Pulmo Emergency

8/13/2019 Pulmo Emergency

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Pulmo-emergency Panvilai


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50


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GASS.aureaus


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Hypoxemia

DO2 = 1.38 x Hb x Osat + Pao2x0.003


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A-a gradient


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Hypoxemia : acute decompensation PaO2 < 60 mmHg activate peripheral

chemoreceptor

Minute vent.

Pul.art.vasoconstriction Right heart failure

sympathetic CO


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Diffusion of gas CO2 > O2 > CO > NO Gas pulmonary

edema Pulmonary capillary RBC rbc

cell


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Normal A-a gradient Hypovantilation Low FiO2 ( high attitude)


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Wide A-a gradient


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Right to left shunt Clinical : hypoxemia despite oxygen supplement, wide Aa gradient Pathology :pulmonary consolidation, pulmonary atelectasis,

and vascular malformations.


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V-q mismatch Clinical : increased A-a O 2 gradient and

hypoxemia improves with supplemental oxygen. PathologyPulmonary emboli, pneumonia, asthma, COPD,

and extrinsic vascular compression


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Respiratory center central hypercapnic chemoreceptors in the

central medulla. peripheral hypoxic chemoreceptors, primarily in

the carotid body in concert with those in theaortic arch.


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Respiratory physiology Minute ventilation= TV (7 ml/kg)* f (respiratory rate)Min.vent maintain PaCO 2 = 4oIncrease CO 2 production increase MVDecrease CO2 production decrease MV

MV < 2 L /min respiratory acidosis


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Minute ventilation

Minute VentilationVE = VT x f New PaCO2x VE = Old PaCO2x VE

Case ICP set ventilator VT = 500 ml , f =12

PaCO2 = 50 mmHg if want PaCO2 = 40 mmHgsetting VT


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New PaCO2x VE = Old PaCO2x VE

40 x 500 x f = 50 x 500 x 12 f = 15


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Dead space = Volume air Physiologic dead space (30 % TV)=

1. Anatomical dead space =trachea, bronchi, and bronchioles

2.Alveolar dead space = absent of alveolar

capillary perfusion with normal ventilation (high v/q mismatch)Disease: COPD,ARDS


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Expired air In patients with normal lungs, ETCO 2 is

approximately 3 mm Hg lower than PACO 2,


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Cyanosis Deoxy Hb > 5 g/dl Met Hb: 1.5 g/dl SulfHb: 0.5 g/dl


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Pseudocyanosis Clinical : not branch with pressure heavy metals [e.g., iron (hemochromatosis),

gold, silver, lead, and arsenic] drugs (e.g., phenothiazine, minocycline,

amiodarone, and chloroquine)

Chrysiasis: rare complication of gold treatment Argyria; chronic ingestion /application of silver


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Arterial blood gas interpretation


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Normal ABG value pH = 7.35 7.45 ( 7.4 +-0.5 ) PaO2 = 80 100 mmHg PaO2 < 80 mmHg = Mild hypoxemia PaO2 < 60 mmHg = Moderate hypoxemia PaO2 < 40 mmHg = Severe hypoxemia

New born = 40 60 mmHg Age > 60 PaO2 = 100 [0.25 x Age (Yr)]


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ABG error Excessive heparin affectspH, PCO 2, and PO 2 Air bubbleslowering the PCO 2 values with an increase in pH

and PO 2.


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PaCO2 = 35 45 mmHg (40 +-5 mmHg) HCO3 = 22 26 mEq/L (24 +-2 ) BE = +-2.5 SaO2 = 95 100 %


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Table 26-2 Expected Pa O2 in Patients Inhaling Various

Concentrations of Oxygen, mm Hg

FIO 2 0.21 (room air) 0.4 0.6 0.8 1.0

PaO 2* 100 227 370 512 655


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Aa-gradient

measures how well alveolar oxygen istransferred from the lungs to the circulation

A normal P(A-a) O 2 is under 10 mm Hg in young, healthy patients predicted by the formula P(A-a)O 2 = 2.5 + 0.21

(age in years) ( 11).

P(A-a)O 2 = 145 PaCO 2 PaO 2.


