Just breathe.NONINVASIVE POSITIVE PRESSURE VENTILATION IN STATUS ASTHMATICUS • 17 episodes of asthma and ARF over a 3-year period in the ICU. • Mean age was 35.4±11.3 years; 10

JUST BREATHEOPTIMAL VENTILATION TECHNIQUES FOR ASTHMATICS IN RESPIRATORY FAILURE

Christine B Davis

Emergency Medicine

Henry Ford Hospital

6 March 2014

GOALS

Analyze current research in order to learn the best methods to ventilate asthmatic patients presenting in respiratory failure with a focus on ventilator settings

Details on pharmacological management and prevention of future episodes of severe asthma are beyond the scope of this presentation

Details of the types and mechanics of various ventilators are beyond the scope of this presentation

ACKNOWLEDGEMENTS

Thank you to Doctors

Gregory Hays

Emmanuel Rivers

Seth Krupp

Michael Mendez

Daniel Ouellete

for their mentorship of this lecture

Asthma affects 300 million people globally

2 million emergency department visits for acute asthma per year

12 million people reporting having had asthma ldquoattacksrdquo in the past year

Accounts for 1 in every 250 deaths worldwide

many of which are preventable

ASTHMATIC IN RESPIRATORY FAILURE

Inability to maintain respiratory effort due to fatigue

Declining mental status Agitation

Cyanosis Profound diaphoresis

Accessory muscle use chest wall retractions

Brief fragmented speech (1-2 words)

Inability to lie supine

Peak expiratory flow or FEV1 lt 35 - 50 of predicted

Arterial O2 sat lt 91

Paradoxical pulse exceeding 25 mmHG

Rapid shallow breathing (respiratory rate gt30 breathsminute)

Failure of medical management (ie O2 bronchodilators corticosteroids Mg anticholinergics heliox ketamine leukotriene receptor agonists)

ASTHMA PATHOPHYSIOLOGY

airflow obstruction mucus plugging

bronchial hyper-responsiveness bronchoconstriction

underlying inflammation airway edema

NONINVASIVE POSITIVE PRESSURE VENTILATION PHYSIOLOGY

Reduces work of breathing

Decreases airway resistance

Relieves the feeling of dyspnea

Re-expands collapsed alveoli

Provides rest for the muscles

of respiration

NONINVASIVE POSITIVE PRESSURE VENTILATION SETTINGS

BiPap

Bilevel positive airway pressure

IPAP pressure applied during patient triggered breaths

EPAP pressure applied in between patient triggered

breaths

FiO2 fraction of O2 percentage that is added to the

delivered air

Vf respiratory rate set as a guarantee for intermittent

bursts of IPAP

CPAP

Continuous positive airway pressure

unchanged during inspiration and expiration

PSV Pressure support ventilation

provides a small amount of pressure during

inspiration to assist the patient as they draw in a

spontaneous breath

CPAP VS BIPAP

Bilevel positive airway pressure (BiPAP)

All that a CPAP does with the added advantage

of adding external positive end-expiratory

pressure (PEEP) to offset the intrinsic PEEP that

builds up during an asthmatic attack


(CPAP)

bronchodilatory effect in asthma

unload fatigued inspiratory muscles

improve gas exchange

prevent methacholine- and histamine-induced

asthma

increases tidal volume

CONTRAINDICATIONS TO NIPPV

Absolute contraindication

need for urgent intubation (eg cardiac or respiratory arrest)

Relative contraindications

facial trauma or surgery

upper airway deformity

inability of patient to cooperate or to maintain cooperation

copious secretions risk for aspiration

recent esophageal anastomosis

ADVERSE EFFECTS OF NONINVASIVE POSITIVE PRESSURE VENTILATION

deg local skin trauma secondary to mask deg eye irritation deg gastric distension

