A simple case of.. Acute severe asthma. MasterclassIC Schiermonnikoog 2017
|
|
|
- Tabitha Gilbert
- 5 years ago
- Views:
Transcription
1 A simple case of.. Acute severe asthma MasterclassIC Schiermonnikoog 2017
2 Case (1) Female, 27 - G1P0 (26 weeks) PMH - several admissions for severe acute asthma (no MV) Progressive dyspnea for 1 week Admitted to another hospital with acute severe asthma Despite MV and various bronchodilators progressive respiratory acidosis transfer to Radboudumc
3 Physiology of pregnancy Increase in cardiac output (both heart rate and stroke volume). In third trimester gravid uterus may compress the vena cava in supine position Increase in minute ventilation (mainly tidal volume) with compensated respiratory alkalosis Fall in FRC without a change in FEV1 or FEV1/FVC ratio Increased GFR and plasma volume combined with albumin and gastric motility may decrease medication levels
4 Asthma and pregnancy Preeclampsia Placenta and placental abruption Obstetric hemorrhage Increased risk of unplanned emergency cesarean delivery Worse outcome
5 Important considerations Permissive hypoxia may not be safe A normal PaCO2 is abnormal (during pregnancy normally compensated respiratory alkalosis - PaCO mm Hg) NPPV may increase the risk of aspiration Delivery of the fetus had only moderate improvement in respiratory function during mechanical ventilation
6 Increased intubation risk Pregnancy related airway hyperemia Increased risk for aspiration Precipitous development of hypoxemia Increase in airway resistance
7 Critical Care Fellow asks the 1 st question Is it true that permissive hypercapnia is contraindicated in pregnancy because of vasoconstriction of the placental vessels?
8 Case (2) Admission Hb 7.6, WBC 16.4, potassium 5.6 ph 6.89, PaCO kpa, PaO2 9.6, HCO3 35.6, BE -2.4 Tv 400 ml, RR 6/min, I:E 1:5, FiO2 50%, PEEPe 0 (Ppeak 59 cmh2o, Pplat 29 cmh2o, PEEPi 21, VEI 22 ml/kg IBW)
9
10 Medical treatment β-agonist bronchodilator with continuous delivery (salbutamol mg/h) - iv salbutamol 0.1 μg/kg/min Systemic corticosteroids (methylprednisolone iv mg/day in 4 divided doses for 48 hrs with tapering as the patient improves) Magnesium sulfate iv (2 gram over 20 minutes) followed by continuous infusion with serum level monitoring Muscular paralysis
11 Mechanical ventilation Restore adequate oxygenation (and ph?) Minimize air-trapping to prevent hypotension/barotrauma Early involvement of obstetrician (fetal monitoring) Buy time
12 Critical Care Fellow asks the 2 nd question Oxygenation is probably sufficient but I am not certain about the level of hypercapnia and the degree of hyperinflation. How would you improve ventilator settings?
13 Contribution of different MV factors to PEEPi generation N = controlled mechanical ventilation Independent factors Flow limitation (+) Major effect P < τ = RRS CRS TE / τrs (-) (< 1.85) Moderate effect P < BMI (+) (> 26 kg/m 2 ) Small effect 0,007 RRS (-) (> 15 cmh2o/l/s) Small effect 0,01 12 Flow limitation VENTILAB group investigators Natalini G. Respir Care 2016;61:
14 Controlled MV = Pplat = PEEPTOT CRS = Volume / (Pplat - PEEPTOT) Rrs = (Pmax - Pplat)/Flowinsp τ = RRS CRS
15 Treatment Treat flow limitation - bronchodilators and sitting position Increase TE / τrs (> 2) Effect of Tv less important
16 Hypercapnia? CO2 transfer from fetal to maternal circulation is gradientdependent Fetal acidosis reduces oxygenation of fetal hemoglobin Fetal (respiratory) acidosis without hypoxia is better tolerated than fetal metabolic acidosis due to hypoxia
17 Extracorporeal CO2 removal Blood flow 400 ml/min - sweep gas O2 10 l/min
18 First 24 hours 7,2 ph PEEPi VEI 22 VEI 20 VEI 13 VEI ,1 7 6, PEEPi 6,8 6, Tidal volume 400 ml and PEEPe 0 0
19 Critical Care Fellow asks the 3 d question Can you explain how a blood flow of only 400 ml can actually result in a substantial decrease in arterial carbondioxide levels?
20 How do we explain ph after 12 hours Before After Before After ph PvCO PvO Filter dysfunction
21 ECCO2R in acute severe asthma Rescue therapy in giant pneumomediastinum causing tamponade ( in stead of surgical decompression) using ultra protective MV Unsafe mechanical ventilation or severe hypercapnic acidosis to prevent pulmonary barotrauma Jones MG. Am J Respir Crit Care Med 2013;187:e5-e6 Pavot A. Medicine 2017;96:41
22 Case series N = ± 10.6 years 13 vv-ecls and 3 va-ecls Hours on ECLS 300 ± 119 Mortality 0% No complications Di Lascio. Perfusion 2017;32:
23 ECLS/ECCO2-R Only 1 case with acute severe asthma during pregnancy (5 weeks duration) - successful Steinack C. J Asthma 2017;54:84-88
24 Case (3) Slow improvement ECCO2-R stop Day 4 Day 4 Day 5 Day 5 Day 5 Day 5 Start PSV
25 Critical Care Fellow asks the 4 th question I have heard different opinions on the use of external PEEP during controlled MV. What is the latest update on its effect on hyperinflation?
