1 Mechanical Ventilation, part 1 Flashcards
The primary function of mechanical ventilation
To provide respiratory support while treating the underlying process that caused respiratory failure
how to approximate alveolar pressure
measure the plateau pressure with an end inspiratory pause in a passively breathing or paralyzed patient
target plateau pressure
less than 30 cm H2O
initial settings in pressure control
start with a pressure control of 10 cm H2O above PEEP and adjust pressure up and down to target tidal volume of 6-8 mL/kg ideal body weight
remarks for patients who are not intubated for severe hypoxemia or obstructive lung disease
consider transitioning to pressure support after a volume-targeted mode because the former may be more comfortable for the patient
Remarks on setting the respiratory rate
- Most adult patients with normal respiratory physiology have adequate ventilation at a respiratory rate of 10 to 20 breaths/min
- However, anticipate demands, e.g., in severe metabolic acidosis (eg DKA), set a higher respiratory rate to maintain adequate minute ventilation
- For patients with obstructive lung disease, set RR at 10-14 for longer expiratory time (counterintuitive, yes)
remarks on obese patients
obese patients and those with tense abdomen require higher PEEP
start at 8-10 cm H2O
remarks on hyperoxia
hyperoxia increases patient mortality in a dose-dependet relationship. Many recommend titrating the FiO2 to target an O2 saturation of no greater than 96% as soon as the patient recovers from the apneic induction period
targets in sedation
target a Richmond Agitation-Sedation Scale (RASS) score of
-2 (awakens and makes eye contact to voice)
to 0 (awake, alert, and calm
Remarks on PEEP
improvements in oxygen saturations through increased PEEP are not immediate, so use incremental changes in pEEP of 2 cm H2O every 10-20 minutes rather than rapidly increasing or decreasing because there is potential for unanticipated hemodynamic, intrathoracic, or intrapulmonary changes
remarks on sedation in mechanical ventilation
although often not an ED issue, ending sedation or using sedation holidays allow for more prompt return to spontaneous ventilation
Remarks on obstructive lung diseases and mechanical ventilation
- The primary pathology is NOT improved by intubation.
- The problems encountered are increased airway resistance, pulmonary hyperinflation, and increased dead space causing hypercapnia
What is dynamic hyperinflation?
- Arterial hypercapnia in obstrucive lung disesaes (asthma/copd) tempts the treating physician to increase the RR to exhale more CO2. However, this is counterproductive because it shortens exhalation time, leading to an additional breath prior to the lungs completely emptying.
- This latter event is called DYNAMIC HYPERINFLATION
- Incomplete emptying can be detected by monitoring the expiratory flow limb in a passively breathing patient
What is auto-PEEP
A.k.a intrinsic PEEP
The difference between the total PEEP (from end-expiratory hold) and the set PEEP.
Ventilator management for obstructive lung diseases
- Slow respiratory rate
- Tolerate hypercapnia
- Check for gas trapping