CSTAT (Static Compliance)

Normal - 40 to 60 ml/cmH2o
Equation - corrected vt/plat-peep
Corrections- PEEP and Proning
*Reflects elastic resistance of lungs + chest wall
*Measured with no airflow

CDYN (Dynamic Compliance)

Normal- 30 to 40 ml/cmH20
Equation- corrected vt/pip-peep
Corrections- Suction, Bronchodilator, + deadspace
*Reflects Airways and Resistance
*Increase in airway resistance=decrease in volume

Vent Check
0800 1000 1200
PIP 35 40 45
Plat 25 30 35
Whats the issue?

*Anytime pplat increases = lung parychemia issue
*PIP only goes up because of Plat
*If PIP goes up but Plat stays constant = Airway issue

Vent Check
0800 1000 1200
PIP 30 38 50
Plat 25 30 35
Whats the issue?

Difference of 5 8 15
*Alveoli and Airway issue

ARDS - Exudative Phase

Exudation = Leaking of fluids
- Accumulation of excessive fluid in lungs
- Damages to endothelium and epithelium tissues
- Endothelium= Inner lining of lung
- Epithelium= Surface of tissue

ARDS- Proliferative Stage

Stiff Lung" looses elasticity
Connective Tissue Proliferate
Loss of surface area + scarring = Bad ARDS

ARDS - 2 Phases/2 Problems
"Ventilation + Oxygenation

Collasped alveoli + Low lung volumes= Stiff Lungs
Exhibited by: Low O2, High rates, Low Vol, Increased WOB
* ARDS pt will need more than "conventional" ventilation

Strategies - VENTILATION (PaCO2)
Permissive Hypercapnea

Tidal Volume - 4 to 7 ml/kg
"Using a low tidal volume strategy is more likley to keep the Plat lower than 35 cmH20"
Effects of low volumes =
- Hypercapnia
- Hypoventilation
- Acidosis

Strategies - VENTILATION (PaCO2)
"High Rates

Compensates for low tidal volume strategy
Lengthened inspiratory ratio improves oxygenation
Produces favorable auto-peep ( entrensic peep, inadvertant peep, air-trapping)

Strategies - OXYGENATION (PaO2)
Lung Recruitment

The increase of mPAW helps reduce shunting and improve oxygenation in ARDS pts"
* mPAW= average of all pressures (PEEP, PPSV, Vt, Flow, RR) so if u need to up mPAW up any one of those.
- PEEP increases mPAW
- PEEP increases FRC
* May perform Optimal PEEP

Strategies- OXYGENATION (PaO2)
Lung Recruitment - Optimal PEEP

Equation - Corrected Vt= Set Vt-(PIPx3)
CSTAT= Cor Vt / Plat-PEEP
*if you subtract Plat-PEEP - look for the option with the smallest number - thats ur optimal peep
- Should not cause great deal of heart side effects

Strategies- OXYGENATION (PaO2)
Lung Recruitment - Super Peep

30 PEEP for 30 min or 40 PEEP for 40 min
- remember do not jump from a PEEP of 30 to pt previous level - must still titrate down

Strategies- OXYGENATION (PaO2)
Lung Recruitment -PEEP

PEEP Causes-
- Decreased CO (Norm 4-8 L/min)
- Decreased BP (Norm 120/80 mmHg)
- Increased ICP (Norm 10-15 mmHg)
hypocapnea
- Increased PCWP (4-12 mmHg)
- Increased PAP (25/10 mmHg)
- Increased CVP (2-6 mmHg)

Strategies- OXYGENATION (PaO2)
Lung Recruitment -Proning

Used to support ARDS pts that require high concentrations of FIO2
Indication =
-FIO2 = 60%
-PEEP=8
-P/F <200
-Bilateral infiltrates on CXR
Contraindications=
Unstable cervical,thoratic, lumbar, pelvic, skull or facial Fx
Cervical &/or skeletal traction
Un

Proning Continued..

Proning Therapy can:
-Improve O2 w/in 1st hour in over 70% of pts
-Improve O2 in 70 to 80% of pts c early ARDS
- Significantly improve P/F ratio
- Improve drainage of secretions
- Reduce vent days
- Shorten stay in ICU

Mode of Ventilation Strategies
PCV - Pressure Control Ventilation

Maintain adequate PIP's and Plats

Mode of Ventilation Strategies
IRV- Inverse Ratio Ventilation

Inspiratory time is greater than expiratory time - 2:1
Highest recorded 4:1
pt needs to be sedated and parylized
Goals=
- Reduce intrapulmonary shunting
- Improve V/Q mismatch
- Decrease deadspace ventilation(Apply peep to fix)
- Increase mPAW (benifits c

Mode of Ventilation Strategies
PC-IRV - Pressure Control IRV

Maintain safe pressures while in IRV

Mode of Ventilation Strategies
APRV & Bilevel

...