26 Case (4) Day stop ECCO2-R Day start PSV with PEEPe 5 Day 5 Day 6 Day 6 Day 7 Day 7 Day 8
27 PS 8 - PEEP 4 PEEPi = 11-3 = 8 cmh2o - 2 = 6 cm H2O
28 Dynamic PEEPi
29 Static PEEPi
30 Case (5) Day extubation Day 10 transfer to general ward
31 Question 1 & 2 Is it true that permissive hypercapnia is contraindicated in pregnancy because of vasoconstriction of the placental vessels? I have heard different opinions on the use of external PEEP during controlled MV. What is the latest update on its effect on hyperinflation?
32 Question 3 & 4 Can you explain how a blood flow of only 400 ml can actually result in a substantial decrease in arterial carbondioxide levels? I have heard different opinions on the use of external PEEP during controlled MV. What is the latest update on its effect on hyperinflation?
33 At term ml/min
34 Maternal oxygenation Maternal Umbilical vein Umbilical artery N = 34, caesarian section 439 PaO2 (mmhg) ,2 18,1 39,3 27,5 36,4 32.7% 65.4% 99.7% FiO2 during operation (%) 22 Rorke MJ. Anaesthesia 1968;23:
35 Effect of hypercapnia on umbilical vein oxygenation Pig sows 400 PaO2 (mmhg) ,5 314,4 292,6 258,3 125,2 0 67,4 54,7 48,2 26,1 31,5 Air O2 100% O2 100% + CO2 6% O2 100% + CO2 50% Air + CO2 5% Hypercapnia improves umbilical vein oxygen pressure Hanka R. J Physiol 1975;247:
36 Effect of hypercapnia on uterine blood flow Addition of 5% CO2 PaCO Stop Hanka R. J Physiol 1975;247:
37 End-inspiratory volume above FRC (VEI) Start apnea Lungvolume N = 9 FRC Inspiration/Expiration Pplat tidal volume Pplat - PEEPi Tv VTrap End-inspiratory volume above FRC (Vei) Tuxen DV. Am Rev Respir Dis 1987;136:
38 Complications during mechanical ventilation Geen Hypotension Barotrauma Hypotension + barotrauma 18% Threshold Complication < threshold (%) Complication > threshold (%) P-value 9% 23% 50% Pplat 20 cm H2O 40% 58% > 0.10 Vei 1.4 L 0% 65% 0.03 Vei 20 ml/kg 14% 63% 0.06 In follow-up study (N = 10) the authors showed that use of Vei to guide MV can prevent these complications N = 22 Tuxen DV. Am Rev Respir Dis 1992;146: Williams TJ. Am Rev Respir Dis 1992;146:
39 Calculation of VEI Volume Crs = Tv / (Pplat - PEEPtot) Compliance VEI = Trapped volume + Tv VEI VEI = Crs Pplat Tv VEI = Tv Pplat Pplat - PEEPtot Trapped volume PEEPtot Pplat Pressure
40 VEI measurement VCV Inspiratory hold + switch to PSV VCV 45 seconds
41 An example 20 Male, 31 COPD IV - exacerbation Waiting list LTx Tv RR 12 - I:E =1:4 VEI (ml/kg) PaCO kpa 0 VEI (C) VEI (V) VEI (GS)
42 CO2 production Glucose + O2 Energy + CO2 ± 200 ml/min v-aco2 difference = 40 ml per liter blood CO of ± 5L/min necessary to remove CO2 load
43 Mixed venous blood contains 52 ml CO2 / 100 ml
44 Conclusion We only need to clear 400 ml of blood of the complete CO2 content to balance VCO2 Because in contrast to alveoli the sweep gas contains no CO2, the gradient is sufficient to remove a major portion of CO2 in a single pass
45
46 The best combination of flow rate and surface area Pigs (N=7) VCO ml/min - increased dead space Use blood flow rate of 1000 ml a surface area 0.8 m 2 and sweep gas of ± 6 l/min Karagiannidis C. Intensive Care Med Exp 2017;5:34
47 Yeo HJ. Crit Care 2017;21:297 ECMO for acute severe asthma N = 272 (ELSO registry) Survivors Non-Survivors Mean duration ECMO hrs 16,5% Canulation-site hemorrhage 13,6% Death due to hemorrhage 1,5% 83,5% Survival associated with: age, bleeding, post- ECMO driving pressure
48 Older studies show increase of VEI 2 FRC (L) PEEPi (cm H2O) 10 1,5 8 FRC (L) PEEPi (cm H2O) 0,5 2 N = 10 0 PEEP 1.3 ± 0.3 PEEP 6.3 ± 0.3 PEEP 10.5 ± 0.3 PEEP 16.1 ± 0.3 Guerin C. Am J Respir Crit Care Med 1997;155:
49 External PEEP PEEPi Manual abdominal compression External PEEP Flow limitation 10 8 No flow limitation 14 8
50 Does PEEPe reduces hyperinflation in controlled ventilation? N = Controlled MV - PEEPi 7 ± 2 mmhg PEEPe 80% PEEPtot 9 ± 2 mmhg Complete High Low Increase < 50% of applied PEEP Only small percentage with no/small increase in hyperinflation 46% 21% 33% No additional hyperinflation with expiratory flow limitation and low RR PEEP absorber Natalini G. Ann Intensive Care 2016;6:53
51 Complete PEEP absorber predicted by.. Flow limitation Low respiratory rate } AUC 0.87 PEEP
52 Caramez MP. Crit Care Med 2005;33: Paradoxical Biphasic Classic
53 10 Sticky airway closure PEEP 8 Hysteresis 8 PEEP 8 8 PEEP 8 6 Increasing stiffness airway 10 2 PEEP Increased radial tension 10 8 Flow retarder Bernoulli principe PEEP 8
Case discussion Acute severe asthma during pregnancy. J.G. van der Hoeven
Case discussion Acute severe asthma during pregnancy J.G. van der Hoeven Case (1) 32-year-old female - gravida 3 - para 2 Previous medical history - asthma Pregnant (33 w) Acute onset fever with wheezing
ARDS Assisted ventilation and prone position. ICU Fellowship Training Radboudumc
