MECHANICAL VENTILATION for ACUTE RESPIRATORY FAILURE Dr.

Malbar Ferrer January 21, 2014 Group TwennyWAN

Note: re6#ew pul'onary phy!#olo%y <talici;ed statements" from the lecturer **"recent audio $tate'ent! #n blue are )ro' the la!t yr;! note!

comfortable! but if it has been so long! then it also puts a strain on the finances. (nfortunatel ! in that scenario! if ou are seeing our relative smile at ou even if the have tracheostom or communicate with ou as long as the are on respirator! what will ou do) *emove the respirator because ou cannot pa an more) +ou are in a dilemma. ** %ulmonar medicine evolved onl in the 1950,s ** respirator" onl developed in the first half of the -0th centur . impetus for mech vent was triggered b the #openhagen %olio /pidemic in the earl 00,s. accompanied b the development of the blood gas machine Copenhagen polio epidemic- people with polio died of pulmonar complications1respirator failure Arterial 2lood 3as Machine **has accelerated and provided the motivation for technicians to develop a more sophisticated machine "measures #$-. $- and p4 3ellow! 5traditional respirators1cuff&F#re pla+e bellow!, . !tart o) re!p#rator &tube is rigid and no cuff1!eal, MECHANICAL VENTILATION The u!e o) a 'a+h#ne to a!!#!t or repla+e the breath#n% e))ort o) a pat#ent The pro+e!! o) u!#n% de6#+e! to e#ther "o"ally or #ar"ially pro6#de o7y%en and -82 between the en6#ron'ent and the al6eolar !pa+e o) the lun%!. The de!#red re!ult #! to 'a#nta#n appropr#ate le6el! o) 282 5appropriate for age or 6ormal for the individual 70"100 %$-8 and 2-82 #n arter#al blood wh#le al!o unload#n% the re!p#ratory 'u!+le!.

What, Why and How to Ad u!t "ent#lator $ett#n%! &Fro' A $#'ple (#)e $upport to An *th#+al D#le''a,

Pulmonary Physiology Pion rs! Andre -ournand . New /or0 D#+0#n!on W. 1#+hard! . 2h#ladelph#a Jul#u! -o'roe . $an Fran+#!+o Walla+e Fenn . 1o+he!ter Her'an 1ahn . 1o+he!ter Ja'e! Wh#ttenber%en . 3o!ton

$+#en+e o) 4ntubat#on !tarted w#th ane!the!#a 1540! . 1e!p#rator be+a'e 'ore !oph#!t#+ated 1950s ventilator became popular Life support with the respirator goes hand in hand with the development in anaesthesia **Mechanical ventilation has evolved from a simple life support to an ethical dilemma. At the end part of most respirator disorders! most especiall lung cancers and end"stage #$%&! putting the patient on mechanical vent is supposed to ma'e him

*9pirometr developed 50 rs ahead of /#3 5machine has variable interpretations and limited understanding": lagging of devt8 2ronchoscope utili;ed in the clinics in the late 1950s 99 (a%%#n% o) de6t o) !p#ro'etry due to 1. Need! +o'pl#+at#on w#th '#nute nu'ber! &0.1, 0.2 to +o'pute )or !p#ro'etry re!ult! , 2. They thou%ht be)ore that -82D #! #rre6er!#ble and w#ll only lead to a pro%re!!#6e, !low death.