ILV- Independant Lung Ventilation
aka "Unilateral lung ventilation

Protect the good lung; prevent the bad lung from worsening"
Indications:
-Unilateral ARDS
-Single Lung Transplants
-Massive unilateral pulmonary embolism

Separation of Lungs

Anatomical = Protect lung from injury or contamination by the diseased lung
-Hemoptysis
-Copious Secretions
*Use Fogarty Tube = need to insert c Bronch
Physiologic= Different vent strategies to maintain adequate ventilation/oxygenation
-Pneummo
-Stab Woun

Strategies- OXYGENATION (PaO2)
Specialty Gases - iNO (Nitric Oxide)

Dosage: Starting initial dose= 20ppm
Indications: Poor O2, Pulmonary HTN= PAP >25mmHg
Adverse Effects: 10 ppm= can cause cell damage, Hemorrhage, Pulmonary Edema, Death
Weaning: FIO2 = Decreased to 40%, PEEP=5, Prior to discontiuation increase FIO2 to 60%

Strategies- VENTILATION (PaCO2)
Specialty Gases - Heliox

Dosage: 80:20 mixture (can use c bronchodilator)
Indications: Increased airway resistance, Upper airway obstruction
Contraindication: Pts requiring more than 50% FIO2
*Does not cure - But alleviates:
-Asthma, Broncholitis, COPD, Croup, Forgin Body Aspirat

High Frequency Ventilation
Hertz (Rate) -VENTILATION (PaCO2)

Hertz (Rate)
BPM/RR= Cycles per minute
- To qualify for HFV = needs to be at least 60cpm
Range= 60cpm=3000cpm- 1cpm=50cps
*How many cpm is 6Hz?
6x60= 360

High Frequency Ventilation
Amplitude/Power - VENTILATION (PaCO2)

Mimicks Tidal Volume- affects CO2 greatly
Turn up AMP= Turn up Power
Strength/depth of oscillation
*Affects CWF "Chest Wiggle Factor"
- Higher the AMP= Deeper Chest wiggle

High Frequency Ventilation
Mean Airway Pressure (Mpaw)
-OXYGENATION (PaO2)

Mimicks PEEP
-Keeps Alveoli open

High Frequency Ventilation
I TIME% - OXYGENATION (PaO2)

Affects I:E Ratio
Generally kept at 1:2 = 33%
Equation: Desired I:E= 1:2
Sum of I:E= 1+2=3
1/3=.33=33%

High Frequency Ventilation
FIO2 - OXYGENATION (PaO2)

New vents blend in O2
Others you have to attach a blender

High Frequency Ventilation
FLOW

Usual flow is about 20ml
Cflow=Continous flow
Volumes<anatomical dead space
*
Decrease HZ = Increase in Vt
*

Principals of High Frequency Ventilation

-HFV delivers volumes less than dead space at high rates
-Sedation is Key
- 3 classifications (HFPPV, HFJV, HFOV)

High Frequency Positive Pressure Ventilation (HFPPV) Passive Exhalation

1 to 1.25 HZ = 60 to 150 cpm
Indication: Pts that are Hypoxemic, Hypercapnic, or both despite aggressive MV
Strategy: Increase RR and Decrease I time to keep PIP low
Hazard: Barotrauma = increased mPAW
Suctioning = Drop in mPAW
Neonates: Risk of Intracran

High Frequency Jet Ventilation
(HFJV) Passive Exhalation

4 to 11 HZ = 240 to 660 cpm
Indication: ARD'S and Pneumo, Severe pulmonary disease complicated by- airleaks,pulmonary hypoplasia, restrictive lung disease, and persistant pulmonary HTN
Hypoplasia=Under development of tissue(genitic)
Hazards: Requires spec

High Frequency Oscillatory Ventilation
(HFOV) Active Exhalation

Highest of Ranges
8 to 30 HZ = 480 to 1,800/min
Adults= Starting is 5
Indications: Adults= when all other modes fail
Infants= Congenital diaphragmatic hernia, Diffuse alevolar disease, Airleaks, Pulmonary hypoplasia

Inital Settings of HFOV

Set up vent in order= mPAW, Flow, Amp/Power, Freq, I time, and FIO2
mPAW =
3 to 5 higher than conventional
-Titrate 3 to 5 for Adults
-Titrate 1 to 2 for Neonate
FLOW=
Adults =35 LPM
>2000g = 20 lpm
<2000g = 10 to 15 lpm
Amp/Power=
Adults = Until adequate

Inital Settings of HFOV Cont..

