralysis : agitation, cough Barbiturate therapyBarbiturate therapy Temperature controlTemperature control VentriculostomyVentriculostomy

Indications for Mechanical Ventilation Indications for Mechanical Ventilation in Post-operative Patientsin Post-operative Patients

Apnea – unreversed anesthetic agentsApnea – unreversed anesthetic agents Iatrogenic hypothermiaIatrogenic hypothermiaNeed to reduce cardiopulmonary stressNeed to reduce cardiopulmonary stressPresence of altered pulmonary mechanicsPresence of altered pulmonary mechanics

Transplant recipientsTransplant recipientsMinimize post-operative cardiopulmonary Minimize post-operative cardiopulmonary

stressstressPre-existing lung disease compromising Pre-existing lung disease compromising

cardiopulmonary reservecardiopulmonary reserve

Algorithm for Mechanical Ventilation of the Post-operative Patient

Ventilate consistentwith underlying

disease

Ventilate consistentwith negative lung

pathology

Consider extubation

Spontaneousbreathing

trial

Titrate FiO2For SpO2> 92%

CMV (A/C), VCV or PCV, VT 10 – 12mL/kg, rate 12/min, I;E:1:3PEEP 5 cm H2O, FiO2:1.0

Adjust rate and tidal volume for normal acid-base

↑PEEP

Prior lungdisease

Single lungtransplant

Tolerated

Spontaneous Breathing efforts.HemodunamicallyStable, FiO2 0.5≦

PEEP 5≦

FiO2

STARTyes

yes

no

no

yes

noyesno

≧0.6<0.6

Initial Ventilator Settings for Postoperative Initial Ventilator Settings for Postoperative Patients with no Prior DiseasePatients with no Prior Disease

Setting Recommendation

Mode A/C (CMV)

Rate 10 - 16/min

Volume/pressure control Pressure or volume

Tidal volume 10-12 mL/kg IBW and plateau pressure

<30 cm H2O

Inspiratory time 1 s

PEEP ≤ 5 cm H2O

FiO2 Sufficient to maintain PaO2 > 80 mm Hg

Flow waveform Descending ramp

Initial Ventilator Settings for Postoperative Initial Ventilator Settings for Postoperative Patients with Prior Obstructive Lung DiseasePatients with Prior Obstructive Lung Disease


Mode A/C (CMV)

Rate 8 – 12 /min


Tidal volume 8-10 mL/kg IBW and plateau pressure

<30 cm H2O

Inspiratory time 0.6 – 1.2 s

PEEP 5 cm H2O; counterbalance auto-PEEP



Initial Ventilator Settings for Postoperative Initial Ventilator Settings for Postoperative Patients with Prior Restrictive Lung DiseasePatients with Prior Restrictive Lung Disease


Mode A/C (CMV)

Rate 15 –25 /min


Tidal volume < 8 mL/kg IBW and plateau pressure

<30 cm H2O

Inspiratory time 1 s

PEEP 5 cm H2O



Respiratory Failure in Neuromuscular Respiratory Failure in Neuromuscular Diseases and Chest Wall DeformitiesDiseases and Chest Wall Deformities Rapid onsetRapid onset

Myasthenia gravisMyasthenia gravis Guillain-Barre syndromeGuillain-Barre syndrome High spinal cord injuryHigh spinal cord injury Prolonged paralysis following use of neuromuscular Prolonged paralysis following use of neuromuscular

blocking agents in ICUblocking agents in ICU Gradual onsetGradual onset

Muscular dystrophyMuscular dystrophy Amyotrophic lateral sclerosisAmyotrophic lateral sclerosis Thoracic deformities (severe scoliosis, kyphosis, Thoracic deformities (severe scoliosis, kyphosis,

kyphoscoliosis) kyphoscoliosis) Post-polio syndromePost-polio syndrome

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Neuromuscular DiseasePatients with Neuromuscular Disease