They ha6e not +orrelated +#%arette !'o0#n% to -82D. <. "ar#able #nterpretat#on= need to +orrelate w#th h#!tory and 2hy!#+al *7a'#nat#on be)ore d#a%no!#! +an be 'ade 99 The +on+ept o) #nternal '#l#eu &e.% 0eep#n% the 6#tal !#%n! w#th#n a ran%e that wa! tau%ht to u! #n Med#+al $+hool, #! be#n% >ue!t#oned #n re+ent ad6an+e'ent!. We !hould be th#n0#n% #n ter'! o) a +han%#n% en6#ron'ent. The +han%#n% at'o!phere o) the body al!o !er6e! a! a +hallen%e to the re!p#rator to +ope w#th that. The do+tor #! the one who de+#de! the pea0 )low, t#dal 6olu'e, o7y%en +on+entrat#on and how 'any rate !o that #n the )a+e o) a +han%#n% d#!ea!e pro+e!!, the re!p#rator +an +ope w#th #t. In$i%a"ions! Hypo7e'#a= refers to $ Al6eolar hypo6ent#lat#on= refers to #$-** from man conditions li'e post anesthesia! snoring! ** h po=emia and alveolar h poventilation" parameters that ou refer to separatel in cases of respirator failure ** although often times if ou are h poventilating! ou are h po=emic as well Altered 'ental !tatu! "#$- retention! chronic respirator failure disorientation. head trauma abnormal breathing.** from stro'e! vehicular accident He'odyna'#+ #n!tab#l#ty= hemorrhage! 3< bleeding! #> problem**! M< 8b!tru+t#on o) the upper a#rway= ** severe allerg with lar ngeal edema! tumor obstructing the airwa 1e>u#re'ent )or !edat#on?%eneral ane!the!#a $e+ret#on!= 99 e!pe+#ally #n !tro0e pat#ent w#th 2ar0#n!on;! d#!ea!e that +annot +ou%h 2o!t operat#6e Ma or Trau'a 99 the!e are the +ond#t#on!, and not d#a%no!e! ASSESSEMENT of IMPEN&IN' VENTILATORY FAILURE PARAMETER T4DA( "8(@M* 1*$241AT81/ 1AT*?2ATT*1N LIMIT A < to B 'l?0% 5minimum to a normal individual8 C2B to <B?'#n (abored, #rre%ular

99 +annot !u!ta#n th#! rate o) breath#n%, w#ll lead to )at#%ue M4N@T* "*NT4(AT48N C 10 (?'#n &increased wor' of breathing8 ** ?> = 1 minute ** increased wor' of breathing cannot be sustained" will go to respi failure "4TA( -A2A-4T/ MAD. 4N$241AT81/ 21*$$@1* 2-82 T1*ND A 1B 'l?0% A 20 +' H28

4n+rea!#n% ** 4ow do ou establish a trend) 2 getting a series of blood gases

"4TA( $4GN$

4n+rea!#n% H1, 32

**>entilator failure refers to #$- in the 2lood gas **?idal volume@ 500 ml %h siologic dead space@ 150 ml area including the airwa s or non"gas e=change portion of the respirator s stem A50 ml in the alveoli where gas e=change occurs 150 1 500 B appro=. 0.A or 11A 511A of ventilation is dead space8 **h perventilation s ndrome" common in females Management ou correct the #$- retention through increasing the tidal volume and ou correct the severe respi al'alosis b increasing dead space 5C but not too much8 dead space = volume that goes in 5correction of respi al'alosis limited to the ratio8 <t,s easier to have a mild respi acidosis than severe respi al'alosis because it is easier to correct acidosis Minute >entilation 5"10 L (tidal volume x RR) *espirator Muscle Datigue1Eea'ness abdominal breathing! abdominal parado=us 5signs of impending respi failure even w1o blood gas8

99 de)#n#t#on !hould be l#0e: A+ute 1e!p#ratory Fa#lure Type 4 !e+ondary to A1D$ or !e+ondary to blunt +he!t #n ury )ro' 6eh#+ular a++#dent,et+. Ho( "o "r a" r s#ira"ory failur 2ro6#de 'e+han#+al 6ent#lat#on a! #nd#+ated Treat the +au!e = "a!oa+t#6e therapy 5h potension8 = Ant#b#ot#+! 5infection@ ** should be started earl ! once diagnosed! give in the ne=t -"G hrs because it affects outcome8 = Nutr#t#on = *le+trolyte repla+e'ent 5especiall H and 6a8 = 3ron+hod#lator! 5asthma and obstruction8 = $tero#d! = $ur%ery 9Me+han#+al "ent#lat#on #! only one o) the treat'ent 'odal#t#e! )or a+ute re!p#ratory )a#lure Ess n"ial an$ Un#ro) n Ca#a*ili"i s of M %hani%al V n"ila"ion ESSENTIAL NONESSENTIAL

