Mechanical Ventilation Flashcards
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 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-dependent 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
in patients with bilateral lug disease and at risk for ARDS, and the plateau pressure is above 30 cm H2O, what to do with tidal volume?
the tidal volume should be incrementally decreased by 1 mL/kg to as low as 4 mL/kg
these protective lower tidal volumes may lead to hypercapnea and acidemia although a pH of >7.20 is usually well tolerated
other options in those with refractory hypoxemia and criteria for severe ARDS
neuromuscular blockade
prone positioning
pulmonary vasodilators
transfer to an ECMO-capable center
remarks on ventilator care bundle
implement it in every patient ASAP. it includes:
-routine measurement of patient height to determine appropriate tidal volume for ventilation
-elevating the head of bed to at least 30 degrees
-decompressing the GI tract
-oral care with chlorhexidine solution every 2 hours
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
maneuvers for obstructive lung disease to prevent lung trapping
increase IFR (inspiratory flow rate)
*typically, it’s 60 LPM
*recommendation in COPD is 80-100 LPM
Remarks on PEEP
improvements 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
other remarks in mechanical ventilation
decrease FIO2 quickly to avoid hyperoxia
start VTE prophylaxis approach
adequate sedation
but think early about Sedation holidays and Spontaneous breathing trials in patients expected to be housed in the ED for ≥24 hours
ARDS definition
Berlin definition
onset with 1 week of a known clinical insult or new or worsening respiratory symptoms
bilateral opacities on chest imaging not fully explained by lobar/lung collapse or nodule
respiratory failure not fully explained by cardiac failure or volume overload
PF ratio ≤300 mm Hg with PEEP ≥5.0 cm H2O