ARDS Assisted ventilation and prone position ICU Fellowship Training Radboudumc Fig. 1 Physiological mechanisms controlling respiratory drive and clinical consequences of inappropriate respiratory drive
Maternal and Fetal Physiology
Background Maternal and Fetal Physiology Anderson Lo, DO Fellow, Maternal-Fetal Medicine Wayne State University School of Medicine SEMCME Fetal Assessment Course July 20, 2018 Oxygen pathway Mother Placenta
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) Rv
ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) Rv.8.18.18 ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) SUDDEN PROGRESSIVE FORM OF ACUTE RESPIRATORY FAILURE ALVEOLAR CAPILLARY MEMBRANE BECOMES DAMAGED AND MORE
ARDS: an update 6 th March A. Hakeem Al Hashim, MD, FRCP SQUH
ARDS: an update 6 th March 2017 A. Hakeem Al Hashim, MD, FRCP SQUH 30M, previously healthy Hx: 1 week dry cough Gradually worsening SOB No travel Hx Case BP 130/70, HR 100/min ph 7.29 pco2 35 po2 50 HCO3
ECMO: a breakthrough in care for respiratory failure. PD Dr. Thomas Müller Regensburg no conflict of interest
ECMO: a breakthrough in care for respiratory failure? PD Dr. Thomas Müller Regensburg no conflict of interest 1 Overview Mortality of severe ARDS Indication for ECMO PaO 2 /FiO 2 Efficiency of ECMO: gas
Respiratory insufficiency in bariatric patients
Respiratory insufficiency in bariatric patients Special considerations or just more of the same? Weaning and rehabilation conference 6th November 2015 Definition of obesity Underweight BMI< 18 Normal weight
ARF, Mechaical Ventilation and PFTs: ACOI Board Review 2018
ARF, Mechaical Ventilation and PFTs: ACOI Board Review 2018 Thomas F. Morley, DO, FACOI, FCCP, FAASM Professor of Medicine Chairman Department of Internal Medicine Director of the Division of Pulmonary,
Experience with Low Flow ECCO2R device on a CRRT platform : CO2 removal
Experience with Low Flow ECCO2R device on a CRRT platform : CO2 removal Alain Combes, MD, PhD, Hôpital Pitié-Salpêtrière, AP-HP Inserm UMRS 1166, ican, Institute of Cardiometabolism and Nutrition Pierre
ECMO/ECCO 2 R in Acute Respiratory Failure
ECMO/ECCO 2 R in Acute Respiratory Failure Alain Combes, MD, PhD, Hôpital Pitié-Salpêtrière, AP-HP Inserm UMRS 1166, ican, Institute of Cardiometabolism and Nutrition Sorbonne Pierre et Marie Curie University,
Introduction and Overview of Acute Respiratory Failure
Introduction and Overview of Acute Respiratory Failure Definition: Acute Respiratory Failure Failure to oxygenate Inadequate PaO 2 to saturate hemoglobin PaO 2 of 60 mm Hg ~ SaO 2 of 90% PaO 2 of 50 mm
RESPIRATORY FAILURE. Dr Graeme McCauley KGH
RESPIRATORY FAILURE Dr Graeme McCauley KGH Definitions Failure to oxygenate-pao2 < 60 Failure to clear CO2-PaCO2 > 50 Acute vs Chronic Hypoxemic failure- type l Hypercapneic failure- type ll Causes of
Critical Care in Obstetrics: An Innovative and Integrated Model for Learning the Essentials
Critical Care in Obstetrics: An Innovative and Integrated Model for Learning the Essentials Respiratory Distress Syndrome and Pulmonary Edema Sonya S. Abdel-Razeq, MD Maternal-Fetal Medicine Surgical Critical
Outcomes From Severe ARDS Managed Without ECMO. Roy Brower, MD Johns Hopkins University Critical Care Canada Forum Toronto November 1, 2016
Outcomes From Severe ARDS Managed Without ECMO Roy Brower, MD Johns Hopkins University Critical Care Canada Forum Toronto November 1, 2016 Severe ARDS Berlin Definition 2012 P:F ratio 100 mm Hg Prevalence:
Wanchai Wongkornrat Cardiovascular Thoracic Surgery Siriraj Hospital Mahidol University
Wanchai Wongkornrat Cardiovascular Thoracic Surgery Siriraj Hospital Mahidol University Assess adequacy of ventilation and oxygenation Aids in establishing a diagnosis and severity of respiratory failure
Lecture Notes. Chapter 3: Asthma
Lecture Notes Chapter 3: Asthma Objectives Define asthma and status asthmaticus List the potential causes of asthma attacks Describe the effect of asthma attacks on lung function List the clinical features
Weaning from Mechanical Ventilation. Dr Azmin Huda Abdul Rahim
Weaning from Mechanical Ventilation Dr Azmin Huda Abdul Rahim Content Definition Classification Weaning criteria Weaning methods Criteria for extubation Introduction Weaning comprises 40% of the duration
Management of refractory ARDS. Saurabh maji
Management of refractory ARDS Saurabh maji Refractory hypoxemia as PaO2/FIO2 is less than 100 mm Hg, inability to keep plateau pressure below 30 cm H2O despite a VT of 4 ml/kg development of barotrauma
Hyaline membrane disease. By : Dr. Ch Sarishma Peadiatric Pg
Hyaline membrane disease By : Dr. Ch Sarishma Peadiatric Pg Also called Respiratory distress syndrome. It occurs primarily in premature infants; its incidence is inversely related to gestational age and