*%roblems in ventilation 5acute h percarbic respirator failure8! inadeFuate o= genation 5acute h po=ic respirator failure8 or impending respirator failure of either t pe. ?here will also be clinical situations where both will be evident. * *espirator failure is a ventilator and o= genation problem V n"ila"ion = a'ount o) %a! that %oe! #n and out o) the lun%! 99 %a!= not u!t o7y%en aloneE +o2, o2, n#tr#+ o7#de and other %a!e! #n the at'o!phere, althou%h 'a or#ty #! n#tro%en 99 at'o!pher#+ pre!!ure F GH0 '' H% A%u" R s#ira"ory Failur *2efore it was categori;ed using A23 Two Types of Respiratory ailure! >entilator Dailure 5gas e=change8 = signified b increasing #$- 5a s mbol of gas e=change in the lungs the ventilator f=n of lungs8 = managed b increasing tidal volume 5intubation and ambu"bagging8 $= genation %roblem 5purel o= genation status8 = managed b increasing the $996ow! it is categori;ed based on the mechanism of *D@ Type 4 o7y%enat#on . pure o7y%enat#on proble' Type 2 6ent#lat#on . -82 retent#onE hyper+apne#+ type Type < . u!ually #n -N$ proble'!, F1- #n po!t=op #! the 'a#n proble' Type 4= -" 99A1F #! not a pr#'ary d#!ea!e but the end re!ult or +o'pl#+at#on o) another d#!ea!e or +ond#t#on.

T#dal "olu'e -ontrol9= 4M", $4M" high@ 10"1-ml1'g Low@ 0"7ml1'g" improves survival b -0 I -ontrol o) F482 2re!!ure !upport "ent#lat#on

Hu'#d#)#+at#on= cold $#%h )eature air needs humidification. /pista=is is d1t cold air which dries up the respi mucosa 4nternal Alar'! Ad u!table )low rate A!!#!t and -ontrol 'ode o) re!p. rate "ar#able #n!p#rat#on I e7p#rat#on t#'e! 2**2= 99can be nonessential! not all the time it is being used D#))erent pre!!ure wa6e)or' D#!play o) )low wa6e)or' H#%h )re>uen+y 6ent#lat#on

*%ermissive #$- retention 5%a#$-B50"55 mm4g8 as long as p4 is normal. p4 has more significance than the value of #$-. the purpose is to maintain low tidal volume to minimi;e barotraumas ** if our p4 is J.A5"J.G5 and our #o- is 50 or 55! it is still o'a as long as the purpose of which is to maintain the low tidal volume ventilation ** low tidal volume ventilation" has a protective mechanism on our alveoli ** >olume ventilator" the ?idal >olume is assured **%ressure ventilator" assured pressure! usuall used if without pulmonar problem! not applicable to patients with #$%&! asthma and restrictive lung disease Th %hoi% of ) n"ila"or s ""ings shoul$ * gui$ $ *y %l arly $ fin $ "h ra# u"i% n$ #oin"s! A+ute 6ent#lator )a#lure the respirator should be able to@ = Nor'al#Je 2-82 = 1edu+e dyna'#+ hyper#n)lat#on = 2re6ent auto=2**2= 99reflection of air trapping during e=piration" can result to barotrauma and pneumothora= = 1e!t the re!p#ratory 'u!+le! Hypo7#+ re!p#ratory )a#lure = 4'pro6e o7y%enat#on