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ABG interpretation

PaCO2 =hypoventilation PaCO2 =hyperventilation


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gas

Alveolar air equation

PAO2 = 713xFiO2-1.2xPaCO2 (FiO2 < 0.6) PAO2 = 713xFiO2-PaCO2 (FiO2 > 0.6)

(A-a)DO2 = PAO2 PaO2

(A-a)DO2 = 140 (PaO2 + PaCO2)

Normal (10-20mmHg)


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PaO2/FiO2 < 400 < 400 lung injury < 200 ARDS


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Acid-base pH predicted pH and measured pH Delta pH = Delta PaCO2 x (1/100) Delta pH = Delta PaCO2 x (1/200) predicted pH < measured pH = acidosis

predicted pH > measured pH = alkalosis


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PaCO2 PaCO2 If PaCO2 pH =Ventilatory Cause

PaCO2 increase =respiratory acidosis

PaCO2 decrease =respiratory alkalosis

If PaCO2 pH =Ventilatory compensation


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Respiratory acidosis

Acute PaCO2 10 mmHg HCO3 1 mEq/L

Chronic PaCO2 10 mmHg HCO3 4 mEq/L

Acute: HCO3 = 0.1 PaCO2 Chronic: HCO3 = 0.4 PaCO2


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Respiratory Alkalosis

Acute PaCO2 10 mmHg HCO3 2 mEq/L

Chronic PaCO2 10 mmHg HCO3 5-6 mEq/L

Acute: HCO 3 = 0.2 PaCO 2Chronic: HCO 3 = 0.5 PaCO 2


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HCO3 HCO3 pH = metabolic cause HCO3 =metabolic acidosis

HCO3=metabolic alkalosis

PaCO2 and HCO3

Met acido PaCO 2 = (1.5 x HCO 3)+8+/-2 mmHg Met alkalo PaCO 2 = (0.7 x HCO 3)+20 mmHg


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Anion gapNa (HCO3 + Cl)

NaHCO30.2xBWxBE mEq

0.2xBWx(24-HCO3) mEq


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Metabolic acidosis HCO 3 < 22Predicted PaCO 2 = 1.5(HCO 3)+82

AG = Na (Cl+ HCO 3) -12 High AG - salicylate, methanol

- -azotemic renal failure -DKA -uremia -lactic

acid

-carbonic anhydrase inhibitor -ion exchange resin


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normal AG HCO 3

-GI-diarrhea -small bowel fistula -ileostomy -ureterostomy colostomy

-kidney -RTA Cl

-Hydrochloric acid -NaCl -ammonium chloride


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AG / HCO3

< 0.8 mixed high gap, normal gap0.8-1.2 pure high gap metabolic acidosis> 1.2 - mixed high gap ,metabolic

alkalosis


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= (Na + + K +) Cl- = Unmeasured anion - Unmeasured cation + Increased AG

Increased UA - high AG metabolic acidosis,hyperalbuminemia, metabolic alkalosis

Decreased AG Decreased UA - hypoalbuminemia

Increased UC - Li+, cationic IgG


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Metabolic alkalosis HCO 3 >26 mEg/l predicted PaCO2= 0.7 ( HCO3 ) +20

PaCO 2 55-60 mmHg

- - ,NG suction -

-NaHCO 3 -Ringer lactate /acetate - citrate

- K - - aldosterone - steriod - Insulin - CO2 (Eucapnic ventilation

posthypercapnia )


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hiccup

Vagal and phrenic nerve

cute: Benign, Self-limited

Chronic: Persistent, Intractable

Gastric distention Central nervous system structural lesions

lcohol intoxication Vagal or phrenic nerve irritation

Excessive smoking Metabolic: uremia, hyperglycemia

brupt change inenvironmentaltemperature

General anesthesia

Psychogenic Surgical procedures: thoracic, abdominal,prostate and urinary tract, craniotomy


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Hiccup Persistence during sleep suggests an organic cause,

and resolution during sleep suggests a psychogenic

cause Treatment1. the pharynx will block the vagal portion of the

reflex arc and abolish the hiccups2. Med:chlorpromazine 25-50 mg IV q 2-4 hr

Plasil 10 mg IVoral treatment can be initiated with nifedipine 10 to

20 mg tid or qid, valproic acid 15 mg/kg per dtaken tid, or baclofen 10 mg tid


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Pleural effusion Positive sign of pleural effusion in upright chest

filmFluid 150-200 ml In CHF: thoracentesis is reserved for those

patients who do not resolve in 3 to 4 days afterdiuresis


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Light criteria for pleural effusion Sensitivity 98 % Specificity 65-86 %Exudate criteria1. Pleural fluid/serum protein > 0.52. Pleural fluid /serum LDH > 0.6

