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Mechanical ventilation in COPD Asthma drtrc

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Conventional Mechanical Ventilation for Respiratory Failure in COPD Dr.T.R.Chandrashekar M.D Director critical care K.R.Hospital, Bangalore .
COPD ,[object Object],[object Object],[object Object]
Systemic effects of COPD Effects Mechanism
Why COPD is Important ? ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
In COPD limitation is EF ,[object Object],[object Object],[object Object],Inspiratory muscle loading and fatigue is of central pathophysiological importance in the development of acute respiratory failure
Pathophysiology of COPD Expiratory flow limitation is the primary problem
Lung Capacity and Disease Space for fresh air TLC
The Vicious Cycle Increased resistance Airtrapping Decreased Compliance ↑ PVR >DH >DH  WOB FATIGUE ↑ PCO2/↓Pao2 ↓ PH V/Q mismatch
Worsening EFL ,[object Object],[object Object],[object Object],[object Object],[object Object],COPD Exacerbation ,[object Object],[object Object],[object Object],[object Object],Tachypnea DH EELV, IC ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Identify & Measure Complications Manage COPD Key factor is DH Auto PEEP PEEPi EELV
Concept of DH ,[object Object],[object Object]
Concept of Auto PEEP, DH ,[object Object]
Identification of Auto PEEP Inspiration Expiration Time (sec) Flow (L/min) } Normal Patient Air Trapping Auto-PEEP
Measurement of Auto PEEP Reduce set PEEP to zero before measuring Auto PEEP Paralysed patient only AT HE END OF EXPIRATION 2 -3 SEC OCCULSION
Auto-PEEP and Volume of Trapped Gas Tuxen, Am Rev Respir Dis 1989; 140:5
WHAT ARE EFFECTS OF AUTO PEEP? ,[object Object],[object Object],[object Object],[object Object]
Mechanical Effects of AECOPD Thorax 2006;61:354-61
AUTOPEEP AND TRIGGER Time (sec) Pressure (cmH 2 0) AUTOPEEP BASELINE BASELINE SHIFTS
Missed breath Auto PEEP Wasted effort, increased WOB
There are only 3 factors that determine auto-PEEP. ,[object Object],[object Object],[object Object],Let us learn how to manipulate these parameters To prevent Auto PEEP
CO2 removal is inversely proportional to Minute Ventilation CO2 removal is inversely proportional to Effective Alveolar Ventilation Effective Alveolar Ventilation = Minute Ventilation – Dead Space Ventilation
COPD on ventilator on VC Vt 500ml, Fio2 40%, PEEP 4cms H2o RR10/mt, I:E 1:2 Po2 is 60, PCo2 is 68 Increase Vt to 500ml Increase RR 15 After one hr repeat ABG shows PO2 of 58 PCO2 of 83 Minute ventilation of 500x10=5000 Minute ventilation of 500x15=7500
Effective Alveolar ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
FRC EELV/DH COPD compliance Resistance PVR
Respiratory rate ,[object Object],[object Object],Inspiration = 2seconds Expiration 4 seconds RR 20 breaths/ mt, I:E Ratio 1:2, TCT=60/20=3 sec Inspiration = 1seconds Expiration 2 seconds 3 sec 1sec 2 sec
Minute ventilation ,[object Object],[object Object],[object Object],[object Object],[object Object]
Manipulate - I:E Ratio Pressure T ime Gives more time for expiration and reduces DH T insp . . I : E = 1 : 2 I : E = 1: 3 PEEP PIP PIP PEEP T insp . T exp Total cycle time
Peak flow ,[object Object],Ins time Tidal volume PEAK FLOW = X 60 A peak flow of around 80-90l/mt
RISE TIME 40 P CIRC cmH 2 O INSP EXP 30 20 10 0 10 -20 80 60 40 20 0 20 -80 40 60 0 4 8 12s 2 6 10 Slow rise Moderate rise Fast rise TE TE TE TI L min V .
PEAK FLOW Peak Flow 30l/mt Peak Flow 90 l/mt
Addition of external PEEP “The Paradox “
 
+6 +6 +7 Pleural Alveolus Mouth start of Inspiration Airway Pressures with Auto-PEEP Auto-PEEP = +6 Wilson et al, U of Iowa
Can PEEP be used in all COPD pts? ,[object Object],[object Object],[object Object],[object Object]
Monitoring the response to external PEEP
0 cm H 2 O PEEP 8 cm H 2 O PEEP Auto peep
Calculation of Exp time constants ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Management of Auto PEEP. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],}}} Low MINUTE VENTILATION
[object Object]
ARF-COPD ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
ARF-COPD ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Baseline Pco2, PH, WOB, Hemodynamic stability, FIO2,Mentation Should be kept in mind while interpreting ABG’s and decision to ventilate
Spontaneous Weaning Controlled Conventional ventilation NIV Mechanical ventilation
Ventilation difficulties in COPD ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Case scenario
Indications for Invasive Mechanical Ventilation. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Intubation and MV ,[object Object],[object Object],If paralysed keep them on relaxants for a day or two. Fill them adequately before induction , Add a small dose of a inotrope in a corpulmonale patient
Ventilatory settings in passive pt ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],7ml/kg 12/mt =80-100l/mt 1:3 or more depending on expiratory time constants
Ventilation in a passive patient ,[object Object],[object Object],[object Object],[object Object]
Paw (cm H 2 O) Normal P Plat (Normal Compliance) Increased PIP } Increased P TA (increased Airway Resistance ) Increased Airway Resistance Begin Inspiration Begin Expiration P aw (cm H 2 O) Time (sec) Airway Resistance Distending (Alveolar) Pressure Expiration PIP Normal Inflation Hold (seconds)
[object Object],[object Object],[object Object],[object Object],[object Object]
Ventilating a spontaneous patient ,[object Object],[object Object],[object Object],[object Object],[object Object]
Ventilating a spontaneous patient ,[object Object],[object Object],[object Object],[object Object]
CYCLING AT 40% OF FLOW CYCLING AT 25% 0F PEAK FLOW PRESSURE SUPPORT Flow cycling Flow Time Peak flow 40% 25%
Weaning ,[object Object],[object Object],[object Object],Steroids + Relaxants Myopathy
Weaning ,[object Object],[object Object],[object Object],[object Object]
IN COPD ,[object Object],[object Object],[object Object],[object Object],[object Object]
Thank you Stop Smoking……