M %hani%al V n"ila"ion

Mode T#dal "olu'e 3@1 &re!p#ratory rate, 2F1 F#82 4:* rat#o 2**2

MO&ES OF VENTILATION 2o!#t#6e 2re!!ure "ent#lat#on -ontrolled Mandatory "ent#lat#on A!!#!t -ontrol= 99most popular $yn+hron#Jed 4nter'#ttent Mandatory "ent#lat#on 2re!!ure $upport

Am*u*ag ) n"ila"ion+ temporar wa before intubating

**Last - are also used in weaning the patient CONTROLLE& MAN&ATORY VENTILATION No pat#ent=6ent#lator #ntera+t#on "ent#lator per)or'! all the wor0 o) breath#n% *a+h breath #! a 'a+h#ne &)#7ed, t#dal 6olu'e del#6ered at !et ba+0 up rate &t#'e tr#%%ered, Ter'#nated a)ter t#dal 6olu'e &"T, #! del#6ered &6olu'e +y+led, 1hyth' "olu'e o) a#r Fre>uen+y "elo+#ty o) a#r del#6ery -on+entrat#on o) o7y%en del#6ered

99 h#%h 6olu'e, low pre!!ure +u)) #! pre)erred than a !'all tube w#th a h#%h pre!!ure, h#%h 6olu'e +u)) **/? tube si;es@ Males@ 7 Demales@ J.5 ** bul' musculature can use up to si;e 10 **si;e of cuff is also a factor in weaning the patient off In$i%a"ions for CMV! No re!p#ratory e))ort $ub e+ted to phar'a+olo%#+ paraly!#! When the pat#ent )#%ht! the 6ent#lator #n the #n#t#al !ta%e! o) 'e+han#+al 6ent#latory !upport= sedate pt -he!t #n ury, +o'ato!e po!t op hea6#ly !edated Tetanu!, !e#Jure d#!order! Head trau'a pat#ent ASSIST CONTROL VENTILATION ,A-C MO&E. 2at#ent=6ent#lator #ntera+t#on 3reath 'ay be 'a+h#ne= or pat#ent=tr#%%ered

** wave form does not go lower than the line because the ventilator is giving all the initiative for the ventilation! no patient effort at all! no pressure coming from the patient **putting patient on a mechanical ventilation will alter the mechanics of the lungs! that is wh ! as much as possible! ou have to provide an atmosphere where the normal ph siolog will be maintained ** Ehat is the normal ph siolog ) ?he pulmonar s stem is operating on a ;ero or negative pressure. 6o positive pressure. ?he moment ou intubate! ou shift that from negative to positive. ?he pressure from the airwa to the alveoli will change. ** Ehat will that change do) Alter mechanics and result to complications li'e erosion of bronchial mucosa! predisposition to pneumonia! alveolar damage 5 alveoli operates on a ;ero to negative pressure8! bronchial circulation affectation *9ecretions provide resistance in giving tidal volume which increases pressure ": decreases o= gen deliver leading to h po=emia *Dibrotic stenosis of the trachea" due to use of inappropriate si;e of cuff. More air needed to inflate cuff":higher pressure radiating to the trancheal mucosa from the cuff. ?his leads to ischemia and fibrosis of the mucosa upon removal of /?. 99 one o) the 'o!t +o''on 99 alternate a!!#!tE #) the pat#ent breathe!, the 'a+h#ne w#ll u!t a!!#!t, but #) the pat#ent doe! not breathe, then the 'a+h#ne w#ll %#6e the ne+e!!ary breath or 6ent#lat#on Com#arison * "( n CMV an$ Assis" Con"rol CMV ASSIST CONTROL 4nd#+at#on!: 4nd#+at#on!: 4n#t#al !et=up 2ro6#de! )ull 6ent#latory !upport 2at#ent! w#thout any 2at#ent! w#th re!p#ratory dr#6e or ha6e been !ub e+ted !pontaneou! to neuro'u!+ular re!p#ratory dr#6e paraly!#! Full 6ent#latory !upport Ad6anta%e!: Ad6anta%e!: No wor0 o) breath#n% M#n#'al wor0 o) breath#n% Allow! pat#ent to +ontrol the re!p#ratory rate D#!ad6anta%e!: A!yn+hrony