ALTHOUGH THERE ARE NO ROBUST RANDOM CONTROL TRIALS FOR NIPPV IN

ASTHMA SHOWING MORTALITY BENEFIT AS THERE ARE FOR PULMONARY

EDEMA COPD AND IMMUNOCOMPROMISED PATIENTS I WILL REVIEW SOME

PROMISING DATA THAT SUGGEST THAT NIPPV CAN BE USEFUL ADJUNCT TO

TREATMENT IN THE ED

A PILOT PROSPECTIVE RANDOMIZED PLACEBO-

CONTROLLED TRIAL OF BILEVEL POSITIVE AIRWAY

PRESSURE IN ACUTE ASTHMATIC ATTACK

30 patients (18 to 50 years old) with a severe asthma exacerbation defined as

respiratory rate gt30 breaths per minute

FEV1 lt60 percent of predicted when measured 30 minutes after inhaled bronchodilator therapy

Also with a history of asthma of at least 1 year and duration of current asthma attack of lt 7 days

Randomly assigned to receive nasal BPAP or sham (subtherapeutic BPAP) for 3 hours in the

emergency department

Arie Soroksky David Stav Isaac Shpirer

Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS

Inspiratory pressure was set at 8 cm H2O then increased gradually by

2 cm H2O every 15 min

to a maximum of 15 cm H2O

or until a respiratory rate of lt 25 breathsmin was reached

Expiratory pressure was set at 3 cm H2O then increased gradually by 1 cm H2O every 15 min


Rationale for these settings

Gradual increase in both the inspiratory and expiratory pressures was aimed at increasing patient comfort and patient

compliance

Values were set in a rather arbitrary manner designed to provide what would be considered by most as a mild PEEP

and mild-to-moderate inspiratory pressure support

RESULTS

Primary endpoint

BiPAP increased the likelihood of a significant improvement in FEV1

80 vs 20 (p lt 0004)

Secondary endpoint

BiPAP reduced the rate of hospitalization

18 vs 63 (p = 00134)

Hospitalization was required for

3 of 17 patients (176) in the BPV group

10 of 16 patients (625) in the control group

Conclusion

In selected patients with a severe asthma attack the addition of BiPAP to conventional treatment can improve lung function alleviate the attack faster and significantly reduce the need for hospitalization

CARDIOPULMONARY RESPONSES TO CONTINUOUS POSITIVE AIR

WAY PRESSURE IN ACUTE ASTHMA

In 21 patients with acute asthma the effects were studied of nasal

continuous positive airway pressure (CPAP) on

expiratory flow

arterial blood gas tensions

cardiovascular status

dyspnea

Shivaram U Miro AM Cash ME Finch PJ Heurich AE Kamholz SL J Crit Care 1993 Jun8(2)87-92

CPAP SETTINGS

CPAP sequence

30 minutes at 5 cm H2O




Six control patients were fitted with a CPAP mask but given no positive-

pressure therapy

RESULTS

Significant reductions in respiratory rate occurred from a baseline of 220 +- 10

198 +- 38 breathsmin at CPAP 5 cm H2O

194 +- 43 breathsmin at CPAP 75 cm H2O (P lt 05)

No significant change occurred in FEV1 heart rate MAP or ABG tension with either level of CPAP

Dyspnea as assessed by a breathlessness score improved during CPAP therapy (P lt 05)

In comparison the control group showed no change in heart rate respiratory rate or breathlessness score

during the study period

Conclusion

These data show that application of CPAP in acute asthma reduces respiratory rate and

dyspnea

NON-INVASIVE MECHANICAL VENTILATION IN STATUS

ASTHMATICUS

Seven-year period retrospective observational study

58 patients were included in the study

25 patients (43) were not eligible for NIMV

11 patients (19) because of respiratory arrest on their arrival

at the Emergency Room

14 patients (24) because of improvement with medical

management

The remaining 33 patients were eligible for NIMV

(57)

11 patients (33) received invasive MV

22 patients (67) were treated with NIMV

3 NIMV patients (14) needed ETI

MM Fernaacutendez A Villagraacute L Blanch R Fernaacutendez Intensive Care Medicine March 2001

Volume 27 Issue 3 pp 486-492

SETTINGS

Pressure support ventilation (PSV)

Trigger sensitivity adjusted to 05 cm H2O

PSV was titrated to achieve a minimum expired

tidal volume of 400 mL

Then increased by steps of 3 cm H2O to

improve patient‟s breathing pattern or ABG

Positive end expiratory pressure (PEEP) applied

until a substantial improvement in the effort

required to trigger the ventilator was noted


(CPAP)

