Difficult ventilationCraig Hore

Intensive CareASH

Check patient

• ETT and suction• Tubing• Examine – bronchospasm; tension

pneumothorax; raised IAP• Patient position• Patient compliance with ventilator• Sedation / NMJB

The ventilator

Protective ventilation

Lung protective strategy

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

Permissive Hypercapnia

Alveolar Recruitment

Low Airway Pressure

Permissive Hypercapnia

• FiO2 - aim SpO2 88 - 92%

• Low tidal volume ~ 6ml/kg (ideal body weight)

• Accept PaCO2 ≤ 70 (or pH ≥ 7.1)

Low Airways Pressure

• Pressure control mode vs volume control mode

• Pplat ≤ 30 cmH2O

• Pmax ≤ 35 cmH2O

PEEP

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

Alveolar Recruitment

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

Staircase recruitment

• Haemodynamically unstable• Oxygenation worsens • What PEEP to leave at?

Ask for help

• SRC• Local intensivist• MRU consultant• ECMO