-o'pl#+at#on!: &99e!pe+#ally #n a!th'a and -82D, Al6eolar hyper6ent#lat#on K re!p#ratory al0alo!#! SYNCHRONI/E& INTERMITTENT MAN&ATORY VENTILATION 2at#ent=6ent#lator #ntera+t#on "ent#lator del#6er! pre!et 'andatory breath! to the pat#ent at or near the be%#nn#n% o) !pontaneou! breathE 'a+h#ne= or pat#ent= tr#%%ered a!!#!ted breath! 4n between, breath! are !pontaneou! and a!!#!ted **(sed as weaning mode ** used if the patient has a high degree of an=iet

TI&AL VOLUME 3a!ed on 43W H=L 'l?0% H=12 'l?0% . 99high tidal volume. alread discouraged $pe+#al !#tuat#on!: = A1D$ = A!th'a?-82D = 1e!tr#+t#6e d#!ea!e &!?p lun% re!e+t#on, 4ow much do ou give) Low tidal volume@ 0"7ml1'g #hec' A23 <f h percapneic! adKust accordingl 4$E &$ +$( H6$E <D <? <9 *<34?) A23@ 6ormocapnia %*/99(*/">$L(M/ L$$%@ 6o overdistention %*/99(*/"DL$E ?<M/ #(*>/9@ 6o auto" %//% VENTILATOR RATE ,0AC1+UP RATE-0UR-RR. Nor'al $pontaneou! 11: 12= 20?'#n Need to e!t#'ate '#nute 6ent#lat#on V n"ila"or s ""ing! 11 F*!t#'ated M#nute "ent#lat#on? T#dal 6olu'e &#n (, *!t#'ated M#nute "ent#lat#on & Male, F 4 7 3$A *!t#'ated M#nute "ent#lat#on &Fe'ale, F <.B 7 3$A Mu!t be +lo!e to a+tual pat#ent rate &lower by 2= 4 +y+le!, A$2us"m n"! New 1ate F &1ate 7 2a-82,?De!#red 2-82 NOTE! &o%3s l %"ur $i$ no" in%lu$ "h su%% $ing "o#i%s *u" "h s ( r in%lu$ $ in las" yr3s no" s4

In$i%a"ions! 2art#al 6ent#latory !upport Wean#n% 'ode A$)an"ag s! Ma#nta#n! re!p#ratory 'u!+le !tren%th A6o#d! 'u!+le atrophy -an be u!ed a! a wean#n% 'ode &isa$)an"ag s! -an #ndu+e 'u!+le )at#%ue PRESSURE SUPPORT VENTILATION $pontaneou! breath! &pat#ent tr#%%ered, are !upported by a pre!et pre!!ure le6el, ter'#nated when )low drop! to #nd#+ate end o) #n!p#rat#on and e7p#rat#on &)low +y+led, "ar#able #n!p#ratory t#'e and t#dal 6olu'e A$)an"ag s! @!ed to lower the wor0 o) !pontaneou! breath#n% and au%'ent a pat#ent;! !pontaneou! "T When +o'b#ned w#th $4M", !#%n#)#+antly redu+e! 82 +on!u'pt#on by de+rea!#n% the wor0 o) breath#n% -an be appl#ed to any 'ode o) M" that per'#t! !pontaneou! breath#n%

