1. MANAGEMENT OFPATIENTS ON MECHANICALVENTILATION DR. PINAKI MAZUMDER Assistant Professor , Dept. of Anesthesiology, Calcutta Medical College.

2. INDICATIONS OF MECHANICAL VENTILATION Inadequate tissue oxygenation Inadequate tissue perfusion Inadequate ventilation MECHANISM OF OXYGEN TRANSPORT

4. Neurogenic (spinal injury)

6. CVA

8. Neuromuscular weakness

9. Muscle dystrophy

10. Neurotoxic snake bite

13. Tracheostomy for long term ventilation

14. Size of endotracheal tube

15. 8.0 to 8.5 mm for adult males

18. 21 to 22 cm mark for males

19. 19 to 20 cm mark for females

20. Nasal tubes require 5 cm additional length.

21. Adhesive tape with counter-traction force for tube fixation

22. Head is kept at neutral position

25. Assist Control mode ventilation (ACV): delivers fixed volume/ pressure in response to spontaneous breath.

27. 8- 10 ml /kg for normal lung

28. 5 – 8 ml/kg for abnormal lung

29. Plateau pressure < 30 cm H2O

30. High volume -> barotrauma/volutrauma

32. High rate ( 20 – 25/ min) in ARDS

33. Low rate for COPDMinute ventilation : 5 – 10 lt/min Inspiration expiration ratio: 1:2 to 1: 3 Oxygen concentration :start with 100% , decrease to 60 % to achieve SpO2 >90% or PaO2 > 60 mm Hg

35. used if SpO2 < 90% on FiO2 0.6

36. start with 3-5 cm H2O , increase up to 15 cm H2O

38. Base excess

41. Ventilatory settings

42. Tidal volume

43. Respiratory rate

44. Minute volume

45. Peak and Plateau pressure

46. Static and Dynamic compliance

47. Gas exchange parameters- PaO2. FiO2 periodically recorded.

48. Goal of Ventilation Adequate oxygenation and ventilation Prevent oxygen toxicity by using FiO2 < 0.6 Use PEEP in refractory hypoxia Maintain normal blood volume, pump function, cardiovascular parameters. Adequate Hb concentration Humidification of the inspired gas Frequent aseptic tracheo-bronchial suction Good physiotherapy and Organ support.

49. Problems during Ventilation Asynchrony between patient and ventilator : Reassure the patient , give sedative analgesic. Increase minute ventilation Give higher FiO2 Increase inspiratory flow rate Manually ventilate with 100% oxygen for 5 minutes- if severe resistance felt, change the tube. Rule out associated problems- acidosis, electrolyte disorders, pain, fever , shock, full bladder or stomach. Neuromuscular blocker - as last resort.

51. Disconnection/ leak in circuit

52. Leakage in cuff

53. Ventilator malfunction

54. High airway pressure alarm

55. Kinking /Blockade of ET tube/ tracheostomy tube

56. Bronchospasm

57. Decreased lung compliance

58. Oxygen alarm

61. Aseptic suction

62. Physiotherapy

63. Postural drainage

65. Weaning from ventilator Patient clinically stable ,underlying disease improved PaO2 > 70 mmHg , PCO2 < 45 mm Hg on FiO2 0.4 , acid base status, electrolytes, blood biochemistry, and chest x ray are near normal Hemodynamically stable No fever or Organ failure or Bleeding Nutritional status is good Neuromuscular function is adequate. bedside test: if respiratory rate > 30 or tidal volume < 300 ml then continue ventilation

66. Modes of weaning Patient connected to ventilator Pressure Support Ventilation (PSV) SIMV with gradual decrease of rate. Patient removed from ventilator Daily T piece trial of 60 mins or initial 15 – 30 mins trial followed by progressive increase in trial duration over the whole day. Extubate if no respiratory distress / clinically stable.

67. Thank you.