Oxygen levels adjusted to maintain O2 gt90

Fixed CPAP values of

5 cmH2O or

75 cmH2O

RESULTS

Significant differences were observed in arterial blood gases on

admission to the Emergency Room between MV and NIMV

PaCO2 (89plusmn29 mmHg vs 53plusmn13 mmHg plt005)

pH (705plusmn021 vs 728plusmn0008 plt005)

HCO3ndash level (22plusmn5 mmoll vs 26plusmn6 mmoll plt005)

No differences were found in the median length of ICU stay (45 vs

3 days) median hospital stay (15 vs 12 days) and mortality (0 vs 4)

Conclusion

Face mask NIMV appears to be a suitable method for improving

alveolar ventilation and can reduce the need for intubation in a

selected group of patients with SA

NONINVASIVE POSITIVE PRESSURE VENTILATION IN STATUS

ASTHMATICUS

bull 17 episodes of asthma and ARF over a 3-year period in the ICU

bull Mean age was 354plusmn113 years 10 patients were female

Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2

PaO2 fraction of inspired oxygen was 315plusmn41

respiratory rate was 291plusmn1

less than 2 hours

pH was 732plusmn002 (p=00012)

PaCO2 was 45plusmn3 (plt00001)

PaO2 403plusmn47

respiratory rate was 22plusmn1 (plt00001)

2 to 6 hours

pH was 736plusmn002 (plt00001)

PaCO2 52plusmn3 (p=0002)

PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4

PaO2 472plusmn67 (p=006)


Gianfranco U Meduri et al Chest 1996110(3)767-774

SETTINGS

Initial ventilatory settings included CPAP at 4 +- 2 cm

H2O to offset intrinsic positive end-expiratory pressure

Pressure support ventilation (PSV) at 14 +- 5 cm H2O

aiming at a respiratory rate less than 25 breathsmin and

an exhaled tidal volume of 7 mLkg or more

PSV was then adjusted following arterial blood gas

results

The mean (+- SD) peak inspiratory pressure to ventilate in

the NIPPV-treated patients was 18 +- 5 cm H2O and

always less than 25 cm H2O

CONCLUSION

In asthmatic patients with ARF NIPPV via a face mask appears highly effective in correcting gas exchange abnormalities

using a low inspiratory pressure (lt25 cm H2O)

NONINVASIVE POSITIVE-PRESSURE VENTILATION IN CHILDREN

WITH LOWER AIRWAY OBSTRUCTION

A prospective randomized crossover study

20 children admitted to the PICU with acute lower airway

obstruction (increased work of breathing wheezing dyspnea)

Randomized to receive either

2 hrs of BiPAP followed by crossover to 2 hrs of standard therapy

or

2 hrs of standard therapy followed by 2 hrs of BiPAP

Thill Peter J MD et al Pediatric Critical Care Medicine Issue Volume 5(4) July 2004 pp 337-342

SETTINGS

spontaneous mode without a backup rate

Oxygen supplementation to keep O2 gt90

inspiratory positive airway pressure (IPAP) of 10 cm H2O

expiratory positive airway pressure (EPAP) of 5 cm H2O

settings remained unchanged throughout the course of the study period

RESULTS

Primary end points

change in respiratory rate

Clinical Asthma Score (CAS) ndash work of breathing wheezing dyspnea

assessment of gas exchange

BiPAP was associated with a decrease in respiratory rate (495 plusmn 139 vs 320 plusmn 62 breathsmin p lt

0001) for all patients after 2 hrs compared with baseline

BiPAP was associated with a lower total CAS (54 plusmn 12 vs 21 plusmn 10 p lt 0001) and lower scores for

each individual component (accessory muscle use wheeze and dyspnea all p lt 01)

CROSSOVER GROUPS

discontinuation of BiPAP in Group 1 at the 2-hr crossover time point was associated with

an increase in both respiratory rate and total CAS by the 4-hr data collection time point