ACUTE RESPIRATORY DISTRESS SYNDROME
ACUTE RESPIRATORY DISTRESS SYNDROME Angel Coz MD, FCCP, DCE Assistant Professor of Medicine UCSF Fresno November 4, 2017 No disclosures OBJECTIVES Identify current trends and risk factors of ARDS Describe
CARDIAC ARREST IN SPECIAL CIRCUMSTANCES 2
CARDIAC ARREST IN SPECIAL CIRCUMSTANCES 2 M1 Objectives To understand how resuscitation techniques should be modified in the special circumstances of: Hypothermia Immersion and submersion Poisoning Pregnancy
Ventilatory Management of ARDS. Alexei Ortiz Milan; MD, MSc
Ventilatory Management of ARDS Alexei Ortiz Milan; MD, MSc 2017 Outline Ventilatory management of ARDS Protected Ventilatory Strategy Use of NMB Selection of PEEP Driving pressure Lung Recruitment Prone
AVOIDING THE CRASH 3: RELAX, OPTIMAL POST-AIRWAY MANAGEMENT AVOIDING THE CRASH: OPTIMIZE YOUR PRE, PERI, AND POST AIRWAY MANAGEMENT
AVOIDING THE CRASH: OPTIMIZE YOUR PRE, PERI, AND POST AIRWAY MANAGEMENT Robert J. Vissers MD Chief, Emergency Medicine, Quality Chair, Legacy Emanuel Medical Center Adjunct Associate Professor, OHSU Portland,
a. Will not suppress respiratory drive in acute asthma
Status Asthmaticus & COPD with Respiratory Failure - Key Points M.J. Betzner MD FRCPc - NYEMU Toronto 2018 Overview This talk is about the sickest of the sick patients presenting with severe or near death
SWISS SOCIETY OF NEONATOLOGY. Supercarbia in an infant with meconium aspiration syndrome
SWISS SOCIETY OF NEONATOLOGY Supercarbia in an infant with meconium aspiration syndrome January 2006 2 Wilhelm C, Frey B, Department of Intensive Care and Neonatology, University Children s Hospital Zurich,
Oxygenation Failure. Increase FiO2. Titrate end-expiratory pressure. Adjust duty cycle to increase MAP. Patient Positioning. Inhaled Vasodilators
Oxygenation Failure Increase FiO2 Titrate end-expiratory pressure Adjust duty cycle to increase MAP Patient Positioning Inhaled Vasodilators Extracorporeal Circulation ARDS Radiology Increasing Intensity
Case Scenarios. Dr Shrikanth Srinivasan MD,DNB,FNB,EDIC. Consultant, Critical Care Medicine Medanta, The Medicity
Case Scenarios Dr Shrikanth Srinivasan MD,DNB,FNB,EDIC Consultant, Critical Care Medicine Medanta, The Medicity Case 1 A 36 year male with cirrhosis and active GI bleeding is intubated to protect his airway,
Bi-Level Therapy: Boosting Comfort & Compliance in Apnea Patients
Bi-Level Therapy: Boosting Comfort & Compliance in Apnea Patients Objectives Describe nocturnal ventilation characteristics that may indicate underlying conditions and benefits of bilevel therapy for specific
Cardiorespiratory Physiotherapy Tutoring Services 2017
VENTILATOR HYPERINFLATION ***This document is intended to be used as an information resource only it is not intended to be used as a policy document/practice guideline. Before incorporating the use of
APRV Ventilation Mode
APRV Ventilation Mode Airway Pressure Release Ventilation A Type of CPAP Continuous Positive Airway Pressure (CPAP) with an intermittent release phase. Patient cycles between two levels of CPAP higher
Mechanical Ventilation in COPD patients
Mechanical Ventilation in COPD patients Θεόδωρος Βασιλακόπουλος Καθηγητής Πνευμονολογίας-Εντατικής Θεραπείας Εθνικό & Καποδιστριακό Πανεπιστήμιο Αθηνών Νοσοκομείο «ο Ευαγγελισμός» Adjunct Professor, McGill
Ventilator ECMO Interactions
Ventilator ECMO Interactions Lorenzo Del Sorbo, MD CCCF Toronto, October 2 nd 2017 Disclosure Relevant relationships with commercial entities: none Potential for conflicts within this presentation: none
Concerns and Controversial Issues in NPPV. Concerns and Controversial Issues in Noninvasive Positive Pressure Ventilation
: Common Therapy in Daily Practice Concerns and Controversial Issues in Noninvasive Positive Pressure Ventilation Rongchang Chen Guangzhou Institute of Respiratory Disease as the first choice of mechanical
CASE PRESENTATION VV ECMO
CASE PRESENTATION VV ECMO Joshua Huelster, MD Fellow in Critical Care Medicine Department of Pulmonary and Critical Care Medicine Hennepin County Medical Center Disclosure There are no conflicts of interest
Dr. Yasser Fathi M.B.B.S, M.Sc, M.D. Anesthesia Consultant, Head of ICU King Saud Hospital, Unaizah
BY Dr. Yasser Fathi M.B.B.S, M.Sc, M.D Anesthesia Consultant, Head of ICU King Saud Hospital, Unaizah Objectives For Discussion Respiratory Physiology Pulmonary Graphics BIPAP Graphics Trouble Shootings
Lecture Notes. Chapter 4: Chronic Obstructive Pulmonary Disease (COPD)
Lecture Notes Chapter 4: Chronic Obstructive Pulmonary Disease (COPD) Objectives Define COPD Estimate incidence of COPD in the US Define factors associated with onset of COPD Describe the clinical features
Post Arrest Ventilation/Oxygenation Management