3. Pleural fluid LDH > 2/3 upper limit LDH


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Pleural fluid Cytology : highest yield is with adenocarcinoma ,

much lower with squamous cell, lymphoma, ormesothelioma

Neutrophil: parapneumonic, PE,pancreatitis Amylase; pancreatitis, rupture esophagus

pH < 7.10 = empyema thoraces If diuretic use : serum to pleural albumindifference of greater than 1.2 g/dL = exudate


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Spontaneous pneumothorax Spontaneous absorption rate 1-2% per d 100% 02 increase rate 3-4x


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Diagnosis of pneumothorax "gold standard"the 6-foot upright PA chest radiographthe sensitivity = 83 percent


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Diagnosis of pneumothorax Ultrasonography : sensitivity 100 percent. Sonographic signs of a pneumothorax include (1) absence of lung sliding (2) "lung point" (3) absence of vertical comet-tail artifacts

arising from the pleural line on a B-mode two-dimensional view.


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DL = the diameter of the

lung measured at thehilar level

DHT is the internaldiameter of thehemithorax measuredat the hilar level.

DL

size of PTX ( in %) =( 1 DL3 / DHT 3 ) x

100


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Primaryspontaneous

Pneumothorax

Small(3 cm apex to cupola)

no increase in pneumothorax

Oxygen 3-4 lpm

repeat chest radiograph in12 to 48 h

ASPIRATE > 4 L

NO

OBSERVE 6 HR

NO RECURRENCED/C FU 24 hr

24 to 28 Frtube with

water seal(no suction).

6 hr


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Indication for ICD 1. secondary spontaneous pneumothorax,2. recurrent pneumothorax3. abnormal vital signs


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Risk of reexpansion pulmonary edema aged 20 to 39 years larger pneumothoraces present for >72 h rapidly expanded with suction.


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Iatrogenic pneumothorax Treatment for iatrogenic pneumothorax

parallels that for spontaneous pneumothorax Hospitalization if post subclavian or pleural biosy


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Treatment ATB no indication


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Pneumonia Pneumococcal lobar Atypical-hilar adenopathy Lung abscess- staph, klebsiella Lung mass-staph, pneumococcal Alcohol-increase oral GN pathogen-

pneumococcal and increaseklebsiella,Haemophilus spp. DM- pneumonia and mycolplasma


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Atypical pneumonia Legionella : GI symptom Chlamydia : associate with adult onset asthma

Mycoplasma :extrapulmonary symptoms1. bullous myringitis2. Rash3. neurologic symptoms4. arthritis and arthralgia5. hematologic abnormalities6. rarely, renal failure.


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Pneumonia in elderly High mortality Atypical legionella Postinfluenza bacterial pneumonia is most

commonly caused by S. pneumoniae, S. aureus, and H. Influenzae

Initially afebrile 1/3 no leukocytosis


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Pneumonia in elderly Poor prognostic indicators1. hypothermia or T > 38.3C (100.9F)2. a low white blood cell count3. Immunosuppression4. gram-negative or staphylococcal infection

5. cardiac disease6. bilateral infiltrates7. extrapulmonary disease


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Nursing home acquired pneumonia Streptococcus pneumoniae, gram-negative bacilli, and Haemophilus influenzae


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Pneumonia in transplant First 3 mo. : GNB (especially Pseudomonas

aeruginosa ), Staphylococcus aureus, and

Legionella predominate > 6 mo.= CAP pathogen


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Lung abscess Most = anaerobe Aerobe bacteria -- More common in

immunocompromise Rx; clinda + 2 nd ceph or ampi/sulbactam


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pathogen Community acquire Streptococcus pneumoniae, Staphylococcus

aureus, Haemophilus influenzae, and Enterobacteriaceae

hospital-acquired aspiration pneumonia Pseudomonas aeruginosa and gram-negative

organisms in Anaerobe: chronic alcoholism, putrid sputum,

lung abscess, periodontal disease

Syndrome and Clinical Antibiotic (Usual Dose)*


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Syndrome and ClinicalSituation

Antibiotic (Usual Dose)*

Aspirationpneumonitis

Signs or symptomslasting >48 h

Levofloxacin 500 mg per dorCeftriaxone 1 2 g per d

Small bowelobstruction or use ofantacids orantisecretory agents

Levofloxacin 500 mg per dorCeftriaxone 1 2 g per d,orCiprofloxacin 400 mg every 12 horPiperacillin tazobactam 3.375 g every 6 horCeftazidime 2 g every 8 h