Group 2 did not improve after 2 hrs of standard therapy but showed improvement in

respiratory rate and total CAS after 2 hrs of BiPAP

CONCLUSION

BiPAP in children with acute lower airway

obstruction can be well tolerated and may

be effective in improving clinical measures

of respiratory distress

MECHANICAL VENTILATION

Andreas Vesalius (31 December 1514 ndash 15

October 1564)

first person to describe mechanical ventilation

De humani corporis fabrica (On the fabric of the

human body)


Associated with significant morbidity and mortality

increased airway resistance airway injury barotrauma hemodynamic instability nosocomial pneumonia

increased length of hospital stay (which can lead to DVT PE myopathies malnutrition and infections)

Last resort ndash

when medical management has failed and noninvasive ventilation is contraindicated or has failed

mortality rate of only 8

but 27 to 45 of patients requiring mechanical ventilatory support experience serious complications

INDICATIONS FOR INTUBATION

Cardiac arrest

Respiratory arrest

Altered mental status

Progressive exhaustion

Silent chest

Severe hypoxia with maximal oxygen delivery

Failure to reverse severe respiratory acidosis despite intensive therapy

pH lt 72

PCO2 increasing by more than 5 mm Hgh or greater than 55 to 70 mm Hg

PO2 of less than 60 mm Hg

Barry Brenner Thomas Corbridge and Antoine Kazzi Intubation and Mechanical Ventilation of the Asthmatic Patient in

Respiratory Failure Proceedings of the American Thoracic Society Vol 6 No 4 (2009) pp 371-379


Assist Control Ventilation (AC)

When patient triggers spontaneous breath it will

force in either the pressure or volume set will stack

breaths

Synchronized Intermittent Mandatory

Ventilation (SIMV)

When patient triggers spontaneous breath the

pressure or volume will be determined by the patient

it will not stack breaths

CONTINUOUS MECHANICAL VENTILATION

Volume control

When the ventilator detects the set volume

having been applied the ventilator cycles to

exhalation

Airway pressure increases in response to reduced

compliance increased resistance or active exhalation

and may increase the risk of ventilator-induced lung

injury

Pressure Control

Limits the maximum airway pressure delivered to the lung

May be difficult to attain adequate tidal volumes against high airway resistance

TROUBLESHOOTING

Check plateau pressures by allowing for an inspiratory pause

If peak pressures are high and plateau pressures are low then you have an obstruction

If both peak pressures and plateau pressures are high then you have a lung compliance issue

TROUBLESHOOTING

Poor oxygenation in asthmatic patient

Paralysis

ALTHOUGH MECHANICAL VENTILATION IS USED COMMONLY FOR ASTHMATICS

THERE IS A PAUCITY OF DATA ON THE BEST SETTINGS AND MODES OF VENTILATION

THE RECOMMENDATIONS FOR SETTINGS COME FROM A FEW SMALL TRIALS AND

RECOMMENDATIONS BASED ON THEORY AND CLINICAL EXPERIENCE

Severe bronchial asthma requiring ventilation

A review of 20 cases and advice on management

Natural history of 20 asthmatics who required

mechanical ventilation

Seven of these patients died (bdquosteady decline

on the vent‟ 2 pneumothoraces etc)

14 were male and 6 were female Age range

was 5-64 years

Webb AK et al Postgraduate Medical Journal (March 1979) 55 16i-170

VENTILATION RECOMMENDATIONS

ldquoThe ventilator chosen must be capable of delivering an adequate volume against a high resistance into

a comparatively non-compliant thoraxrdquo

ldquoA variable IE ratio is a great advantagehellipThe expiratory time should be sufficiently longhellipif the

inspiratory phase begins prior (to the end of expiration) further air trapping may occurrdquo

ldquoThe authors used low volumes with slow respiratory ratesrdquo


THE EFFECTS OF VENTILATORY PATTERN ON HYPERINFLATION AIRWAY

PRESSURES AND CIRCULATION IN MECHANICAL VENTILATION OF

PATIENTS WITH SEVERE AIR-FLOW OBSTRUCTION

9 patients with severe air-flow obstruction (5 asthma

4 chronic air-flow obstruction) requiring mechanical

ventilation were studied while sedated and

therapeutically paralyzed

Pulmonary hyperinflation during steady-state

ventilation was quantified by measuring total exhaled

volume during 20- to 40-s apnea (end-inspiratory

lung volume VEI)