M@$T MN8W -8N-*2T$: "ent#lator! are not +apable o) 6ary#n% T# or #n!p#ratory )low w#th the a+tual 'a+h#ne rate *7. 3@1 F 10?'#nE Ttot F H !e+! 4:* rat#o F 1:<E T# F 1.B ! A+tual 1ate: <0?'#nE Ttot F 2 !e+! 4:* rat#o F <:1E T# F 1.B ! The 'a+h#ne;! ba+0=up rate !hould be +lo!e to the pat#ent;! a+tual rate D#!+repan+#e! between a+tual &tr#%%ered, and !et 'a+h#ne &ba+0=up, rate pro'ote breath#n% pattern! w#th #n6er!e 4:* t#'#n% rat#o! RESPIRATORY RATE H8W D8 /8@ MN8W 4F TH* $*TT4NG 4$ 14GHTN A3G: Nor'o+apneaE No a+#do!#! ?al0alo!#! 4:* rat#o: 1:2=< 2re!!ure=Flow Tra+#n%: No auto=2**2 A@T8=2**2 @n#ntent#onal pre!en+e o) a po!#t#6e end=e7p#ratory pre!!ure 4t #! pr#'ar#ly brou%ht about by #nade>uate e7p#ratory t#'e The 4:* rat#o #! one o) the pr#'ary deter'#nant o) auto=2**2 )or'at#onE the h#%her the 4:* rat#o, the %reater the po!!#b#l#ty o) auto=2**2 4:* 1AT48 K F(8W=1AT* $*TT4NG Nor'al $pontaneou! 4:* rat#o: 1:2=< "ent#lator $ett#n%! )or 4:* rat#o: 1:2=4 $pe+#al $#tuat#on!: 8b!tru+t#6e (un% D#!ea!e "ent#lator $ett#n%! )or )low rate: 2ea0 #n!p#ratory )low! !hould #deally 'at+h pat#ent;! pea0 #n!p#ratory de'and Th#! nor'ally re>u#re! pea0 )low! to be !et at 40 to 100 (?'#n, depend#n% on "* and dr#6e to breathe. 2*AM F(8W 1AT* -al+ulat#on: 2F1 F T#dal "olu'e &(, ? 4n!p#ratory T#'e T# &'#n, Newer 6ent#lator!: 40 . 100 (2M that a+h#e6e! the de!#red 4:* and doe! not lead to 6ery h#%h pea0 a#rway pre!!ure! M@$T MN8W -8N-*2T$ 4:* 1AT48 The )ollow#n% )a+tor! deter'#ne the 4:* rat#o &auto 2**2,

I&EALI/E& SPIRO'RAM OF 0REATH &ELIVERE& &URIN' VOLUME MECHANICAL VENTILATION

*FF*-T 8F 4N-1*A$4NG TH* 4N$241AT81/ F(8W 8N TH* 4:* 1AT48

*FF*-T 8F D*-1*A$4NG F(8W 1AT* 8N 4:* 1AT48

*FF*-T 8F D*-1*A$4NG 1AT* 8N 4:* 1AT48

*FF*-T 8F 4N-1*A$4NG 1AT* 8N 4:* 1AT48

$*"*1* -A1D481*$241AT81/ D/$F@N-T48N: 100O (*$$ $*"*1* -A1D481*$241AT81/ D/$F@N-T48N: 40O H8W D8 /8@ MN8W 4F TH* $*TT4NG 4$ 14GHTN A3G: (ea!t F#82 !how#n% ade>uate 2a82 at 82 !at C 50O 2ul!e o7#'eter: 82 !at C 50O *FF*-T 8F -HANG4NG "T 8N 4:* 1AT48 STRATE'IES TO IMPROVE O6Y'ENATION 4n+rea!e F#82 4'pro6e 6ent#lat#on and redu+e 'e+han#+al dead !pa+e 2**2 4'pro6e +#r+ulat#on Ma#nta#n he'o%lob#n le6el

S nsi"i)i"y $ett#n%: 2re!!ure tr#%%er#n% !hould be !et at the 'o!t !en!#t#6e le6el that pre6ent! !el)=+y+l#n%. Generally, th#! #! .0.B to .1.B +' H28. Flow tr#%%er#n% !y!te'! are %enerally 'ore e))#+#ent than pre!!ure tr#%%er#n%, but the +l#n#+al !#%n#)#+an+e o) th#! #! un+lear. The!e !y!te'! !hould al!o be !et at 'a7#'u' !en!#t#6#ty &1 to < (?'#n,. & sir $ FiO5