Aspirationpneumonia


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Community-acquired

Levofloxacin or Ceftriaxone

Residence ina long-termcare facility

Levofloxacin 500 mg per dorPiperacillin tazobactam 3.375 g every 6 horCeftazidime 2 g every 8 h

Severeperiodontaldisease,putridsputum, oralcoholism

Piperacillin tazobactam 3.375 g every 6 hImipenem 0.5 1.0 g every 6 8 hLevofloxacin 500 mg per d plusclindamycin 600 mg every 8 hmetronidazole 500 mg every 8 hCiprofloxacin 400 mg every 12 h plusclindamycin 600 mg every 8 h ormetronidazole 500 mg every 8 hCeftriaxone 1 2 g per d plus clindamycin600 mg every 8 hmetronidazole 500 mg every 8 h


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Hemoptysis Mild < 20 mL of blood in 24 h moderate : 20 to 600 mL in 24 h

massive hemoptysis >600 mL in 24 h, > 200ml/time


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Etiology of hemoptysis Infectious: bronchitis, pneumonia, lung abscess, TB Neoplastic: lung cancer, bronchial adenoma Cardiovascular: PE, MS, CHF, pulmonary hypertension, pulmonary

angiodysplasia Alveolar hemorrhage syndromes: Behet syndrome, Goodpasture

syndrome, Wegener granulomatosus Hematologic: uremia, platelet dysfunction, anticoagulant therapy Traumatic: FB aspiration, ruptured bronchus, arterio-

tracheobronchial fistula (aortic aneurysm) Iatrogenic: bronchoscopy, lung biopsy Inflammatory: bronchiectasis, cystic fibrosis


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Common cause of massive hemoptysis

Bronchiectasis TB

CA Aneurysm Pulmonary angiodysplasia Lung abscess


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treatment

Position bleeding lung down ET tube No 8 to allow bronchoscope

coagulopathy : FFP Med; cough suppressant


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Lung transplant

Signs of rejection includecough, chest tightness, fever ( 0.5C above baseline),

hypoxemia, decline in FEV 1 ( 10 percent), and thedevelopment of infiltrates on the chest radiograph Ddx from infection by bronchoscopy Rx: methylprednisolone 500-1000 mg

Cytomegalovirus is the most commonly encountered viral agent implicated in posttransplant pulmonaryinfection


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Active TB

thin-walled cavities (5 mm) tend to be infective and, when thick-walled (10 mm), squamous cell

carcinoma of the lung enters into the differential diagnosis differential diagnoses of cavitarypulmonary lesions include infections from

Staphylococcus, Klebsiella, anaerobes,and non-infectious causes like squamous cell

carcinoma of the lung, pulmonaryinfarcts, Wegeners granulomatosis, and rheumatoid

nodules


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TB

Gold standard = C/s XDR = INF + Rifam


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Pulmonary embolism

Site of clotMost = lower ext.

RiskHereditary: antithrimbun/proteinc-s def, factor V

laden, antiphospholipid Acquire : malignancy, trauma, major surgery, post

partum in 1 month, pregnancy, polycythemia vera, reduced mortality, obese, central venouscatheter, bedrest > 48 hr


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Chest film in PE

Unilateral basilar atelectasis Western mark (oligemia)

Hamptonhump


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Pleural basedopacity

Lunginfarction

Hamptonshump


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Pulmonaryoligemia

WesternMark Sign


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tintinalli


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ECG

Symmetrical T inversion can present in lead V1- V4

Most = sinus tachycardia S13T3 is nonspecific


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echo

Differential with V-infarc good apex motion RV dilate (Normal RV diameter is not greater

than 2.5 cm)


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All of the following statements are TRUE about diagnostictests for PE EXCEPT

(A) The V /Q scan is 98 percent sensitive and 35percent specific for PE

(B) Duplex ultrasound is 95 percent sensitive and

95 percent specific for DVT(C) The difficulty in using V/Q scan findings forthe diagnosis of PE is the lack of a standardizeddefinition for clinical suspicion

(D) A D-dimer of less than 500 U/mL has a negativepredictive value of 90 percent

(E) Spiral CT is up to 90 percent sensitive and 96percent specific for PE

10%

D-dimer


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D dimer


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D-dimer

Best = elisa assay At 500 ng/dl (sense 94,spec 55)

False negative; on warfarinFalse positive 1 wk after surgery, pregnancy or

post partum, malignancy pretest propability < 40 %


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Diagnosis

Low to moderate prop in VQ CTA Normal VQ ruled out

High prop with negative CTA furtherinvestigation

Positive VQ in case of pretest propability < 40%-> further investigation

Positive VQ in case of pretest propability >40%=diagnosis


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PE: spiral CT versus VQ

Specificity of spiral CT= high probability VQSensitivity of spiral CT=low probability VQ

Spiral Use of contrast False negative insubsegmental PE Helpful in nondiagnostic VQ(COPD,PARENCHYMAL LUNGDIS.)

