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Airway and Ventilation Skills - Essentials Guide

Learn airway evaluation, mechanical ventilation basics, settings, non-invasive ventilation, intubation needs, difficult intubation prediction, and indications for mechanical ventilation. Upgrade your knowledge on ventilator controls and settings for optimal patient care.

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Airway and Ventilation Skills - Essentials Guide

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  1. Airway and Mechanical Ventilator Skills and Knowledge 部立雙和醫院胸腔內科 內科加護病房 陳資濤

  2. Contents • Evaluate the patients who needs intubation • Introduction of mechanical ventilation • Ventilator settings • Elements of ventilator settings • Introduction of non-invasive ventilation (NIV)

  3. Who Needs to be intubated? • 1.供氧失敗 • 藉由脈搏血氧計(oximetry)(但容易因局部性或全身性灌流不足,嚴重貧血,與指甲油受到干擾),動脈血氧分析,或病人的發紺表現評估 • 2.通氣失敗 • 藉由鼻導管(cannula)上的二氧化碳分析儀(capnometry)(不一定總是反應真正的二氧化碳分壓,但可以提供通氣量改變的趨勢),動脈血氧分析,或病人呼吸作功的費力程度來評估. • 3.無法保護呼吸道 • 有潛在異物嗆入的風險者,如痰量變得稠又多,咳嗽反射不足,抽痰後吞嚥功能不良等.嘔吐反射(gag reflex)無法正確評估呼吸道的保護效果. • 4.神經學症狀或心肺功能惡化而需要轉送其他單位或緊急處置的病人

  4. Prediction of Difficult Intubation • L = Look (觀察) • E = Evaluate the mouth opening and airway position (評估開口程度與氣道位置) • M = Mallampati score • O = Obstruction (排除阻塞) • N = Neck mobility (評估頸部活動度)

  5. The 3-3-2 Rule • 3: The mouth opening ≧ 3 fingers • 3: Tip of the chin to the hyoid bone ≧ 3 fingers • 2: Hyoid bone to the top of the thyroid cartilage ≧ 2 fingers

  6. Mallampati Score

  7. 傳統/高階呼吸器 Bennett MA-1 Dräger Evita XL

  8. Indications for Mechanical Ventilation • Respiratory arrest • ARDS • Acute respiratory distress with accessory muscle breathing • Hypoxemia or hypercapnia with respiratory acidosis • pH <7.3, PaO2 < 60mmHg or PaCO2 >45mmHg • Severe chest contussion • General anesthesia

  9. Elements of ventilator settings • Control How the ventilator knows how much flow to deliver. • Volume Controlled (volume limited, volume targeted) and Pressure Variable • Pressure Controlled (pressure limited, pressure targeted) and Volume Variable • Dual Controlled (volume targeted (guaranteed) pressure limited)

  10. Elements of ventilator settings • Cycling How the ventilator switches from inspiration to expiration. • Time cycled – such as in pressure controlled ventilation • Flow cycled – such as in pressure support • Volume cycled – the ventilator cycles to expiration once a set tidal volume has been delivered: this occurs in volume controlled ventilation. If an inspiratory pause is added, then the breath is both volume and time cycled

  11. Elements of ventilator settings • Triggering What causes the ventilator to inspiration. • Time – the ventilator cycles at a set frequency as determined by the controlled rate. • Pressure – the ventilator senses the patient's inspiratory effort by way of a decrease in the baseline pressure. • Flow – modern ventilators deliver a constant flow around the circuit throughout the respiratory cycle (flow-by). A deflection in this flow by patient inspiration, is monitored by the ventilator and it delivers a breath. This mechanism requires less work by the patient than pressure triggering.

  12. Elements of ventilator settings • Breath pattern What causes the ventilator to cycle from inspiration. • Mandatory (controlled) - which is determined by the respiratory rate. • Assisted - as in assist control, synchronized intermittent mandatory ventilation, pressure support • Spontaneous - no additional assistance in inspiration, as in CPAP

  13. Elements of ventilator settings • Flow pattern • Sinusoidal - this is the flow pattern seen in spontaneous breathing and CPAP • Decelerating - most intensivists and respiratory therapists use this pattern in volume targeted ventilation also, as it results in a lower peak airway pressure than constant and accelerating flow, and better distribution characteristics • Constant - flow continues at a constant rate until the set tidal volume is delivered • Accelerating - flow increases progressively as the breath is delivered. This should not be used in clinical practice.

  14. Elements of ventilator settings • Mode • CMV - Conventional controlled ventilation, without allowances for spontaneous breathing. Many anesthesia ventilators operate in this way. • Assist-Control - Where assisted breaths are facsimiles of controlled breaths. • Intermittent Mandatory Ventilation - Which mixes controlled breaths and spontaneous breaths. Breaths may also be synchronized to prevent "stacking". • Pressure Support - Where the patient has control over all aspects of his/her breath except the pressure limit.

  15. CMV

  16. A/CV

  17. SIMV

  18. PSV(pressure support ventilation) Spontaneous inspiratory efforts trigger the ventilator to provide a variable flow of gas in order to attain a preset airway pressure. Can be used in adjunct with SIMV.

  19. Oxygen in  FIO2  mean alveolar pressure PEEP Re-open alveoli and  shunt Carbon dioxide out  ventilation  RR  tidal volume Main determinants

  20. 非侵入性正壓呼吸器 Mark 7 (IPPB)

  21. Evidences for Use of NPPV

  22. Contraindications to NIV

  23. Thank you very much for attention!

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