PEEP @!ed #n +on un+t#on w#th other 'ode! A#rway pre!!ure #! 'a#nta#ned at a !et rate 4nd#+at#on!: Hypo7e'#a or to redu+e F#82 to non to7#+ le6el! De+rea!e wor0 o) breath#n% )ro' e7tr#n!#+ 2**2 4ntrapul'onary !hunt K re)ra+tory hypo7e'#a De+rea!ed F1- K lun% +o'pl#an+e

$T*2 1: -8M2@T* F81 Al6eolar 282 Al6eolar 282 F G1< &F#82, . 2a-82?0.L $T*2 2: -8M2@T* F81 aA82 rat#o aA82 F 2a82? 2A82 $T*2 <: -8M2@T* F81 D*$41*D F#82 F#82 -8MM8N *M2414- $*TT4NG$: 2**2

Nor'al $pontaneou! 2**2: Pero "ent#lator $ett#n%!: 4n#t#ally !et at B +' H28 Ad u!ted later on depend#n% on the )ollow#n%: A3G re!ult! F#82 re>u#re'ent! Toleran+e to 2**2 -ard#o6a!+ular 1e!pon!e! T4T1AT48N 8F 82T4MA( 2**2 @$4NG 2a82 and -8M2(4AN-* 2**2 0 B L 10 12 2a82 4< HG GG 7A G5 -8M2(4AN-* 2H << <G GA 41

"*NT4(AT81=1*(AT*D -A@$*$ 2AT4*NT=1*(AT*D -A@$*$ 2AT4*NT="*NT4(AT81 A$/N-H18N/ A+ute hypo7e'#a dur#n% 'e+han#+al 6ent#lat#on *T or a#rway ob!tru+t#on $u+t#on#n% A#r trapp#n% -han%e! #n po!#t#on Atele+ta!#! 2neu'othora7 2ro%re!!#on o) underly#n% d#!ea!e $uper#'po!ed pneu'on#a?a!p#rat#on 2ul'onary e'bolu! T88($ 4N T18@3(*$H88T4NG A(A1M$ 2H/$4-A( *DAM4NAT48N G1A2H4-A( D4$2(A/ ALA*M9 (8W *DHA(*D "8(@M* A(A1M (8W 4N$241AT81/ 21*$$@1* A(A1M H4GH 4N$241AT81/ 21*$$@1* A(A1M A2N*A A(A1M H4GH 1*$241AT81/ 1AT* A(A1M H4GH and (8W F#82 A(A1M VENTILATOR+RELATE& CAUSES $/$T*M (*AM -41-@4T MA(F@N-T48N 4NAD*T@AT* F#82 4NAD*T@AT* "*NT4(AT81/ $@2281T

4n+rea!e! end=e7p#ratory or ba!el#ne a#rway pre!!ure to a 6alue %reater than at'o!pher#+ &0 +' H28 on the 6ent#lator 'ano'eter, 8)ten u!ed to #'pro6e o7y%enat#on !tatu! part#+ularly #n tho!e pat#ent! who are re)ra+tory to #n+rea!#n% F482 Not a Q!tand alone 'odeRE alway! u!ed #n +on un+t#on w#th other 'ode! o) 6ent#latory !upport D#!ad6anta%e! De+rea!ed 6enou! return 3arotrau'a Alterat#on! o) renal )un+t#on K water 'etabol#!' 94n+rea!ed 4-2 . due to #'pedan+e o) return )low )ro' the bra#n #n pat#ent! w#th nor'al lun% +o'pl#an+e. Alterat#on!S. Due to de+rea!ed renal per)u!#on a! a re!ult o) de+rea!ed 6enou! return K -8. CAUSES OF SU&&EN RESPIRATORY &ISTRESS IN A PATIENT ON VENTILATOR