Negative VQmore sense

than negativespiral CT


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pregnancy

upper limit of a normal D-dimer increases witheach trimester of pregnancy but should not

exceed 1000 g/L at any time half-dose injection of radioactive material to

perform a perfusion lung scanOr a CT angiogram without indirect venography can be performed and the uterus shielded duringimage acquisition (< VQ)


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obese

> 190 kg Use doppler us and D-dimer to guide

You respond to a code blue on the labor -and-delivery ward. The nurse tells you that the patient is a previously healthy 41-year-old African-American


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y p p y y y woman, 4 days status post normal spontaneous vaginal delivery. Shecomplained of chest pain and dyspnea and then fell to the floorunconscious. No seizure activity was noted. Although initially pulseless, vital signs returned with assisted ventilations. You find the patientconfused, grunting, and cyanotic. Vital signs are BP 68/50 mm Hg, HR 121 beats per minute (sinus tachycardia), and RR 28, with pulse oximetry of 78percent on high-flow oxygen.

Physical examination shows distended neck veins, normal heart sounds with aprominent S2, a thready pulse with cool, cyanotic extremities, and adequatetidal volume with no rales or wheezes. Chest x-ray is normal. Bedsideultrasound of the heart shows a dilated right ventricle with parodoxicalseptal wall motion. In addition to immediate intubation and fluidresuscitation, what is the MOST appropriate therapeutic intervention?

(A) Emergent diagnostic spiral CT(B) Heparin bolus of 80 U/kg intravenously followed by 18 U/kg infusion(C) LMWH 1 U/kg every 12 h(D) r-tPA at a dose of 100 mg over 2 h(E) Emergent transfer to the angiography suite for pulmonary arteriography

and local infusion of urokinase


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Anticoagulant

IV UFH or SC LMWH for initial treatment ofPTE

With/without overlapping with warfarin Recommend LMWH SC over IV UFH in acutenonmassive PTE

LMWH SC/IV UFH for at least 5 days

In renal failure recommend IV UFH over LMWHSC


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anticoagulant

Prefer LMWH (grade Ia) if high risk for bleeding ,obese, renal insufficiency

monitor factor 10 A Massive PE heparin 80 U/kg bolus then 18

/kg/hr Enoxaparin 1 mg/kg sc bid

with a pretest probability >50 percent, empiricheparin should be administered


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Thrombolytic

Definite= PE with cardiogenic shock Other clinical judge case by case including

severe hypoxia Use sk- 250,000 u IV over 30 min then 100,000

/hr for 24 hr


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Surgery; RV emboli Severe refractory hypotension


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PE with arrest

CPR no pulse returns within a few minutes bolus inject 100 mg of alteplase or an equivalent

dose of fibrinolytic therapy whilecardiopulmonary resuscitation is continued forat least 20 min ROSC image to locateembolus surgical thrombectomy


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Pitfall

hypercoag state heparin(LMWH has no effect)

Ventilation/Perfusion scintigraphy Required cooperation Not proper for unstable cases

Pulmonary CTA Not available Required contrast agent


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Systemic/local thrombolysis Acute massive PTE with clinical unstable Systemic thrombolysis is recommend, unless

contraindicated Recommend not to use local thrombosis Short term thrombolysis over long term infusion In those case, CVT should be consulted as initial

management


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Thrombus defragmentation therapySurgical thromboembolectomy Only in unstable case with contraindicate for

thrombolysis

Until now no evidence of benefit over lytictherapy


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COPD with AE


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Acute asthmatic attack


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Asthma in Pregnancy

No side effect of medication (B2-agonists,sterods) but fetal hypoxia may be greater risk

Physiologic hyperventilation leads to higher PaO2;

if PaO2 less than 70 mmHg represents severehypoxemia

less than 35 mmHg represents respiratory failure


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Anterior mediastinal mass

Obscure heart border differential diagnoses of masses in the

anterior mediastinum include the 5 T s:thyroid masses, teratoma, thymic masses,

(terrible) lymphoma, and thoracic aneurysm.

