1. Difficult ventilation Craig Hore Intensive Care ASH

8. Check patient • ETT and suction • Tubing • Examine – bronchospasm; tension pneumothorax; raised IAP • Patient position • Patient compliance with ventilator • Sedation / NMJB

9. The ventilator

13. Protective ventilation

14. Lung protective strategy

15. Permissive Hypercapnia Alveolar Recruitment Low Airway Pressure A Randomised Controlled Trial Of Staircase Recruitment Manoeuvres, High PEEP And Low Airway Pressure (PHARLAP) Carol L. Hodgson, Alistair Nichol, David Tuxen, Jamie Cooper, Michael Bailey, Jenny Keating, Anne Holland, David Pilcher, Andrew Westbrook, Andrew Davies, and Andrew Hilton

16. Permissive Hypercapnia • FiO2 - aim SpO2 88 - 92% • Low tidal volume ~ 6ml/kg (ideal body weight) • Accept PaCO2 ≤ 70 (or pH ≥ 7.1)

17. Low Airways Pressure • Pressure control mode vs volume control mode • Pplat ≤ 30 cmH2O • Pmax ≤ 35 cmH2O

19. PEEP

20. PEEP The first point of the PEEP PV curve corresponds to the increase in EELV induced by PEEP (∆EELV). On this example, the recruitment induced by PEEP is measured at a pressure of 20cmH2OMathematical model of the pressure–volume (PV) curve. PV curves

21. Alveolar Recruitment

22. Staircase recruitment • PCV 15 ± 3 • Start at PEEP 10 cmH2O • Step up: PEEP 20 / 30 / 40 for 2 mins • Step down 2.5 cmH2O for 3 mins

23. Staircase recruitment • Haemodynamically unstable • Oxygenation worsens • What PEEP to leave at?

24. Ask for help • SRC • Local intensivist • MRU consultant • ECMO