Ventilator curves. Fellowonderwijs 2 feb 2012
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1 Ventilator curves Fellowonderwijs 2 feb 2012
2 Mechanical ventilation Supported Ventilator affects patients respiratory drive Monitor interaction patient - ventilator Controlled Monitor interatcion patient - ventilator
3 Waveform analysis Provide optimal ventilation Prevent adverse events of MV Most common: P,aw, flow, volume Advanced: Paralysis, P,es, P,ga, E,di
4 Control of breathing
5 Control of breathing
6 Peripheral chemosensors Chest 2000
7 S"mulus transduc"on Pa,
8 Hypoxic drive in caro"d endarteryectomy ET-O2 5.3 kpa pre-op O2 response post-op O2 response 27 kpa
9 Hypoxic drive in caro"d endarteryectomy ET-O2 5.3 kpa pre-op O2 response post-op O2 response 27 kpa
10 O 2 responsiveness of caro"d bodies
11 Central chemosensors
12 Effect of CO 2 on V E 2-5 L/min/mmHg change in Pco2
13 Pulmonary receptors stretch receptors
14 Chest wall and muscle receptors
15 Effectors
16 Mechanics of respiration
17 Equation of Motion (spontaneous) P,mus (t) = P,res (t) + P,el (t) P,mus (t) = R,rs * V (t) + E,rs * V,FRC (t) P,mus (t) = R,rs * V (t) + E,rs * V,EE (t) + PEEP,i
18 Equation of Motion (spontaneous) P,mus (t) = P,res (t) + P,el (t) P,mus (t) = R,rs * V (t) + E,rs * V,FRC (t) P,mus (t) = R,rs * V (t) + E,rs * V,EE (t) + PEEP,i Determines TV VE
19 Equation of Motion (mechanical vent) P,TOT (t) = P,mus (t) + P,aw P,aw = PTOT (t) - Pmus (t) P,aw = V (t) * Rrs + VFRC (t) *E,rs - P,mus(t)
20 Pressures applied to respiratory system
21 Function of pressure delivered by ventilator
22 Function of pressure delivered by ventilator Trigger variable
23 Function of pressure delivered by ventilator control variable Trigger variable
24 Function of pressure delivered by ventilator control variable cycle-off variable Trigger variable
25 1. Trigger variable Pressure Flow Volume Edi
26
27
28 Function of pressure delivered by ventilator control variable
29 2. Control variable (P or V ) Independent Dependent AVC volume, flow P,aw PC/PSV P,aw Volume, flow NAVA volume, flow, Paw
30 Function of pressure delivered by ventilator cycle-off variable
31 3. Cycle off variable Time (AVC, PC) Volume P,aw (PC, PS, VC) Flow (PS) E,di Ideally coincide with end neurla inspiration
32 Forms of asynchrony
33 Asynchrony
34 Asynchrony
35 Asynchrony
36 Asynchrony
37 Asynchrony
38 I. Waveforms in triggering phase 1. trigger delay 2. ineffective efforts 3. autotriggering
39 Waveforms in triggering phase
40 Waveforms in triggering phase
41 Dynamic hyperinflation Causes: Low elastic recoil respiratory system High TV, high RR Increased expiratory resistance Short neural expiratory time
42 Dynamic hyperinflation Consequences: 1. Elastic threshold load on inspiratory muscles P,mus (t) = R,rs * V (t) + E,rs * V,EE (t) + PEEP,i 2. Trigger delay / wasted efforts
43 Dynamic hyperinflation: trigger delay
44 Dynamic hyperinflation: trigger delay
45 Dynamic hyperinflation: trigger delay
46 Dynamic hyperinflation: trigger delay
47 Dynamic hyperinflation: wasted effort
48 Dynamic hyperinflation: wasted effort
49 Dynamic hyperinflation: wasted effort 1. Inspiratory muscle activity 2. Relaxation expiratory muscle 3. cardiac oscillations
50 Dynamic hyperinflation: wasted effort
51 Dynamic hyperinflation: wasted effort
52 P,aw less sensitive to detect asynchrony than V
53 P,aw less sensitive to detect asynchrony than V P,aw is less sensitive: (low circuit resistance during TE) P,aw = V E * R,exp,circuit P,aw = V E * Rexpcrircuit
54
55 Wasted effort during inspiration: ACV AVC controlled most sensitive
56 Wasted effort during inspiration: PSV most sensitive controlled
57 Asynchrony: APRV?
58 Prevention trigger delay / wasted efforts 1. Decrease hyperinflation 2. Increase Pmus during trigger phase (sedation) 3. Application PEEP,E 4. Decrease trigger threshold 5. Decrease inspiratory resistance (tube / bronchodilators)?