Tuxen DV1 Lane S Am Rev Respir Dis 1987 Oct136(4)872-9

SETTINGS

3 levels of minute ventilation (10 16 and 26 Lmin)

And at each minute ventilation 3 levels of tidal volume (VT) (06 10 and 16 L)

3 levels of inspiratory flow (VI) (40 70 and 100 Lmin for VT = 10 L)

CONCLUSION

There were progressive increases in end-expiratory lung volume

when tidal volume was increased

or when expiratory time (TE) was decreased

either by an increase in rate (and hence minute ventilation) or by a decrease in inspiratory

flow (at a constant minute ventilation)

Reaching lung volumes as high as 36 +- 04 L above functional residual capacity

PRESSURE-CONTROLLED VENTILATION IN

CHILDREN WITH SEVERE STATUS ASTHMATICUS

Retrospective review at DMC Children‟s Hospital PICU of all patients who received

mechanical ventilation for status asthmaticus

Pressure-controlled ventilation was used for 40 patients admitted for 51 episodes of

severe status asthmaticus

Sarnaik Ashok Pediatric Critical Care Medicine March 2004 -Volume 5 - Issue 2 - pp 133-138

SETTINGS

Pressure control

Rate

Inspiratory and expiratory time

All titrated based on blood gas values flow waveform and exhaled tidal volume

RESULTS

Before

Median pH 721 (range 665ndash739)

Median Pco2 65 torr (29ndash264 torr)

4 hours after

Median pH increased to 731 (698ndash745 p lt 005)

Median Pco2 decreased to 41 torr (21ndash118 torr p lt 005)

bull Median duration of mechanical ventilation was 29 hrs (4ndash107 hrs)

bull ICU stay was 56 hrs (17ndash183 hrs)

bull Total hospitalization was 5 days (2ndash20 days)

CONCLUSION

Pressure-controlled ventilation is an effective ventilatory strategy in severe status asthmaticus in children

INVASIVE AND NONINVASIVE VENTILATION IN PATIENTS WITH

ASTHMA

Recommended Settings

Pressure or volume control ventilation per individual or institutional preference and patient characteristics

Avoid air-trapping

Inspiratory time 08ndash12 s (high flow constant rather than descending-ramp flow)

Frequency 10ndash15 breathsmin

Tidal volume 6ndash8 mLkg

Plateau pressure lt 30 cm H2O

PEEP 0 cm H2O

FIO2 adequate to provide SpO2 88ndash92

Benjamin D Medoff Respiratory Care June 1 2008 vol 53 no 6 740-750

INTUBATION AND MECHANICAL

VENTILATION OF THE ASTHMATIC PATIENT IN

RESPIRATORY FAILURE

Control of hyperinflation and auto-PEEP

Reduction of respiratory rate

Reduction of tidal volume

An initial set-up of 80 Lmin with a decelerating waveform configuration might be appropriate in adults

Shortening of inspiration with a square wave pattern and an inspiratory flow rate of 60 Lmin allows greater time for exhalation in each respiratory cycle and might help control hyperinflation

Auto-PEEP and Plateau pressure should be followed during mechanical ventilation

Hypercapnia is preferable to hyperinflation

Hypercapnia should not be used in the presence of increased intracranial pressure

An acceptable level of hypercapnia and acidosis is a pH as low as 715 and a Paco2 of up to 80 mm Hg

Barry Brenner Thomas Corbridge and Antoine Kazzi Proceedings of the American Thoracic

Society Vol 6 No 4 (2009) pp 371-379

CLINICAL REVIEW MECHANICAL VENTILATION

IN SEVERE ASTHMA

Low tidal volumes and respiratory rate

Prolong expiratory time as much as possible

Shorten inspiratory time as much as possible

Monitor for the development of dynamic hyperinflation (auto-PEEP peak plateau pressure)