Progressive ventilatory failureProgressive ventilatory failure

Acute ventilatory failureAcute ventilatory failure

Oxygenation is not usually an issue – except Oxygenation is not usually an issue – except

in patients with acquired critical illness in patients with acquired critical illness

neuromusculopathy following prolonged neuromusculopathy following prolonged

mechanical ventilationmechanical ventilation

Algorithm for Mechanical Ventilation of the Patient with Neuromuscular Disease without Lung Disease

CMV (A/C), VCV, VT 15 mL/kg, FiO2 0.40Rate 10/min, Ti 1 s, PEEP 0 cm H2O

↓FiO2↑FiO2 ↑PEEP

In-Exsufflattor

↑VT

↑VT

↑rate

↑rate

In-Exsufflattor

Maintain therapy

↓rate or ↓VT

Considermechanical dead space

Secretionsor

atelectasis

dyspnea dyspnea

secretions

pHPplat

SpO2<95%

SpO2

START

yes

yes

yes

no

no

yes

no

no

noyes

>7.45

7.35-7.45

<7.35

>25

≦25

>95%<92%

92-95%

Methods to Treat AtelectasisMethods to Treat Atelectasis

In-exsufflatorIn-exsufflator

Maximal insufflation capacityMaximal insufflation capacity

HyperinflationHyperinflation

Assisted coughAssisted cough

Peak cough flow > 160 L/minPeak cough flow > 160 L/min

Mechanical Insufflation-ExsufflationMechanical Insufflation-ExsufflationArtificial cough machineArtificial cough machineStimulating cough by inflating the lung with Stimulating cough by inflating the lung with

pressure, followed by a negative pressure pressure, followed by a negative pressure to produce a high expiratory flowto produce a high expiratory flow

Inspiratory pressure :25-35 cm H2O for 1-Inspiratory pressure :25-35 cm H2O for 1-2 seconds2 seconds

Expiratory pressure:-40 cm H2O for 1-2 Expiratory pressure:-40 cm H2O for 1-2 secondsseconds

Treatment periods: 5-6 breathsTreatment periods: 5-6 breaths

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Cardiovascular FailurePatients with Cardiovascular Failure

Increased work of the myocardiumIncreased work of the myocardium

Decrease myocardial work with MVDecrease myocardial work with MV

Increased work of breathingIncreased work of breathing

Reduce the work of breathing with MVReduce the work of breathing with MV

HypoxemiaHypoxemia

Reverse hypoxemia with MVReverse hypoxemia with MV

Algorithm for Mechanical ventilation of the Patient with Cardiac Failure

Awake andcooperative

Patienttolerates

PaCO2>45 mm Hg

PaCO2.45 mm Hg

Acute MI

Pplat

pH

Hemodynamicstability

SpO2<92%;Pulmonary edema

CMV (A/C), VCV or PCV, VT 8-10mL/kg, Pplat < 30 cm H2O, I;E:1:2PEEP 5 cm H2O, FiO2 1.0

Mask CPAP,5-10 cm H2O, FiO2 1.0

Continue therapy,Definitive medical therapy

Titrate FiO2For SpO2>92%

↑PEEP

NPPV

Manipulate PEEP and FiO2

↑ rate

↓VT

↓ rate

STARTyes

yes

yes

yes

yes

no

no

yesno

no

no

no

intubate

intubate

<30

≧30

<7.35

7.35-7.45

>7.45

no

yes

Bersten AD et al New Engl J Med 1991 325:1825Poppas A et al Am J Respir Crit Care Med 2002 165:4

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with AsthmaPatients with Asthma

Acute ventilatory failureAcute ventilatory failure

Impending acute ventilatory Impending acute ventilatory

failurefailure

Severe hypoxemiaSevere hypoxemia

Ventilator Strategy Ventilator Strategy in Patients with Acute Asthmain Patients with Acute Asthma

