Nothing else matters if you can’t breathe

You are called stat to the ER

You meet in the - ER First things first---What do you do? What do you know?

What do you need?

Respiratory Failure :Definition:

“The inability to maintain either normal delivery of O2 to the tissues or the removal of CO2 from the tissues”

SIGNS and SYMPTOMS Patient will ….. have an RR >28 bpm have a HR > 120 bpm be diaphoretic unable to speak in full sentences begin to tire

Intubate and Ventilate

Bag

Suction

Intubate

Ventilate

WHAT TO DO WHAT TO SET FIRST

Delivery of Inspired O2

Next StepFIO2

AND

PEEP

MODES of MV

PHASE II Monitoring and Assessing

MonitorAdjusting - primary controlsCorrecting an ABGAdjusting – secondary controls

Monitoring the patient

Patient Assessment

Hemodynamics

Vital signs

Adjusting ventilator controls

Correcting an ABG To normalize a high PaCO2

↓ or remove deadspace ↑ Vt ↑ f

To normalize a low PaCO2 ↑Deadspace ↓ f ↓ Vt

Increase a low PaO2 FIRST -↑ FiO2 by 5-10% up

to 60% THEN - ↑ PEEP by 5

Decrease a high PaO2 FIRST - ↓ FiO2 to < 60% THEN -↓ PEEP

Adjusting Vent : Secondary ControlAKA fine tuning

I:E ratioAdjust inspiratory plateauPositioning patientAdjust pressure supportPEEP/CPAP therapyCalculate minimum flowrate

Waveforms

PHASE III – Weaning From The Ventilator

Assessment for WeaningDecreasing Ventilator SettingsWeaning Methods

Assessment for Weaning

ABG

Bedside PFT

Decrease Ventilator Settings

Ventilator Settings : RR,FIO2,PEEP

LOWEST POSSIBLE VENTILATOR SETTINGSSIMV/IMV 4 breathsFIO2 of 40% PEEP 0f 5cm H2O

WEANING METHODSTraditional method/Trial and error/T-piece trial

IMV/SIMV

PSVIPAP support for difficult to wean

Summary of adverse conditions

↑ HR by > 20 bpmΔ in Bp by 10-20 torr↑ in PaCO2 by 10 torrRR ↑ 10 or > 30 bpmStridor

Chronically Ventilator-Dependent Patients

23

Definition: ventilator dependency remains

following 3 months of weaning attempts.

Once dependency established, goal is to restore highest level of independence.

END of LIFETerminal Weaning

Refers to weaning in the face of catastrophic and irreversible illness

Decision is made by patient and/or family in consultation with physician.

May be due to advanced directives, current patient decision, or very poor prognosis

3Phases of mechanical Ventilation:

Phase 1 Initiating mechanical Ventilation

Phase 2 Monitoring and adjusting ventilator

Phase 3 Weaning and extubating from the ventilator

SUMMARY