David R Stather Crit Care 2005 9(6) 581ndash587 Published online Sep 8 2005

PROPOSED INITIAL VENTILATOR SETTINGS

Goal

pH above 72

Plateau pressure under 30 cmH2O

Pressure control mode

setting the pressure to achieve a tidal volume of

6ndash8 mlkg

respiratory rate of 11ndash14 breathsmin

PEEP at 0ndash5 cmH2O

INVASIVE MECHANICAL VENTILATION IN ADULTS

WITH ACUTE EXACERBATIONS OF ASTHMA

Carlos A Camargo UpToDate Literature review current through Jan 2014

SETTINGS

Respiratory rate 10 to 14 breathsmin

Tidal volume less than 8 mLkg

Minute ventilation less than 115 mLkg

Inspiratory flow of 80 to 100 Lmin

Extrinsic positive end-expiratory pressure (extrinsic PEEP) less than 80 percent of the intrinsic PEEP

VENTILATING PATIENTS WITH ACUTE SEVERE

ASTHMA WHAT DO WE REALLY KNOWBURNS SUZANNE AACN ADVANCED CRITICAL CARE ISSUE VOLUME 17(2)

APRILJUNE 2006 P 186ndash193

Avoiding hyperinflation and associated complications

Low tidal volumes

Low respiratory rates

Short inspiratory times

Long expiratory times

PEEP increases lung volumes and aggravates hyperinflation and circulatory compromise

Use PEEP cautiously and to ensure vigilant monitoring to determine the effect

SUMMARY ndash NONINVASIVE POSITIVE PRESSURE VENTILATION

Consensus is that invasive mechanical ventilation should be avoided if noninvasive ventilation is an option

BiPap preferred over CPAP as can reduce the pressure during exhalation

Recommended initial settings

IPAP 8 - 10

EPAP 3 - 5

Titrate for correction of pH O2 saturation tachypnea

SUMMARY ndash INVASIVE MECHANICAL VENTILATION

Last resort

Pressure control allows for control of pressure but may not allow for adequate tidal volumes


No PEEP

FiO2 for sat gt 88 - 92

Tidal volume 6-8 mlkg

Keep plateau pressure lt 30 mmHG

pH gt 72 PCO2 lt 80

Respiratory rate 10 ndash 14

Inspiratory flow rate 60 ndash 100 Lmin

Minute ventilation lt 115 mLkg (volumemin)

REFERENCES

Carson KV Usmani ZA Smith BJ Noninvasive ventilation in acute severe asthma current evidence and future perspectives

Curr Opin Pulm Med 2014 Jan20(1)118-23

Jungblut SA Heidelmann LM Westerfeld A Frickmann H Koumlrber MK Zautner AE Ventilation Therapy for Patients Suffering from

Obstructive Lung Diseases Recent Pat Inflamm Allergy Drug Discov 2013 Dec 29

Boldrini R Fasano L Nava S Noninvasive mechanical ventilation Curr Opin Crit Care 2012 Feb18(1)48-53

Chowdhury O Wedderburn CJ Duffy D Greenough A CPAP review Eur J Pediatr 2012 Oct171(10)1441-8 Epub 2011 Dec 16

Louie S Morrissey BM Kenyon NJ Albertson TE Avdalovic M The critically ill asthmatic--from ICU to discharge

Clin Rev Allergy Immunol 2012 Aug43(1-2)30-44

Soroksky A Klinowski E Ilgyev E Mizrachi A Miller A Ben Yehuda TM Shpirer I LeonovY Noninvasive positive pressure ventilation in acute asthmatic attack Eur Respir Rev 2010 Mar19(115)39-45

Murase K Tomii K Chin K TsuboiT Sakurai A Tachikawa R Harada Y TakeshimaY Hayashi M Ishihara K The use of non-invasive ventilation for life-threatening asthma attacks Changes in the need for intubation Respirology 2010 May15(4)714-20

Crummy F Naughton MT Non-invasive positive pressure ventilation for acute respiratory failure justified or just hot air Intern Med J 2007 Feb37(2)112-8

Burns SM Ventilating patients with acute severe asthma what do we really know AACN Adv Crit Care 2006 Apr-Jun17(2)186-93