Major concern: auto-PEEPMajor concern: auto-PEEPTo minimize auto-PEEPTo minimize auto-PEEPPermissive hypercapniaPermissive hypercapniaUse of inhaled bronchodilators and Use of inhaled bronchodilators and

systemic steroids to reduce the airway systemic steroids to reduce the airway inflammation, edema, swelling and inflammation, edema, swelling and bronchospasmbronchospasm

Risk of barotrauma and hypotensionRisk of barotrauma and hypotension

Algorithm for Mechanical Ventilation of Patient with AsthmaSTART

Decrease minute ventilation

CMV (A/C), PCV or VCV, VT 4-8 mL/kg, Pplat 30 cm H2O≦rate 8-20/min, Ti 1 s, PEEP 5 cm H2O, FiO2 1.0

SpO2

Auto-PEEP

Auto-PEEP

Pplat<25 cm H2OpHPplat>

30 cm H2O

Administer bronchodilators

↑VT ↑rate

↑FiO2↓FiO2

↓VT↓rate

yes

yes

yesyes

no

nono

92-95%

>95% <92%

>7.45 <7.30

7.30-7.45

Afzal M et al Clin Rev Allergy Immunol 2001 20:385Mansel JK et al Am J Med 1990 89:42Koh Y Int Aneshesiol Clin 2001 39:63

no

Indications for Mechanical Indications for Mechanical Ventilation in Patients with Burn Ventilation in Patients with Burn

and Smoke Inhalationand Smoke Inhalation Smoke inhalation or pulmonary burn with Smoke inhalation or pulmonary burn with

respiratory failure (ARDS)respiratory failure (ARDS) Severe burn with chest wall restrictionSevere burn with chest wall restriction Respiratory depression due to inhalation of Respiratory depression due to inhalation of

systemic toxin (carbon monoxide)systemic toxin (carbon monoxide) Respiratory failure due to secondary infection – Respiratory failure due to secondary infection –

pneumonia, sepsispneumonia, sepsis Postoperative skin graft or escharotomyPostoperative skin graft or escharotomy

Algorithm for Mechanical Ventilation of Patient with Burn and Inhalation Injury

CMV (A/C), PCV or VCV, VT 6 to 12 mL/kg, FiO2 1.0,rate 15/min, Ti 1 s

Consider:BronchodilatorsDiureticsSecretion clearancePEEPRecruitment maneuverProneInhaled nitric oxide

Treat with:Bronchodilators, diuretics

Titrate FiO2 forSpO2 92%≧

Maintainventilator settings

↑ rate

↑ VT

↑ FiO2

↓ VT

↓ rate

ConsiderVT ↑↓ FiO2

↓Chest wall compliance

Pplat>30 pH

PaO2

FiO2<0.6

FiO2<0.6

ABGresults

Pplat>30Cm H2O

yes

yes

yes

yes

yes

no

no

no

no

no

no

<7.30>7.45

7.30-7.45

>100<70

70-100

Continue 100% O2

CO poisoningyes

START

Fitzpatrick JC et al Respir Care Clin N Am 1997 3:21

Indications for Mechanical Indications for Mechanical Ventilation in Patients with Ventilation in Patients with

Bronchopleural FistulaBronchopleural Fistula

Bronchopleural fistula is not by Bronchopleural fistula is not by itself an indication for mechanical itself an indication for mechanical ventilation, but may be necessary ventilation, but may be necessary in the following settings:in the following settings:ApneaApneaAcute ventilatory failureAcute ventilatory failureImpending acute ventilatory failureImpending acute ventilatory failureOxygen deficit Oxygen deficit

Algorithm for Mechanical Ventilation of Patient with Bronchopleural Fistula

CMV (A/C), VCV or PCV, rate 6-20/minVT 4 – 8 mL/kg, Ti≤ 1 s

PEEP 3 cm H2O, FiO2:1.0

Exhaled VT

>75%Inhaled VT

Systemicaly evaluate changes in:Tidal volumeRespiratory RatePEEPInspiratory timePressure control vs. volume control

