CLINICAL VIGNETTE 2016; 2:3

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1 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; 2:3 1

2 MECHANICAL VENTILATION ABOLUDE M. O. Department of Anaesthesia, Lagos State University Teaching Hospital, Ikeja, Lagos, Nigeria. Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 2

3 INTRODUCTION CLASSIFICATION INDICATION FOR MECHANICAL VENTILATION (MV) TYPES OF VENTILATOR MODES OF VENTILATOR COMPLICATIONS OF MV/MGT CONCLUSION Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 3

4 INTRODUCTION A METHOD TO MECHANICALLY ASSIST OR REPLACE SPONTANEOUS BREATHING FIRST DESCRIBED- GALEN ALSO VESALIUS AND GORGE POE Type I respiratory failure- low oxygen, and normal or low carbon dioxide levels Type II respiratory failure- low oxygen, with high carbon dioxide Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 4

5 PRINCIPLES OF VENTILATION 1. NEGATIVE-PRESSURE VENTILATION ALSO KNOWN AS DRINKER AND SHAW TANK DEVELOPED IN 1929 REFINED DURING POLIO EPIDEMIC 1940 PRINCIPLES=VACCUM-AIR INFLOW 2. POSITIVE-PRESSURE VENTILATION PPV CAN BE CLASSIFIED INTO: 1. NON-INVASIVE POSITIVE PRESSURE VENTILATION(NIPPV) A METHOD OF POSITIVE PRESSURE VENTILATION WITHOUT USE OF ETT AN EXAMPLE IS WATER S CIRCUIT 2. INVASIVE POSITIVE PRESSURE VENTILATION Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 5

6 GUIDELINES FOR MV RESPIRATORY GAS TENSION DIRECT INDCES: -PaO2 < 50mmHg or PaCO2 >50mmHg in absence of metabolic acidosis DERIVED INDICES: -PaO2/FiO2 < 300mmHg MODES OF MECHANICAL VENTILATORS 1. PRESSURED-CYCLE VENTILATORS: delivers inspired gas to the lungs until a preset pressure level is reached 2. VOLUME-CYCLED VENTILATORS: DELIVERS A PRESET TIDAL VOLUME TO THE PATIENT REGARDLESS OF THE PRESSSURE REQUIRED TYPES OF MECHANICAL VENTILATORS 1. TRANSPORT VENTILATORS 2. ICU VENTILATORS 3. NICU VENTILATORS Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 6

7 MODES OF MECHANICAL VENTILATORS COMMON MODES OF VENTILATION 1. CMV (controlled mech. Ventilation) 2. ACV (assist-controlled ventilation) 3. IMV (intermittent mandatory ventilation) 4. SIMV (synchronised IMV) 5. PCV (pressure-controlled ventilation) 6. PSV (pressure-support ventilation) 7. IRV (inverse ratio ventilation) 8. HFV (High-frequency ventilation) ADJUNCT MODES PEEP- Positive end-expiratory pressure CPAP- continuous positive airway pressure BiPAP- bilevel positive airway pressure Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 7

8 BAG-VALVE-MASK RESUSCITATOR Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 8

9 A MECHANICAL VENTILATOR Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 9

10 INDICATIONS FOR MV 1. HYPOXIA (HYPOXIC FAILURE) TYPE I -Pneumonia -Pulmonary edema from any cause -CVA -ARDS -Acute lung injury -Muscular dystrophies -Pneumothorax -COPD, shock, Sepsis, Hypotension 2. VENTILATORY FAILURE TYPE II -Drug overdose(opiates,narcotics) -Head injury -CVA -Gullian Barre -Poliomyelitis -Muscular dystrophies -Amyotropic muscular sclerosis -Myaesthenia gravis -Kyphoscoliosis Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 10

11 MODES OF MV CMV: -USED IN PT WITH NO RESP. EFFORT -PRESET RESP. FREQUENCY & VT -HEAVILY SEDATED AND PARALYSED -UNCONSCIOUS PATIENT, APNEIC ACV: - PATIENT CAN BREATH -DELIVERS A SET MINIMUM NUMBER OF MANDATORY BREATHS IF SPONTANEOUS R.R FALLS BELOW PRESET SIMV: -THIS MODE PREVENTS THE STACKING OF BREATHS -BY TIMIMING MECHANICAL BREATHS TO COINCIDE WITH SPONTANEOUS BREATH IMV: ALLOWS PATIENT TO BREATHE SPONTANEOUSLY THROUGH THE CIRCUIT WHILE THE VENTILATOR INTERMITTENTLY DELIVERS POSITIVE-PRESSURE AT A PRESET TIDAL VOLUME AND FREQUENCY A MODE FOR WEANING PATIENT OF VENTILATOR LESS BAROTRAUMA Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 11

