Mechanical ventilation 1

Asthma pathophysiology

26 yo Samoan• SOB, no chest pain, subacute onset

• Known asthmatic, poorly compliant with inhalers

• Builder, works with concrete

• Family members with coryza symptoms recently

• Increasing SOB and wheeze last 48hours

• o/e sats 96% NRB, HR 120, BP 150/80, bilateral wheeze, diaphoretic, talking in words, working hard

Initial ABG

Initial CXR

CXR 30 min laterwith NIV

What do you think about the use of NIV in this situation?

Should he be intubated?

• Severity of respiratory failure • Cardiopulmonary reserve • Adequacy of compensation • Expected speed of response to treatment • Risk of complications associated with ventilation • Availability of staff with high level of airway skills,

the time of the day, how busy the ICU is etc

Patient is urgently transferred to ICU and intubated … Set the ventilator

Initial mechanical ventilation profile after intubation

Initial ABG 30min post

ETT insertion

Gas trapping and hyperinflation

What parameters would you check regularly and why?

Treatment of sick asthmatic

• Standard therapy: O2, salbutamol nebs, ipratropium nebs, steroid (? aminophylline), appropriate mechanical ventilation

• Refractory therapy: ketamine, magnesium, adrenaline, inhalational agents (sevo, isoflurane), heliox

Emergency alarm sounds Sudden desaturation & Increased pressures

Minimal AE bilaterally

Urgent CXR requested

72 hours down the track and bronchospasm has settled but persistent

air leak and bubbling via drain. What is the diagnosis?

What is your further management?

Bronchopulmonary fistula management

• Adequate sized ICC

• Ventilation measures

• Low TV, low PEEP, short inspiratory time, spontaneous breathing

• Independent lung ventilation

• HFOV

• ECMO

• Endobronchial occlusion