Frequency=
Adults= 5HZ
Neonates
>2000g = 8 to 10 Hz
1500g to 2000g =10Hz
1000g to 1500g = 10 to 12 Hz
<1000g = 12.5 to 15 Hz
FIO2=
Always 100%
-Titrate to 60% then PEEP
- Keep SpO2 between 90 to 95%

ECMO

Inclusion Criteria:
80% or greater risk of mortality
Predictors of high mortality rate:
P(A-a)O2
- (Pb-PH20)xFIO2-(PaCO2/0.8) - PaO2
Oxygen Index (OI)
- (mPAW x FIO2) / PaO2
PaO2
- 35 to 50mmHg for 2 to 12 hours
pH
<7.25 for 2 hours c Hypotension

ECMO

Exclusion Criteria
Gestational age less than 34 weeks
Weighing less than 2,000g
Mechincial ventilation more than 2 weeks prior
Irreversible Cardiac disease
Multi System Organ Failure
Irreversible respiratory failure

Venoarterial (VA) ECMO

*
Perferred Method
*
Incision in the Right Jugular Vein - goes to Right Atrium (R side collects blood) - Goes threw ECMO for Oxygenation - blood is returned from ECMO to Cartoid Artery - Aortic Arch to be distributed systemically
Supports Cardiac function

Venovenous (VV)

Incision in the Right Juglar Vein - down to the Right Atrium (Right side collects systemic blood) - Right atrium collects blood then to ECMO - ECMO collects for Oxygenation - then blood is reinserted into Femoral Vein
Complications: Bleeding (Heprin) ICH,

Weaning and Extubation
Pressure support vs. ATC vs.T-piece

Pressure Support-
5 to 15 cmH2O
pt with spont. breaths

Weaning and Extubation
Pressure support vs. ATC vs.T-piece

ATC
-Determines tracheal pressures and gives variable pressure support levels known as variableonspiratory flow compensation

Weaning and Extubation
Pressure support vs. ATC vs.T-piece

T-Piece Weaning
Disconnect for 5 to 10 min
place back on for 50 min
Off again for 30 min
On for 30 min
Then off for a hour..so on
- benifitual for pts that are sedated but have adequate respiratory drive
- Humidified and set to 10 LPM
120 Ml open deadspac

-Weaning and Extubation
Pressure support vs. ATC vs.T-piece

Can keep pt on Vent and on CPAP mode
- Alarms on Vent can help therapist if pt desats

Knowedge based Weaning Systems

-Closed loop knowledge based system
-Various PSV management based on measurements
-Measures Airway Pressures, PEEP, Spontaneous RR, Spontaneous Vt, and ETCO2
- Auto adjusts PSV to keep measurements within normal
Predicts time for extubation

Weaning and Extubation Recommendations

1. Pathology of Ventilator Dependance
-Is the Primary disease process reversed?
-Look for 4 factors for dependance of ventilator
*Respiratory, Metabolic, Cardiovascular, Psychological

Weaning and Extubation Recommendations

2. Assessment of weaning does the pt meet criteria?
-Reversal of underlying problem?
-Adequate Oxygenation?
- PaO2 > 60 on FIO2 <40%
- PEEP < 5-8 cmH20
- FIO2 < 40 to 50%
-Adequate Ventilation?
- pH >7.25
-Hemodynamically stable
-Capable of initiating ins

4 Factors of Muscle Strength

1. Vital Capacity (not a good predictor- needs pt effort)
2. RR (Above 35 bpm indicates pt not ready to wean)
3. Vt
4. RSBI (Most used- More Reliable)

RSBI

Most Reliable test for deermining pts weaning
- Equation RR/Vt
- Normal 60 to 105
- Above 105 = Not ready for weaning
*Closer to zero better the score
*Have pt breathe slow and deep

Methodology

- Small amount of CPAP c no PSV for 30 to 120 min
- CPAP c ATC and observe for 30 to 120 min
-T-Piece trial for 30 to 120 min

Problems suggesting Weaning process not tolerated

- Dyspena
- Fatigue
- Pain
- Anxiety
- Diaphoresis
- Pallor
- Cyanosis
- Drowsiness
- Restlessness
- Accessory Muscle Use

Removal of the Artifical Airway

- Scissors
- Nasal Cannula
- Yankeur
- Towel
- 10 cc Syringe
*Prior to extubation assess for cuff leak test if inflammation is suspected

Difficulties of Extubation

-Hoarseness, Sore throat, Cough= Common
*Serious if : WOB, Airway Obstruction, Stridor, Aspiration
- Consider NIPPV before reintubation