Ventilator Management

  • Two Strategies of Ventilation:
    • Injury:
      • This strategy is for patients with lung injury and those prone to lung injury
        • Essentially this means every intubated patient:
          • Except those with obstruction
    • Obstruction:
      • Use this strategy when patients are in the midst of an Asthma / COPD exacerbation
  • Injury Strategy:
    • Based on ARDSnet:
      • ARMA Study:
        • N Engl J Med 2000;342,1301-1308
    • Mode:
      • Assist Control (AC)-Volume
    • Tidal Volume (Vt):
      • Equals:
        • Protection
      • Start at 6 to 8 ml / kg:
        • Based on PBW
      • If ALI / ARDS:
        • The goal is to get down to 6 mo / kg:
          • Why?
            • Injured lungs are baby lungs
      • This setting should not be altered:
        • To fix ventilation
      • It only gets changed:
        • For lung protection/
          • To prevent:
            • Barotrauma / volutrauma
    • Flow Rate (IFR):
      • Equals:
        • Comfort
      • Start at 60 to 80 liters per minute (lpm)
      • This setting controls:
        • How quickly the air goes in
    • Rate (RR):
      • Equals:
        • Ventilation
      • Initially start at 16 to 18 breaths per minute (bpm):
        • Adjust based on:
          • CO2 and ventilatory needs
      • Alveolar gas volume (Va):
        • For maintaining normal CO2 when not intubated:
          • Is 60 ml /kg / min
        • We need to double that:
          • To 120 cc/kg/min:
            • When intubated because of:
              • Increased deadspace:
                • Need double that volume (240 ml /kg / min) to send CO2 from 40 to 30
        • Try to keep mildly hypercarbic
    • FiO2/PEEP:
      • Equals:
        • Oxygenation
      • Start at:
        • 100% FiO2 and PEEP of 5
      • Wait 5 minutes:
        • Then draw an ABG
      • Then set the FiO2 between 30% to 40%:
        • Start titrating:
          • Based on the ARDS Net protocol chart:
          • Go up every 5 to 10 minutes:
            • Quicker if low saturation
      • Oxygenation goal:
        • PaO2 between:
          • 55 mmHg to 80 mmHg
        • SpO2 between:
          • 88% to 95%
      • Use a minimum PEEP of:
        • 5 cm H2O
      • Consider use of incremental FiO2 / PEEP combinations such as shown below to achieve goal:
  • Check Plateau Pressure:
    • Check it after:
      • Initial settings and at regular intervals thereafter
    • Use the inspiratory hold button:
      • Hold for 0.5 seconds:
        • Look at pressure gauge
    • The peak pressure:
      • Is essentially meaningless
    • Plateau pressure:
      • Must be maintained less than 30 cm H20
    • Keep lowering the tidal volume (Vt):
      • Until Plat less than 30 cm H20:
        • You may need to go as low as 4 ml / kg
    • Disadvantages of this strategy:
      • It is not the most comfortable strategy of ventilation for awake, spontaneously breathing patients:
        • Use sedation / pain medications
      • Give enough flow:
        • If you see the patient sucking the straw:
          • Increase the IFR setting
  • Obstructive Strategy:
    • Goal is to:
      • Give as much expiratory time as possible
    • Mode:
      • Assist Control
    • Vt:
      • 8 ml / kg by PBW
    • IFR:
      • 80 to 100 lpm
    • PEEP:
      • 0 to 5 cmH20
    • FiO2:
      • Use whatever you need:
        • Most use 40%
    • RR:
      • Start at 8 to 10 bpm:
        • Look for:
          • I:E of 1:4 or 1:5:
            • Adjust the rate to achieve this
  • Permissive Hypercapnia:
    • Patients will need a lot of sedation / opioids
    • Keep pH above:
      • 7.1:
        • Rarely:
          • You may need a bicarbonate drip to accomplish this
  • AutoPEEP and Airtrapping:
    • They decrease venous return
    • Impede expiration
    • Impede spontaneous ventilation
  • Other Concerns:
    • Large Tubes:
      • At least size 8.0 ET whenever possible:
        • For both male and female patients.
      • Pulmonary toilet and ICU care:
        • Is miserable with small tubes
        • Biofilm forms:
          • Within the first two days reducing tube size dramatically
  • Ventilator Alarms:
    • Treat them like a code announcement:
      • The closest person should run to the patients bedside and assess the situation.

#Arrangoiz #Teacher #Surgeon

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