Titrate FiO2 for SpO2 92-95%

pH rate rate

Start

yes

no

7.25-7.45

>7.45<7.25

Indications for Mechanical Ventilation in Indications for Mechanical Ventilation in Patients with Drug OverdosePatients with Drug Overdose

ApneaApnea

Acute respiratory failureAcute respiratory failure

Impending acute respiratory Impending acute respiratory

failurefailure

Algorithm for Mechanical Ventilation of Patient with Drug Overdose

CMV (A/C), VCV or PCV,,rate 10/minVT 8 to 12 mL/kg, Ti 1 s,

PEEP 5 cm H2O, FiO2 1.0

SpontaneousBreathing

trial

Consider extubation

↑PEEP

Titrate FiO2for SpO2 > 92%

Adjust rate and tidal volume fornormal acid-base

FiO2

tolerated

Spontaneousbreathing effortshemodynamicallystable, FiO2 0.5≦

PEEP 5≦

START

yes

yes

nono

<0.60

≧0.60

謝謝 !如有問題請發問 !

謝謝 !如有問題請發問 !

Ventilator Setting for ALI or ARDSVentilator Setting for ALI or ARDSOpen Lung ApproachOpen Lung Approach

Maintaining a low plateau Maintaining a low plateau pressurepressure

Monitoring tidal volumeMonitoring tidal volumeUsing recruitment maneuvers and Using recruitment maneuvers and

high levels of PEEP to maximize high levels of PEEP to maximize alveolar recruimentalveolar recruiment

Algorithm for ventilator management of ARDS using the open lung approach

Consider prone positionConsider accepting lower level of oxygenationConsider inhaled nitric oxide

CMV (A/C). PCV to achieve VT of 4-8 mL/kg, Ti to Avoid auto-PEEP. Rate 20/min. FiO2 1.0. PEEP 10 cm H2O

Recruitment maneuver PEEP 20 cm H2OFiO2 to maintain SpO2 90-95%Decrease PEEP to maintain SpO2 90-95%

↑ pressure control if Pplat < 30 cm H2O↑rate (avoid auto-PEEP)Consider accepting lower pH

Recruitment maneuver↑ increase PEEP↑increase FiO2

Maintain ventilator settings

↓FiO2↓ PEEP if FiO2 < 0.05

↓pressure control↓ rate

SpO2

SpO2

pH

<90%

≧90%

90-95%

>95%<90%

7.25-7.45

<7.25 >7.45

START

Amato MBP et al. N Engl J Med 1998 338:347

The ARDSnet protocol for ventilation of The ARDSnet protocol for ventilation of patients with ALI and ARDSpatients with ALI and ARDS

Initial ventilator tidal volume and rate Initial ventilator tidal volume and rate adjustmentadjustment Calculate predicted body weightCalculate predicted body weight

Male = 50 + 2.3 [ht (in) – 60 ] kgMale = 50 + 2.3 [ht (in) – 60 ] kg Female = 45.5 + 2.3 [ht (in) – 60 ] kgFemale = 45.5 + 2.3 [ht (in) – 60 ] kg

Mode : volume Assist-ControlMode : volume Assist-Control Set initial tidal volume to 8 mL/kg PBWSet initial tidal volume to 8 mL/kg PBW Reduce tidal volume to 7 mL/kg PBW after 1-2 hrs Reduce tidal volume to 7 mL/kg PBW after 1-2 hrs

and then to 6 mL/kg PBW after a further 1-2 hrsand then to 6 mL/kg PBW after a further 1-2 hrs Set initial ventilator rate to maintain baseline Set initial ventilator rate to maintain baseline

minute ventilation (not > 35 /min)minute ventilation (not > 35 /min)ARDS Network N Engl J Med 2000; 342:1301