53


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74 yo man with COPD WITH AE After start


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74 yo man with COPD WITH AE. After start

bipap with I 10 E 4 20 , rate 10, 20 min later thepatient oxygenation is not improve which of thefollowing change most likely increase patientoxygenation.

a) increase in IPAP for 10-15 b) Increase rate from 10-12c) Decrease EPAP from 4 to 2d) Increase EPAP from 4 to 7 IPAP from 10-15e) Decrease EPAP from 4 to 2 and IPAP from 10

to 5


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BIPAP

oxygenation.: PEEP (concomitantly increaseIPAP to maintain positive pressure

differentiation during inspiration) and Fio2 PaCO2: rr


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Non invasive1. Consciousness( CO2 retension 15-

30 )

2. Co-operate3. CVS stable4. Asphyxia, aspiration, airway obstruction ect5. PaO2 < 60 with 100%O2


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Problem with NPPV Oxygen concentration Rebreathing esp EPAP< 4 cmH2O

Dyssynchrony Rise time


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BiPAP IPAP ~8 cmH2O acute 10-16

20 ( OSA 40) EPAP;Rebreathing esp EPAP< 4 cmH2O Back up rate 12-24 Rise time 0.05-0.1 sec 0.3-0.4 sec Maximum inspiratory time I:E

1:1 Blender, Humidifier


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COPD pH > 7.30-7.35

PaCO2 45-60 mmHg RR >25 Accessory muscle,paradoxical abdominalmotion


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63 yo woman present with ARDS. Which of the


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63 yo woman present with ARDS. Which of thefollowing summarized best ventilationstrategies in ARDS?

a) Owing to low compliance, pt need higher TV,higher PEEP to ensure adewuate ventilaiton

b) Owing to significant airway obstruction, ptrequire very low or no PEEP similar to asthmato avoid air trapping

c) Owing to low compliance , pt require low TV,and higher PEEP to avoid barotrauma

d) Owing to high compliance, pt donot requirePEEP


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ALI and ARDS Bilateral pulmonary infiltration or edema without LV failure (PCWP


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0.4-0.60.210.4-0.61.00.4-0.6FiO 2

Deceleratingor square



DeceleratingDeceleratingwaveform

5-100-335-15 5PEEP

606060-10040-8040Peak flow

(L/min)

10-1410-148-1212-208-12RR

8-1212-148-106-810-12VT(ml/kg)

SIMVSIMVSIMV

Due to low TV, give higher PEEPto keep adequate oxygenation

(FiO2 < 0.5)

A/C,SIMV

A/C A/C,SIMV

A/C A/C orSIMV

Mode

EDCB Asettingcondition

CHFNeuromuscCOPDARDSPeriop


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0.4-0.60.210.4-0.61.00.4-0.6FiO 2





5-100-335-15 5PEEP

606060-10040-8040Peak flow

(L/min)

10-1410-148-1212-208-12RR

8-1212-148-106-810-12VT(ml/kg)

SIMVSIMVSIMV

GoalKeep pH normal

O2Sat >90%Pplat


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following objective

a) Pt purposefully hypoventilated, maintainingelevated PaCO2 to keep airway pressure at safelevel

b) Pt purposefully hyperventilated to bring PaCO2 back to normal because ventilatory failure isprimary reason for intubation

c) Initial ventilator setting are no different thanpatient intubated for altered mental status

d) Inspiratory flow rates are set very low to avoidcausing very high peak airway pressures

e) The inspiratory flow curve should be ramp-style wave instead of square style wave to maximizedexpiratory times

A/C,SIMV

A/C A/C,SIMV

A/C A/C orSIMV

Mode




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0.4-0.60.210.4-0.61.00.4-0.6FiO 2





5-100-335-15 5PEEP

606060-10040-8040Peak flow

(L/min)

10-1410-148-1212-208-12RR

8-1212-148-106-810-12VT(ml/kg)

SIMVSIMVSIMV

A/C,SIMV

A/C A/C,SIMV

A/C A/C orSIMV

Mode



DHII t i i PEEP


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0.4-0.60.210.4-0.61.00.4-0.6FiO 2





5-100-335-15 5PEEP

606060-10040-8040Peak flow

(L/min)

10-1410-148-1212-208-12RR

8-1212-148-106-810-12VT(ml/kg)

SIMVSIMVSIMVIntrinsicPEEP

autoPEEPDynamicairway collapse

Maximizeexp.time to

avoid air trap by shorten

inspitime(highinsp.flow) andsquare wave

form, decrease

min.vent ( Vt or RR)


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Pulmo Emergency