Post Arrest Ventilation/Oxygenation Management Richard Branson MSc RRT Professor of Surgery University of Cincinnati Editor-In-Chief Respiratory Care 0 Presenter Disclosure Information Richard Branson
NIV in Acute Respiratory Failure: Where we fail? Dr Shrikanth Srinivasan MD,DNB,FNB,EDIC Consultant, Critical Care Medicine Medanta, The Medicity
NIV in Acute Respiratory Failure: Where we fail? Dr Shrikanth Srinivasan MD,DNB,FNB,EDIC Consultant, Critical Care Medicine Medanta, The Medicity Use of NIV 1998-2010 50 45 40 35 30 25 20 15 10 5 0 1998
Noninvasive respiratory support:why is it working?
Noninvasive respiratory support:why is it working? Paolo Pelosi Department of Surgical Sciences and Integrated Diagnostics (DISC) IRCCS San Martino IST University of Genoa, Genoa, Italy ppelosi@hotmail.com
The Association Between Oxygenation Thresholds and Mortality During Extracorporeal Life Support
The Association Between Oxygenation Thresholds and Mortality During Extracorporeal Life Support Laveena Munshi, MD, MSc November 1, 2016 Critical Care Canada Forum Interdepartmental Division of Critical
Shock is defined as a state of cellular and tissue hypoxia due to : reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen
Shock is defined as a state of cellular and tissue hypoxia due to : reduced oxygen delivery and/or increased oxygen consumption or inadequate oxygen utilization The effects of shock are initially reversible
ARF. 8 8 (PaO 2 / FIO 2 ) NPPV NPPV ( P = 0.37) NPPV NPPV. (PaO 2 / FIO 2 > 200 PaO 2 / FIO 2 NPPV > 100) (P = 0.02) NPPV ( NPPV P = 0.
Monica Rocco, MD; Donatella Dell'Utri, MD; Andrea Morelli, MD; Gustavo Spadetta, MD; Giorgio Conti, MD; Massimo Antonelli, MD; and Paolo Pietropaoli, MD (ARF) (NPPV) 19 ARF ( 8 8 3 ) NPPV 19 (PaO 2 / FIO
Keeping Patients Off the Vent: Bilevel, HFNC, Neither?
Keeping Patients Off the Vent: Bilevel, HFNC, Neither? Robert Kempainen, MD Pulmonary and Critical Care Medicine Hennepin County Medical Center University of Minnesota School of Medicine Objectives Summarize
Mechanical Ventilation in COPD patients
Mechanical Ventilation in COPD patients Θεόδωρος Βασιλακόπουλος Καθηγητής Πνευμονολογίας-Εντατικής Θεραπείας Εθνικό & Καποδιστριακό Πανεπιστήμιο Αθηνών Νοσοκομείο «ο Ευαγγελισμός» Adjunct Professor, McGill
Chronic Obstructive Pulmonary Disease
136 PHYSIOLOGY CASES AND PROBLEMS Case 24 Chronic Obstructive Pulmonary Disease Bernice Betweiler is a 73-year-old retired seamstress who has never been married. She worked in the alterations department
NIV use in ED. Dr. Khalfan AL Amrani Emergency Resuscitation Symposium 2 nd May 2016 SQUH
NIV use in ED Dr. Khalfan AL Amrani Emergency Resuscitation Symposium 2 nd May 2016 SQUH Outline History & Introduction Overview of NIV application Review of proven uses of NIV History of Ventilation 1940
Extracorporeal Membrane Oxygenation (ECMO)
Extracorporeal Membrane Oxygenation (ECMO) Policy Number: Original Effective Date: MM.12.006 05/16/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 11/01/2014 Section: Other/Miscellaneous
Basic mechanisms disturbing lung function and gas exchange
Basic mechanisms disturbing lung function and gas exchange Blagoi Marinov, MD, PhD Pathophysiology Department, Medical University of Plovdiv Respiratory system 1 Control of breathing Structure of the lungs
Respiratory Physiology Part II. Bio 219 Napa Valley College Dr. Adam Ross
Respiratory Physiology Part II Bio 219 Napa Valley College Dr. Adam Ross Gas exchange Gas exchange in the lungs (to capillaries) occurs by diffusion across respiratory membrane due to differences in partial
ARDS & TBI - Trading Off Ventilation Targets
ARDS & TBI - Trading Off Ventilation Targets Salvatore M. Maggiore, MD, PhD Rome, Italy smmaggiore@rm.unicatt.it Conflict of interest Principal Investigator: RINO trial o Nasal high-flow vs Venturi mask
Asthma and COPD in the ICU
Asthma and COPD in the ICU Prescott Woodruff, MD, MPH Assistant Professor Medicine in Residence Pulmonary and Critical Care Medicine, Department of Medicine Acute Exacerbations of Asthma Asthma exacerbations
Year in Review Intensive Care Training Program Radboud University Medical Centre Nijmegen
Year in Review 2013 Intensive Care Training Program Radboud University Medical Centre Nijmegen Contents ARDS Ventilator associated pneumonia Tracheostomy and endotracheal intubation Enteral feeding Fluid
ECLS Registry Form Extracorporeal Life Support Organization (ELSO)
ECLS Registry Form Extracorporeal Life Support Organization (ELSO) Center ID: Center name: Run No (for this patient) Unique ID: Birth Date/Time Sex: (M, F) Race: (Asian, Black, Hispanic, White, Other)
Agenda. Mechanical Ventilation in Morbidly Obese Patients. Paolo Pelosi. ESPCOP, Ostend, Belgium Saturday, November 14, 2009.