Subsequent tidal volume adjustmentsSubsequent tidal volume adjustments Plateau pressure goal : Plateau pressure goal : ≤ 30 cm H2O≤ 30 cm H2O Check inspiratory plateau pressure (PCheck inspiratory plateau pressure (Pplatplat) with 0.5 s ) with 0.5 s

pause at least every 4 hrs and after each change in pause at least every 4 hrs and after each change in PEEP and tidal volumePEEP and tidal volume

If PIf Pplatplat >30 cm H2O, decrease tidal volume by 1 mL/kg PBW, >30 cm H2O, decrease tidal volume by 1 mL/kg PBW, if necessary to 4 mL/kg PBWif necessary to 4 mL/kg PBW

If PIf Pplatplat < 25 cm H2O and tidal volume < 6 mL/kg PBW, < 25 cm H2O and tidal volume < 6 mL/kg PBW, increase tidal volume by 1 mL/kg PBW until Pincrease tidal volume by 1 mL/kg PBW until Pplatplat >25 cm H2O >25 cm H2O and tidal volume =6 mL/kg and tidal volume =6 mL/kg

If breath stacking or severe dyspnea occurs, tidal volume may If breath stacking or severe dyspnea occurs, tidal volume may be increased (not required) to 7 or 8 mL/kg PBW 1f Pbe increased (not required) to 7 or 8 mL/kg PBW 1f Pplatplat < 25 < 25 cm remains ≤ 30 cm H2Ocm remains ≤ 30 cm H2O



Arterial oxygenationArterial oxygenationGoal : PaO2 55-80 mm Hg or SpO2 88 – Goal : PaO2 55-80 mm Hg or SpO2 88 –

95%95%Use these FiO2/PEEP combinations to Use these FiO2/PEEP combinations to

achieve oxygenation goalachieve oxygenation goal

--FiO2 0.3 0.4 0.4 0.5 0.5 0.6 0.7 0.7 0.7 0.8 0.9 0.9 0.9 1.0

PEEP 5 5 8 8 10 10 10 12 14 14 16 16 18 20-24


Figure 1. Probabilities of Survival and of Discharge Home While Breathing without Assistance, from the Day of Randomization (Day 0) to Day 60 among Patients with Acute Lung Injury and ARDS, According to Whether Patients Received Lower or Higher Levels of PEEP.


Respiratory rate and arterial pHRespiratory rate and arterial pH Arterial pH Goal : 7.30 – 7.45Arterial pH Goal : 7.30 – 7.45 A. Acidosis managementA. Acidosis management

If pH 7.15 – 7.30If pH 7.15 – 7.30 Increase set rate until pH >7.30 or PaCO2 < 25 (max rate = 35/min)Increase set rate until pH >7.30 or PaCO2 < 25 (max rate = 35/min) If set rate = 35 /min and pH < 7.30, NaHCO3 may be given (not If set rate = 35 /min and pH < 7.30, NaHCO3 may be given (not

required)required) If pH < 7.15If pH < 7.15

Increase set respiratory rate to 35 /minIncrease set respiratory rate to 35 /min If set rate = 35 /min and pH < 7.15 and NaHCO3 has been considered, If set rate = 35 /min and pH < 7.15 and NaHCO3 has been considered,

tidal volume may be increased in 1 mL/kg PBW steps until pH > 7.15 tidal volume may be increased in 1 mL/kg PBW steps until pH > 7.15 (Pplat target may be exceeded)(Pplat target may be exceeded)

Alkalosis managementAlkalosis management Decrease set rate until patient rate > set rate. Minimum set rate = Decrease set rate until patient rate > set rate. Minimum set rate =

6 /min6 /min I:E Ratio Goal : 1:1 – 1:3I:E Ratio Goal : 1:1 – 1:3

Adjust flow and inspiratory flow waveform to achieve goalAdjust flow and inspiratory flow waveform to achieve goal


Recruitment ManeuversRecruitment Maneuvers

In the first 80 patients, higher-PEEPIn the first 80 patients, higher-PEEP

group, => assessed the safety and group, => assessed the safety and efficacy of recruitment maneuversefficacy of recruitment maneuvers

single sustained inflations of the lungs tosingle sustained inflations of the lungs to

higher airway pressures and volumes than higher airway pressures and volumes than are obtained duringare obtained during tidal ventilationtidal ventilation

An effort to improve arterial oxygenation.An effort to improve arterial oxygenation.