59 Autotriggering
60 Autotriggering
61 Autotriggering
62 Autotriggering
63 Autotriggering
64 Autotriggering
65 Autotriggering Causes Low threshold Circuit leaks Water in tubings Cardiogenic oscillations (Hiccup) Not an issue in PAV or NAVA
66 Respiratory drive Initial P,aw decrease (isometric contraction)
67 Respiratory drive
68 Respiratory drive
69 Respiratory drive
70 Respiratory drive
71 II. Waveforms during pressurization / cycle off
72 Respiratory effort ACV: Independent variables: Flow and volume P,aw: dependent P,TOT (t) = P,mus (t) + P,aw = P,res (t) + P,el (t) P,aw = PTOT (t) - Pmus (t) P,aw = V (t) * Rrs + VFRC (t) *E,rs - P,mus(t)
73 Respiratory effort: ACV
74 Respiratory effort: ACV
75 Respiratory effort: ACV
76 Respiratory effort PSV / PC: Independent variables: P,aw Dependent: volume and flow => No relation between P,mus and P,aw! To asess effort: examine flow (and volume)
77 Respiratory effort: PSV
78 Respiratory effort: PSV
79 Respiratory effort: PSV
80 Respiratory effort: PSV
81 Respiratory effort: PSV 127 deg 138 deg 144 deg Interaction P,mus and T,insp: No effort: Ti depends on and V,th Effort: Ti unpredictable
82
83 constant flow: Inadequate support?
84 P,mus during AVC
85 Severe airway obstruction PSV 1. high R,aw 2. acute insp muscle relaxation 3. exp muscle activation
86 End inspiratory increase P,aw
87 End inspiratory increase P,aw
88 Inspiratory rise time Overshoot in pressure screen dump
89 Expiratory asynchrony
90 Expiratory asynchrony
91 Expiratory asynchrony
92 Expiratory asynchrony
93 Expiratory asynchrony Early cycle off
94 Expiratory asynchrony Elastic recoil > P,mus Early cycle off
95 Expiratory asynchrony Elastic recoil > P,mus Elastic recoil < P,mus Early cycle off
96 Expiratory asynchrony Elastic recoil > P,mus Elastic recoil < P,mus Early cycle off Causes: Low PS Short Tau, RS High V,th
97 Cycle off delay Causes: Excessive PS Long Tau, RS Low V,th
98 Waveform in expiration
99 Waveform in expiration
100 Waveform in expiration Information on resistance
101 Waveform in expiration Information on resistance P,aw = V E * Rexp,circuit - PEEP
102 P,aw during expiration V E
103 Waveform in expiration Information on resistance P,aw = V E * Rexp,circuit - PEEP
104 Waveform in expiration Information on resistance P,aw = V E * Rexp,circuit - PEEP
105 Waveform in expiration Information on resistance P,aw = V E * Rexp,circuit - PEEP
106 Conclusion Curves provide information on P-V synchrony
107 Examples
108 Type of triggering?
109 Type of triggering? Zero flow Drop in pressure = Pressure triggering
110 Type of triggering? Zero flow Drop in pressure = Pressure triggering Flow trigering
111
112 PSV Flow triggering Wasted effort Trigger delay Increased R,aw
113 PSV Flow triggering Wasted effort Trigger delay Increased R,aw
114 Type of asynchrony? What has been done to improve?
115 Type of asynchrony? What has been done to improve? PSV Flow triggering Wasted effort Trigger delay
116 Type of asynchrony? What has been done to improve? PSV Flow triggering Wasted effort Trigger delay (B) Reduced trigger threshold
117 What type of asynchrony? What would you do? tekst
118 What type of asynchrony? What would you do? tekst Higher insp flow (TV =) More time expiration
119 Autotriggering?
120 Autotriggering?
121 Interpret the waveform
122 Interpret the waveform PSV Autotriggering Ineffective efforts delayed cycle off exp muscle contraction
123 Interpret the waveform PSV Autotriggering Ineffective efforts delayed cycle off exp muscle contraction
124 Interpret the waveform PSV Autotriggering Ineffective efforts delayed cycle off exp muscle contraction
125
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