Mechanical Ventilation in Morbidly Obese Patients t Paolo Pelosi Department of Ambient, Health and Safety University of Insubria - Varese, ITALY ppelosi@hotmail.com ESPCOP, Ostend, Belgium Saturday, November
Veno-Venous ECMO Support. Chris Cropsey, MD Sept. 21, 2015
Veno-Venous ECMO Support Chris Cropsey, MD Sept. 21, 2015 Objectives List indications and contraindications for ECMO Describe hemodynamics and oxygenation on ECMO Discuss evidence for ECMO outcomes Identify
NON-INVASIVE VENTILATION. Lijun Ding 23 Jan 2018
NON-INVASIVE VENTILATION Lijun Ding 23 Jan 2018 Learning objectives What is NIV The difference between CPAP and BiPAP The indication of the use of NIV Complication of NIV application Patient monitoring
Lecture Notes. Chapter 2: Introduction to Respiratory Failure
Lecture Notes Chapter 2: Introduction to Respiratory Failure Objectives Define respiratory failure, ventilatory failure, and oxygenation failure List the causes of respiratory failure Describe the effects
Landmark articles on ventilation
Landmark articles on ventilation Dr Shrikanth Srinivasan MD,DNB,FNB,EDIC Consultant, Critical Care Medicine Medanta, The Medicity ARDS AECC DEFINITION-1994 ALI Acute onset Bilateral chest infiltrates PCWP
Extracorporeal support in acute respiratory failure. Dr Anthony Bastin Consultant in critical care Royal Brompton Hospital, London
Extracorporeal support in acute respiratory failure Dr Anthony Bastin Consultant in critical care Royal Brompton Hospital, London Objectives By the end of this session, you will be able to: Describe different
Learning Objectives. 1. Indications versus contra-indications 2. CPAP versus NiVS 3. Clinical evidence
Learning Objectives 1. Indications versus contra-indications 2. CPAP versus NiVS 3. Clinical evidence Pre-hospital Non-invasive vventilatory support Marc Gillis, MD Imelda Bonheiden Our goal out there
Sub-category: Intensive Care for Respiratory Distress
Course n : Course 3 Title: RESPIRATORY PHYSIOLOGY, PHYSICS AND PATHOLOGY IN RELATION TO ANAESTHESIA AND INTENSIVE CARE Sub-category: Intensive Care for Respiratory Distress Topic: Acute Respiratory Distress
Prepared by : Bayan Kaddourah RN,MHM. GICU Clinical Instructor
Mechanical Ventilation Prepared by : Bayan Kaddourah RN,MHM. GICU Clinical Instructor 1 Definition Is a supportive therapy to facilitate gas exchange. Most ventilatory support requires an artificial airway.
ARDS Management Protocol
ARDS Management Protocol February 2018 ARDS Criteria Onset Within 1 week of a known clinical insult or new or worsening respiratory symptoms Bilateral opacities not fully explained by effusions, lobar/lung
i. Zone 1 = dead space ii. Zone 2 = ventilation = perfusion (ideal situation) iii. Zone 3 = shunt
Respiratory Review I. Oxygen transport a. Oxygen content of blood i. Dissolved oxygen =.003 x PaO 2, per 100 ml plasma 1. Henry s Law ii. Oxygen on hemoglobin = 1.34 ml x sat x Hgb iii. CaO 2 = Dissolved
1. When a patient fails to ventilate or oxygenate adequately, the problem is caused by pathophysiological factors such as hyperventilation.
Chapter 1: Principles of Mechanical Ventilation TRUE/FALSE 1. When a patient fails to ventilate or oxygenate adequately, the problem is caused by pathophysiological factors such as hyperventilation. F
ARDS and Lung Protection
ARDS and Lung Protection Kristina Sullivan, MD Associate Professor University of California, San Francisco Department of Anesthesia and Perioperative Care Division of Critical Care Medicine Overview Low
Surgery Grand Rounds. Non-invasive Ventilation: A valuable tool. James Cromie, PGY 3 8/24/09
Surgery Grand Rounds Non-invasive Ventilation: A valuable tool James Cromie, PGY 3 8/24/09 History of mechanical ventilation 1930 s: use of iron lung 1940 s: First NIV system (Bellevue Hospital) 1950 s:
High Flow Humidification Therapy, Updates.