12 INITIAL VENTILATOR SETTINGS PEEP = 5cm H2O VT = 7-10ml/kg INSP. PRESSURE = 20cm H2O FREQUENCY = 10-15/min I:E RATIO = 1:2 PRESSURE TRIGGER = -2cmH2O FLOW TRIGGER = 2L/min INITIAL FiO2 = 100% PRESSURE SUPPORT = 15cm H2O Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 12

13 Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 13

14 CONTINOUS I.V SEDATION MORPHINE 50mg IN 50mg N/S INTO 50mls SYRINGE(1mg/ml) 2-3mls BOLUS,INFUSION=3mls/hr Dose range=0-5mls/hr FENTANYL 2500mcg (UNDILUTED) IN 50mls SYRINGE(50mcg/ml) 2-3 mls BOLUS,INFUSION=3mls/hr Dose range=0-5ml PENTAZOCINE 300mg IN 50mls IN 50mls N/S INTO 50mls SYRINGE(6mg/ml) GIVE 2-3mls BOLUS THEN INFUSION AT 3mls/hr Dose range=0-5mls/hr PETHIDINE 500mg IN 50mls N/S INTO 50mls SYRINGE(10mg /ml) 2-3mls BOLUS,INFUSION=3mls/hr Dose range=0-5mls/hr MIDAZOLAM 50mg IN 50mls N/S INTO 50mls SYRINGE GIVE 2-3mls BOLUS,THEN STAR INFUSION AT 3mls/hr, CAN GO UP TO 5mls/hr IF SEDATION SCORE < 2 PROPOFOL 10mg/ml GIVE 2-3mls BOLUS THEN START INFUSION 5mls/hr CAN GO UP TO 10mls/hr CAN ADD MIDAZOLAM FOR DIFFICULT TO WEAN PATIENT Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 14

15 PARALYSIS PARALYSIS MAY BE OF BENEFIT IN SPECIFIC SITUATION e.g INTRACRANIAL HYPERTENSION OR UNCONVENTIONAL MODE OF RESPIRATION DRAWBACKS TO PARALYSIS LOSS OF NEUROLOGIC EXAMINATION ABOLISHED COUGH POTENTIAL FOR AN AWAKE PARALYSED PATIENT DEATH FROM VENTILATOR DISCONNECT DIFFICULT WEANING Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 15

16 COMPLICATIONS OF MV PNEUMOTHORAX; BAROTRAUMA VAP, BRONCHITIS DECREASED CO/BP DUE TO INCREASE INTRATHORACIC PRESSURE SEVERE HYPOXIA/HYPERCARBIA FROM ACCIDENTAL DISCONNECTION WATER RETENTION- ADH IS INCREASED IN PATIENT ON MV GI BLEEDS DUE TO STRESS ULCER- NEED FOR PROPHYLAXIS DIFFICULTY IN WEANING FROM VENTILATOR Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 16

17 WEANING FROM MV INTACT AIRWAY REFLEXES AND A COOPERATIVE PATIENT ARE ALSO MANDATORY PRIOR TO COMPLETION OF WEANING SIMILIARLY ADEQUATE OXYGENATION(ARTERIAL Hb SATURATION >90% WITH <5cmH2O PEEP IS IMPERATIVE PRIOR TO EXTUBATION CLINICAL SIGNS OF IMPROVEMENT WHICH MAY BE SUPPORTED BY LAB AND RADIOGRAPHIC FINDINGS THE MOST USEFUL WEANING PARAMETERS ARE ABG, R.R, RSBI WEANING MODES ON MV IMV SIMV PSV Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 17

18 REFRENCES CLINICAL ANAESTHESIOLOGY BY MORGAN 7 th OXFORD HANDBOOK OF ANAESTHESIA BARASH CLINICAL ANAESTHESIA 5 th EDITION ANAESTHESIA SECRETS 3 rd EDITION ANAESTHESIA AND RESUSCITATION 2001 EDITION Copyright- Frontiers of Ikeja Surgery, 2016; 2:3 18

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