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Ventilator Use and Weaning

Ventilator Use and Weaning

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Ventilator Use and Weaning

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  1. Ventilator Use and Weaning 台大醫院 外科加護病房 柯文哲醫師

  2. Indication of Intubation • airway obstruction • airway protection • bronchial hygiene • ventilator use

  3. History of Ventilator • 1952 ~ 1953 : • Europe polio epidemics • 1 ~ 2 % respiratory failure

  4. Ventilator Type 1. negative pressure e.g. iron lung 2. positive pressure endotracheal intubation

  5. Iron lung

  6. How to understand ventilator ? 1. time cycle begin 2. pressure trigger ↗ 3. flow trigger inspiration ↘ terminate 1. time controlled 2. volume controlled 3. pressure controlled 4. flow controlled expiration : passive process

  7. ventilator v pt

  8. Noun Explanation • Inspiration time • I/E ratio • respiration rate (RR) • tidal volume (VT) • oxygen fraction (FiO2) • flow rate

  9. flow pattern decelerating accelerating horizontal

  10. PEEPautoPEEP Ventilator v V pt

  11. sensitivity • pressure trigger P ventilator V pt P time >

  12. sensitivity • flow trigger F F Base flow: 10 L/min Trigger flow: 3 L/min V pt

  13. disadvantage of pressure trigger 1. autotrigger 2. effort P V pt

  14. peak airway pressure • mean airway pressure PAP P ---------------------------------------------------------------- MAP Time

  15. plateau time , pressure • end-inspiratory pause , inflation hold P time pt v

  16. Restrictive lung disease Vs Obstructive lung disease P t

  17. Ventilator Mode • CMV • ACMV • SIMV + PS • PC • PS • CPAP

  18. ACMV (assisted controlled mandatory ventilation )

  19. PC ( pressure control )

  20. PS ( pressure support )

  21. SIMV + PS

  22. The Board on Ventilator • setting part : what you set • demonstration part : the actual condition • warning part : beyond the limit value

  23. Care of the Intubated Patients • 1. check position of the tube • too deep → one lung • too shallow → balloon above or • on the cord • 2. sputum suction

  24. Cough Mechanism • 1. deep inspiration • 2. close the glottis • 3. abd. wall contract • 4. suddenly open glottis

  25. intubated patients can not cough effectively

  26. Complication of Ventilator Use • barotrauma • infection • hemodynamic effect • discomfort

  27. Ventilator Fighting • disconnect & ambu bagging • save life then diagnosis

  28. Ventilator weaning

  29. Components of Normal Ventilation • CNS • spinal cord • phrenic n. • intercostal n. • neuromuscular junction • muscle • thoracic cage • airway • lung

  30. CNS 1. structural lesion : CVA head injury infection degeneration 2. dysfunction : drug , anesthesia , alcohol metabolic factor

  31. Spinal Cord • cervical spinal cord injury • infarction • inflammation

  32. phrenic n. (75%) intercostal n. (25%) • iatrogenic • Guillain-Barre syndrome

  33. Neuromuscular Junction • myasthenia gravis • m. relaxant drugs • depolarizing : succinylcholine • non-depolarizing : pavulon • tetanus • botulism

  34. Muscle • cardiac output • hypoxia • anemia • nutrition • m. mass

  35. Thoracic Cage • deformity : • scoliosis , thoracoplasty , funnel chest • space occupying lesion : • hemothorax , pneumothorax , etc....

  36. Airway • asthma • spasm (hyper-reactive airway ) • foreign body

  37. Lung Parenchyma • ARDS • pneumonia • atelectasis • lobectomy, pneumonectomy • embolism

  38. Q : how to wean the ventilator ? A : Why to ventilate this patient ? Are there new problems during the ventilator use ?

  39. WEANS NOW

  40. WEANS NOW weaning parameter : PI max >-25 mmHg TV >5 ml/kg VC >10 - 15 ml/kg RR <30/min MV <10 L/min MMV>2 MV PE max.>35 mmHg

  41. WEANS NOW • endotracheal tube • too small ? • obstruction ? • esp. in large patients with hyperventilation

  42. WEANS NOW • alkalosis • PaCO2<32 mmHg → apnea • But in sepsis , head injury , anxiety

  43. WEANS NOW nutrition

  44. WEANS NOW secretion respiration Vs cough

  45. WEANS NOW neuromuscular disease

  46. WEANS NOW obstruction asthma, bronchospasm hyper-reactive airway

  47. WEANS NOW • wait

  48. Continuous Flow Vs Demand Flow