High Flow Humidification Therapy, Updates. Bernardo Selim, M.D. I have no relevant financial relationships to disclose. Assistant Professor, Pulmonary, Critical Care and Sleep Medicine, Mayo Clinic What
ECCO 2 Removal The Perfusionists Perspective
ECCO 2 Removal The Perfusionists Perspective BelSECT Education evening 2016-06-15 D. Hella, Th. Amand, J-N Koch Definition ECCO 2 Removal: Process by which an extracorporeal circuit is used for removing
Recent Advances in Respiratory Medicine
Recent Advances in Respiratory Medicine Dr. R KUMAR Pulmonologist Non Invasive Ventilation (NIV) NIV Noninvasive ventilation (NIV) refers to the administration of ventilatory support without using an invasive
Handling Common Problems & Pitfalls During. Oxygen desaturation in patients receiving mechanical ventilation ACUTE SEVERE RESPIRATORY FAILURE
Handling Common Problems & Pitfalls During ACUTE SEVERE RESPIRATORY FAILURE Pravit Jetanachai, MD QSNICH Oxygen desaturation in patients receiving mechanical ventilation Causes of oxygen desaturation 1.
Asthma Management in ICU. by DrGary Au From KWH
Asthma Management in ICU by DrGary Au From KWH Overview of Asthma Pathophysiology Therapeutic options Medical treatment NPPV Mechanical ventilation Salvage therapy ~ 235 million people worldwide were affected
Non-invasive Positive Pressure Mechanical Ventilation: NIPPV: CPAP BPAP IPAP EPAP. My Real Goals. What s new in 2018? OMG PAP?
Non-invasive Positive Pressure Mechanical Ventilation: What s new in 2018? Geoffrey R. Connors, MD, FACP Associate Professor of Medicine University of Colorado School of Medicine Division of Pulmonary
OXYGENATION AND ACID- BASE EVALUATION. Chapter 1
OXYGENATION AND ACID- BASE EVALUATION Chapter 1 MECHANICAL VENTILATION Used when patients are unable to sustain the level of ventilation necessary to maintain the gas exchange functions Artificial support
Capnography. Capnography. Oxygenation. Pulmonary Physiology 4/15/2018. non invasive monitor for ventilation. Edward C. Adlesic, DMD.
Capnography Edward C. Adlesic, DMD University of Pittsburgh School of Dental Medicine 2018 North Carolina Program Capnography non invasive monitor for ventilation measures end tidal CO2 early detection
CLINICAL VIGNETTE 2016; 2:3
CLINICAL VIGNETTE 2016; 2:3 Editor-in-Chief: Olufemi E. Idowu. Neurological surgery Division, Department of Surgery, LASUCOM/LASUTH, Ikeja, Lagos, Nigeria. Copyright- Frontiers of Ikeja Surgery, 2016;
Arterial Blood Gases. Dr Mark Young Mater Health Services
Arterial Blood Gases Dr Mark Young Mater Health Services Why do them? Quick results Bedside test Range of important information Oxygenation Effectiveness of gas exchange Control of ventilation Acid base
Extracorporeal Membrane Oxygenation (ECMO)
Extracorporeal Membrane Oxygenation (ECMO) Policy Number: Original Effective Date: MM.12.006 05/16/2006 Line(s) of Business: Current Effective Date: HMO; PPO; QUEST Integration 01/01/2017 Section: Other/Miscellaneous
Tissue is the Issue. PEEP CPAP FiO2 HFNC PSV HFNC. DO 2 = CO [(Hb x 1.34) SaO PaO 2 ] perfusione
![Tissue is the Issue. PEEP CPAP FiO2 HFNC PSV HFNC. DO 2 = CO [(Hb x 1.34) SaO PaO 2 ] perfusione](/thumbs/79/78902905.jpg "Tissue is the Issue. PEEP CPAP FiO2 HFNC PSV HFNC. DO 2 = CO [(Hb x 1.34) SaO PaO 2 ] perfusione")
Tissue is the Issue perfusione PEEP CPAP FiO2 HFNC PSV HFNC DO 2 = CO [(Hb x 1.34) SaO 2 + 0.003 PaO 2 ] O2 HFNC PEEP CPAP PSV ARF ACPE HIGH FLOW NASAL CANNULA High and Exact FiO2, High Flow heating and
What is the next best step?
Noninvasive Ventilation William Janssen, M.D. Assistant Professor of Medicine National Jewish Health University of Colorado Denver Health Sciences Center What is the next best step? 65 year old female
MECHANICAL VENTILATION PROTOCOLS
GENERAL or SURGICAL Initial Ventilator Parameters Ventilator Management (see appendix I) Assess Patient Data (see appendix II) Data Collection Mode: Tidal Volume: FIO2: PEEP: Rate: I:E Ratio: ACUTE PHASE
3. Which of the following would be inconsistent with respiratory alkalosis? A. ph = 7.57 B. PaCO = 30 mm Hg C. ph = 7.63 D.
Pilbeam: Mechanical Ventilation, 4 th Edition Test Bank Chapter 1: Oxygenation and Acid-Base Evaluation MULTIPLE CHOICE 1. The diffusion of carbon dioxide across the alveolar capillary membrane is. A.