Stather DR Stewart TE Clinical review Mechanical ventilation in severe asthma Crit Care 20059(6)581-7 Epub 2005 Sep 8

Webb AK et al Severe bronchial asthma requiring ventilation A review of 20 cases and advice on management Postgraduate Medical Journal (March 1979) 55 16i-170

REFERENCES

REFERENCES (CONT)

Sarnaik AP Daphtary KM Meert KL Lieh-Lai MW Heidemann SM Pressure-controlled ventilation in children with severe status asthmaticus

Pediatr Crit Care Med 2004 Mar5(2)133-8

Meduri GU Cook TR Turner RE Cohen M Leeper KV Noninvasive positive pressure ventilation in status asthmaticus Chest 1996110(3)767

Brenner B Corbridge T Kazzi A Intubation and mechanical ventilation of the asthmatic patient in respiratory failure

J Emerg Med 2009 Aug37(2 Suppl)S23-34 doi 101016jjemermed200906108

Brandao DC Lima VM FilhoVG Silva TS Campos TF Dean E de Andrade AD Reversal of bronchial obstruction with bi-level positive airway pressure and nebulization in patients with acute asthma J Asthma 2009 May46(4)356-61

Rogovik A Goldman R Permissive hypercapnia Emerg Med Clin North Am 2008 Nov26(4)941-52 viii-ix

Medoff BD Invasive and noninvasive ventilation in patients with asthma Respir Care 2008 Jun53(6)740-48 discussion 749-50

Oddo M Feihl F Schaller MD Perret C Management of mechanical ventilation in acute severe asthma practical aspects

Intensive Care Med 2006 Apr32(4)501-10 Epub 2006 Jan 27

Thill PJ McGuire JK Baden HP Green TP Checchia PA Noninvasive positive-pressure ventilation in children with lower airway obstruction Pediatr Crit Care Med 2004 Jul5(4)337-42 Erratum in Pediatr Crit Care Med 2004 Nov5(6)590

Richard Nowak Thomas Corbridge and Barry Brenner Noninvasive Ventilation Journal of Emergency Medicine 2009-08-01 Volume 37 Issue 2 Supplement Pages S18-S22

Shapiro JM Management of respiratory failure in status asthmaticus Am J Respir Med 20021(6)409-16

Molini Menchoacuten N Ibiza Palacios E Modesto AlapontV Ventilation in special situations Mechanical ventilation in status asthmaticus Sociedad Espantildeola de Cuidados Intensivos Pediaacutetricos An Pediatr (Barc) 2003 Oct59(4)352-62

REFERENCES (CONT)

Sydow M Ventilating the patient with severe asthma nonconventional therapy Minerva Anestesiol 2003 May69(5)333-7

Pierson DJ Indications for mechanical ventilation in adults with acute respiratory failure Respir Care 2002 Mar47(3)249-62 discussion 262-5

British Thoracic Society Standards of Care Committee Non-invasive ventilation in acute respiratory

failure Thorax 2002 Mar57(3)192-211

Hess D Chatmongkolchart S Techniques to avoid intubation noninvasive positive pressure ventilation and heliox therapy IntAnesthesiol Clin 2000 Summer38(3)161-87

Sabato K Hanson JH Mechanical ventilation for children with status asthmaticus Respir Care Clin N Am 2000 Mar6(1)171-88

Peter Shearer MD Andy Jagoda MD Emergency airway management in acute severe asthma UpToDate Literature review current through Jan 2014 | This topic last updated Jan 30 2014

Carlos A Camargo Jr MD DrPH Jerry A Krishnan MD PhD Invasive mechanical ventilation in adults with acute exacerbations of asthma UpToDate Literature review current through Jan 2014 | This topic last updated Oct 15 2013

Shivaram U Miro AM Cash ME Finch PJ Heurich AE Kamholz SL Cardiopulmonary responses to continuous positive airway pressure in acute asthma J Crit Care 19938(2)87

Fernaacutendez MM VillagraacuteA Blanch L Fernaacutendez R Non-invasive mechanical ventilation in status asthmaticus Intensive Care Med 200127(3)486