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Mechanical ventilation in COPD Asthma drtrc

  • 1. Conventional Mechanical Ventilation for Respiratory Failure in COPD Dr.T.R.Chandrashekar M.D Director critical care K.R.Hospital, Bangalore .
  • 2.
  • 3. Systemic effects of COPD Effects Mechanism
  • 4.
  • 5.
  • 6. Pathophysiology of COPD Expiratory flow limitation is the primary problem
  • 7. Lung Capacity and Disease Space for fresh air TLC
  • 8. The Vicious Cycle Increased resistance Airtrapping Decreased Compliance ↑ PVR >DH >DH  WOB FATIGUE ↑ PCO2/↓Pao2 ↓ PH V/Q mismatch
  • 9.
  • 10. Identify & Measure Complications Manage COPD Key factor is DH Auto PEEP PEEPi EELV
  • 11.
  • 12.
  • 13. Identification of Auto PEEP Inspiration Expiration Time (sec) Flow (L/min) } Normal Patient Air Trapping Auto-PEEP
  • 14. Measurement of Auto PEEP Reduce set PEEP to zero before measuring Auto PEEP Paralysed patient only AT HE END OF EXPIRATION 2 -3 SEC OCCULSION
  • 15. Auto-PEEP and Volume of Trapped Gas Tuxen, Am Rev Respir Dis 1989; 140:5
  • 16.
  • 17. Mechanical Effects of AECOPD Thorax 2006;61:354-61
  • 18. AUTOPEEP AND TRIGGER Time (sec) Pressure (cmH 2 0) AUTOPEEP BASELINE BASELINE SHIFTS
  • 19. Missed breath Auto PEEP Wasted effort, increased WOB
  • 20.
  • 21. CO2 removal is inversely proportional to Minute Ventilation CO2 removal is inversely proportional to Effective Alveolar Ventilation Effective Alveolar Ventilation = Minute Ventilation – Dead Space Ventilation
  • 22. COPD on ventilator on VC Vt 500ml, Fio2 40%, PEEP 4cms H2o RR10/mt, I:E 1:2 Po2 is 60, PCo2 is 68 Increase Vt to 500ml Increase RR 15 After one hr repeat ABG shows PO2 of 58 PCO2 of 83 Minute ventilation of 500x10=5000 Minute ventilation of 500x15=7500
  • 23.
  • 24. FRC EELV/DH COPD compliance Resistance PVR
  • 25.
  • 26.
  • 27. Manipulate - I:E Ratio Pressure T ime Gives more time for expiration and reduces DH T insp . . I : E = 1 : 2 I : E = 1: 3 PEEP PIP PIP PEEP T insp . T exp Total cycle time
  • 28.
  • 29. RISE TIME 40 P CIRC cmH 2 O INSP EXP 30 20 10 0 10 -20 80 60 40 20 0 20 -80 40 60 0 4 8 12s 2 6 10 Slow rise Moderate rise Fast rise TE TE TE TI L min V .
  • 30. PEAK FLOW Peak Flow 30l/mt Peak Flow 90 l/mt
  • 31. Addition of external PEEP “The Paradox “
  • 32.  
  • 33. +6 +6 +7 Pleural Alveolus Mouth start of Inspiration Airway Pressures with Auto-PEEP Auto-PEEP = +6 Wilson et al, U of Iowa
  • 34.
  • 35. Monitoring the response to external PEEP
  • 36. 0 cm H 2 O PEEP 8 cm H 2 O PEEP Auto peep
  • 37.
  • 38.
  • 39.
  • 40.
  • 41.
  • 42. Spontaneous Weaning Controlled Conventional ventilation NIV Mechanical ventilation
  • 43.
  • 44.
  • 45.
  • 46.
  • 47.
  • 48.
  • 49. Paw (cm H 2 O) Normal P Plat (Normal Compliance) Increased PIP } Increased P TA (increased Airway Resistance ) Increased Airway Resistance Begin Inspiration Begin Expiration P aw (cm H 2 O) Time (sec) Airway Resistance Distending (Alveolar) Pressure Expiration PIP Normal Inflation Hold (seconds)
  • 50.
  • 51.
  • 52.
  • 53. CYCLING AT 40% OF FLOW CYCLING AT 25% 0F PEAK FLOW PRESSURE SUPPORT Flow cycling Flow Time Peak flow 40% 25%
  • 54.
  • 55.
  • 56.
  • 57. Thank you Stop Smoking……