PATIENT+ RELATE& CAUSES A1T4F4-4A( A41WA/ 2183(*M$ $*-1*T48N$ 2N*@M8TH81AD 2@(M8NA1/ *D*MA 318N-H8$2A$M 2@(M8NA1/ *M38(4$M D/NAM4- H/2*14NF(AT48N AND A@T8=2**2 D1@G=4ND@-*D 2183(*M$ A#r Flow F 2re!!ure to o6er+o'e a#rway re!#!tan+e and +o'pl#an+e &!t#))ne!!, 2ea0 a#rway pre!!ure 2lateau a#rway pre!!ure

PATIENT+VENTILATOR ASYNCHRONY De6elop! when the pat#ent;! 6ent#latory de'and! are not 'et by the 6ent#lator;! del#6ered breath! $een #n: 2at#ent! w#th h#%h #ntr#n!#+ re!p#ratory rate! 2at#ent! w#th a#rway ob!tru+t#on, auto=2**2 4nappropr#ate 6ent#lator !ett#n%!

A41WA/ "$ 2A1*N-H/MA( -A@$*$ H4GH 4N$241AT81/ 21*$$@1* A(A1M T4M* 21*$$@1* T1A-4NG W4TH 4N$241AT81/ H8(D 4n+rea!ed 242, no +han%e 2A2 F A41WA/ 4n+rea!ed 242 and 2A2 F 2A1*N-H/MA( "8(@M* 21*$$@1* (882 $h#)t to the r#%ht w#th #n+rea!ed loop area F A41WA/ $h#)t to the r#%ht w#thout +han%e #n loop area F 2A1*N-H/MA(

G*N*1A( 214N-42(*$ 8F MANAG*M*NT 1*M8"* TH* 2AT4*NT F18M TH* "*NT4(AT81 4N4T4AT* MAN@A( "*NT4(AT48N @$4NG $*(F= 4NF(AT4NG 3AG -8NTA4N4NG 100O 8D/G*N 2*1F81M 1A24D 2H/$4-A( *DAM4NAT48N AND A$$*$$ M8N4T81*D 4ND*-*$ -H*-M 2AT*N-/ 8F A41WA/$ 4F D*ATH 4$ 4MM4N*NT, -8N$4D*1 AND T1*AT TH* M8$T (4M*(/ -A@$*, 2N*@M8TH81AD, A41WA/ 83$T1@-T48N 8N-* $TA34(4P*D, @ND*1TAM* M81* D*TA4(*D A$$*$$M*NT 2#+ture!U

Q 4t alway! pay! to +o''un#+ate.R Q The b#%%er, the better, r#%ht, %#rl!NR Q The do+tor !hould d#a%no!e !o'et#'e!, !hould treat o)ten t#'e!, but +o')ort all the t#'e.R 3y: Arn#e, Jed, N#+
Do you 0now what;! the +lo!e!t to 'y heartNNNNNNNN (un%S 40aw (@NGUUU:D

Tuotable Tuote! )ro' Do+ Ferrer Q4t #! o0ay to be #%norant )or one day than be #%norant )or the re!t o) your l#)e. Q QMed#+#ne #! -8MM8N $*N$*U /ou only need to 0now 4 th#n%!. Mnow the !tru+ture, !o 'a!ter your ANAT8M/. Mnow the )un+t#on!, !o 'a!ter your 2H/$48(8G/. Mnow what #! abnor'al, !o !tudy your 2ATH8(8G/. Mnow the 2HA1MA-8(8G/ be+au!e that w#ll help #n the treat'ent. The re!t are u!t !pe+#)#+!. Q QA 'ale who ha! hyper6ent#lat#on !yndro'e #! al!o a )e'aleUR :2 Q4t ta0e! one to 0now oneUR Q The 'o!t dan%erou! pro)e!!#on would be our pro)e!!#on #) we don;t ha6e h#%h eth#+al !tandard!.R