NIV in COPD Acute and Chronic Use
NIV in COPD Acute and Chronic Use Dr C M Chu MD, MSc, FRCP, FCCP Consultant Physician Department of Medicine & Geriatrics United Christian Hospital, Hong Kong NIV in COPD I. AE-COPD/ARF II. III. Weaning
INTRODUCTION The effect of CPAP works on lung mechanics to improve oxygenation (PaO 2
2 Effects of CPAP INTRODUCTION The effect of CPAP works on lung mechanics to improve oxygenation (PaO 2 ). The effect on CO 2 is only secondary to the primary process of improvement in lung volume and
Causes and Consequences of Respiratory Centre Depression and Hypoventilation
Causes and Consequences of Respiratory Centre Depression and Hypoventilation Lou Irving Director Respiratory and Sleep Medicine, RMH louis.irving@mh.org.au Capacity of the Respiratory System At rest During
Critical Care Monitoring. Assessing the Adequacy of Tissue Oxygenation. Tissue Oxygenation - Step 1. Tissue Oxygenation
Critical Care Monitoring 1 Assessing the Adequacy of Tissue oxygenation is the end-product of many complex steps 2 - Step 1 Oxygen must be made available to alveoli 3 1 - Step 2 Oxygen must cross the alveolarcapillary
NIV - BI-LEVEL POSITIVE AIRWAY PRESSURE (BIPAP)
Introduction NIV - BI-LEVEL POSITIVE AIRWAY PRESSURE (BIPAP) Noninvasive ventilation (NIV) is a method of delivering oxygen by positive pressure mask that allows for the prevention or postponement of invasive
Respiratory Mechanics
Respiratory Mechanics Critical Care Medicine Specialty Board Tutorial Dr Arthur Chun-Wing LAU Associate Consultant Intensive Care Unit, Pamela Youde Nethersole Eastern Hospital, Hong Kong 17 th June 2014
Respiratory Medicine. Some pet peeves and other random topics. Kyle Perrin
Respiratory Medicine Some pet peeves and other random topics Kyle Perrin Overview 1. Acute asthma Severity assessment and management 2. Acute COPD NIV and other management 3. Respiratory problems in the
a. Describe the physiological consequences of intermittent positive pressure ventilation and positive end-expiratory pressure.
B. 10 Applied Respiratory Physiology a. Describe the physiological consequences of intermittent positive pressure ventilation and positive end-expiratory pressure. Intermittent positive pressure ventilation
Cardiorespiratory Interactions:
Cardiorespiratory Interactions: The Heart - Lung Connection Jon N. Meliones, MD, MS, FCCM Professor of Pediatrics Duke University Medical Director PCVICU Optimizing CRI Cardiorespiratory Economics O2:
Anaesthetic considerations for laparoscopic surgery in canines
Vet Times The website for the veterinary profession https://www.vettimes.co.uk Anaesthetic considerations for laparoscopic surgery in canines Author : Chris Miller Categories : Canine, Companion animal,
Respiratory Pathophysiology Cases Linda Costanzo Ph.D.
Respiratory Pathophysiology Cases Linda Costanzo Ph.D. I. Case of Pulmonary Fibrosis Susan was diagnosed 3 years ago with diffuse interstitial pulmonary fibrosis. She tries to continue normal activities,
The Art and Science of Weaning from Mechanical Ventilation
The Art and Science of Weaning from Mechanical Ventilation Shekhar T. Venkataraman M.D. Professor Departments of Critical Care Medicine and Pediatrics University of Pittsburgh School of Medicine Some definitions
Acute Respiratory Distress Syndrome (ARDS) An Update
Acute Respiratory Distress Syndrome (ARDS) An Update Prof. A.S.M. Areef Ahsan FCPS(Medicine) MD(Critical Care Medicine) MD ( Chest) Head, Dept. of Critical Care Medicine BIRDEM General Hospital INTRODUCTION
OSCAR & OSCILLATE. & the Future of High Frequency Oscillatory Ventilation (HFOV)
& & the Future of High Frequency Oscillatory Ventilation (HFOV) www.philippelefevre.com What do we know already? Sud S et al. BMJ 2010 & Multi-centre randomised controlled trials of HFOV verses current
1. What is delayed sequence intubation? Can it be used for severe Asthma exacerbation? 2. What about pregnancy and Asthma is so important?
Chapter 073 Asthma Episode Overview 1. 10 different causes of a wheeze. 2. List 8 risk factors for death from asthma 3. List 6 objective findings of severe asthma 4. 10 therapies for an acute severe asthma
7/4/2015. diffuse lung injury resulting in noncardiogenic pulmonary edema due to increase in capillary permeability
Leanna R. Miller, RN, MN, CCRN-CMC, PCCN-CSC, CEN, CNRN, CMSRN, NP Education Specialist LRM Consulting Nashville, TN Objectives Identify the 5 criteria for the diagnosis of ARDS. Discuss the common etiologies
Mechanical Ventilation. Assessing the Adequacy of Tissue Oxygenation. Tissue Oxygenation - Step 1. Tissue Oxygenation
1 Mechanical Ventilation Assessing the Adequacy of 2 Tissue oxygenation is the end-product of many complex steps - Step 1 3 Oxygen must be made available to alveoli 1 - Step 2 4 Oxygen must cross the alveolarcapillary