Recruitment ManeuversRecruitment Maneuvers

One or two such maneuvers were One or two such maneuvers were conducted during the first fourconducted during the first four days, by days, by applying CPAP 35 to 40 cmH2O for 30 applying CPAP 35 to 40 cmH2O for 30 seconds. seconds.

The subsequentThe subsequent mean increase in arterial mean increase in arterial oxygenation was small and transient.oxygenation was small and transient.

Discontinued recruitment maneuvers for Discontinued recruitment maneuvers for the remainderthe remainder of the trial.of the trial.

General Guideline for Initial Ventilator General Guideline for Initial Ventilator Settings for Adult PatientsSettings for Adult Patients

Tidal VolumeTidal Volume 8 to 12 mL/kg IBW8 to 12 mL/kg IBW Avoid over-distensionAvoid over-distension Prefer volume on the steep part of the pressure-volume Prefer volume on the steep part of the pressure-volume

curvecurve Maintain PMaintain Pplat plat at 30 cm H2O or lessat 30 cm H2O or less

10-12 mL/kg IBW is a good starting point for most of the 10-12 mL/kg IBW is a good starting point for most of the patientspatients

12 – 15 mL/kg IBW –neuromuscular diseases or post-12 – 15 mL/kg IBW –neuromuscular diseases or post-operative patients with normal lungs operative patients with normal lungs

8-10 mL/kg IBW in SIMV with adequate expiratory time 8-10 mL/kg IBW in SIMV with adequate expiratory time In ARDS patients, start with 8 mL/kg, reduce gradually to 6 In ARDS patients, start with 8 mL/kg, reduce gradually to 6

mL/kg to maintain PmL/kg to maintain Pplat plat at 30 cm H2O or lessat 30 cm H2O or less

Alarm and Backup Ventilation Settings Alarm and Backup Ventilation Settings for Initial Ventilator Setup (Adult)for Initial Ventilator Setup (Adult)

Low pressure 8 cm H2O 0r 5-10 cm H2O below PIPLow pressure 8 cm H2O 0r 5-10 cm H2O below PIP

Low PEEP/CPAP 3-5 cm H2O below PEEPLow PEEP/CPAP 3-5 cm H2O below PEEP

High pressure limit 50 cm H2O High pressure limit 50 cm H2O

adjust to 10-20 cmH2O above PIPadjust to 10-20 cmH2O above PIP

Low exhaled tidal volume 100 mL or 10-15% below set VLow exhaled tidal volume 100 mL or 10-15% below set VTT

Low exhaled minute ventilation 2-5 L/min or 10-15% below backup minuteLow exhaled minute ventilation 2-5 L/min or 10-15% below backup minute

ventilationventilation

High minute ventilation 5 L/min or 10-15% above baseline High minute ventilation 5 L/min or 10-15% above baseline

minute ventilation minute ventilation

Oxygen percentage 5% above and below set O2 %Oxygen percentage 5% above and below set O2 %

Temperature 2°C above and below set temperatureTemperature 2°C above and below set temperature

High temperature not to exceed 37°CHigh temperature not to exceed 37°C

Apnea delay 20 secondsApnea delay 20 seconds

Apnea values Tidal volume and rate set to achieve full Apnea values Tidal volume and rate set to achieve full

ventilatory support with 100 % O2ventilatory support with 100 % O2

Documents

Ventilator Management In Different Disease Entities