Tuxen DV and Lane SThe effects of ventilatory pattern on hyperinflation airway pressures and circulation in mechanical ventilation of patients with severe airflow obstructionAm Rev Respir Dis 1987136872ndash879

Tan IKS Bhatt SB Tam YH Oh TE Effects of PEEP on dynamic hyperinflation in patients with airflow limitation Br J Anesth 199370267ndash272

Marini JJ Should PEEP be used in airflow obstruction Am Rev Respir Dis 19891401ndash3

the end

GOALS

Analyze current research in order to learn the best methods to ventilate asthmatic patients presenting in respiratory failure with a focus on ventilator settings

Details on pharmacological management and prevention of future episodes of severe asthma are beyond the scope of this presentation

Details of the types and mechanics of various ventilators are beyond the scope of this presentation

ACKNOWLEDGEMENTS


Gregory Hays

Emmanuel Rivers

Seth Krupp

Michael Mendez

Daniel Ouellete





























of respiration


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

ACKNOWLEDGEMENTS


Gregory Hays

Emmanuel Rivers

Seth Krupp

Michael Mendez

Daniel Ouellete





























of respiration


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end




























of respiration


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end























of respiration


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end











of respiration


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end







of respiration


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


BiPap




breaths


delivered air


bursts of IPAP

CPAP






spontaneous breath

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CPAP VS BIPAP







(CPAP)





asthma

















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end
















TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end







TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end





TREATMENT IN THE ED











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end











Chest 2003123(4)1018-1025 doi101378chest12341018

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

BIPAP SETTINGS









compliance



RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

RESULTS

Primary endpoint


80 vs 20 (p lt 0004)

Secondary endpoint


18 vs 63 (p = 00134)




Conclusion






expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end





expiratory flow



dyspnea


CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CPAP SETTINGS

CPAP sequence






pressure therapy

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

RESULTS








Conclusion


dyspnea


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


ASTHMATICUS







management


(57)






SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

SETTINGS











(CPAP)



5 cmH2O or

75 cmH2O

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

RESULTS








Conclusion





ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


ASTHMATICUS



Initiation of NIPPV

pH was 725plusmn001

PaCO2 was 65plusmn2



less than 2 hours



PaO2 403plusmn47


2 to 6 hours



PaO2 367plusmn47


12 to 24 hours

pH was 738plusmn002

PaCO2 45plusmn4




SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

SETTINGS







results




CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CONCLUSION










or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end








or



SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

SETTINGS






RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

RESULTS

Primary end points








CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CROSSOVER GROUPS





CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CONCLUSION







October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end



October 1564)



human body)





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end





Last resort ndash





Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


Cardiac arrest

Respiratory arrest



Silent chest



pH lt 72









breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end





breaths


Ventilation (SIMV)





Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


Volume control



exhalation




injury

Pressure Control



TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

TROUBLESHOOTING




TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

TROUBLESHOOTING


Paralysis












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end












was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end








was 5-64 years



















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


















lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end











lung volume VEI)


SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

SETTINGS




CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CONCLUSION














SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end








SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

SETTINGS

Pressure control

Rate



RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

RESULTS

Before



4 hours after






CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

CONCLUSION



ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


ASTHMA



Avoid air-trapping





PEEP 0 cm H2O





RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end



RESPIRATORY FAILURE











Society Vol 6 No 4 (2009) pp 371-379


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


IN SEVERE ASTHMA







Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


Goal

pH above 72




6ndash8 mlkg






SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end




SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

SETTINGS










Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end





Low tidal volumes










IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end





IPAP 8 - 10

EPAP 3 - 5



Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end


Last resort



No PEEP




pH gt 72 PCO2 lt 80




REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

REFERENCES















REFERENCES

REFERENCES (CONT)















REFERENCES (CONT)














the end

REFERENCES (CONT)















REFERENCES (CONT)














the end

REFERENCES (CONT)














the end

the end

Documents

Just breathe.NONINVASIVE POSITIVE PRESSURE VENTILATION IN STATUS ASTHMATICUS • 17 episodes of asthma and ARF over a 3-year period in the ICU. • Mean age was 35.4±11.3 years; 10