1. Mechanical Ventilation in Special Conditions

2. Mechanical Ventilation: Outline
Head injury
Chest Trauma
Bronchopleural Fistula 3 3 3 3 3 3

3. Traumatic Brain Injury

4. Prevalence of extracerebral organ dysfunction in TBI

5. Cerebral Compliance Curve
CPP= MAP-ICP
Intracranial pressure
CPP
Intracranial volume

6. Cerebral Compliance Curve
PaCO2
PaO2
CPP
Cerebral Blood Flow 50
100
150

7. Head Injury: MV Monitoring
Peak alveolar pressure, airway pressure, auto-PEEP
PaCo2 end tidal PCO2
Intracranial pressure
Jugular venous oxygen saturation
Pulse oximetry
Heart rate and systemic blood pressure

8. Hyperventilation in Traumatic Brain Injury
Causes cerebral vasoconstriction
Decreases cerebral blood flow
Decreases cerebral blood volume
Increases ICP
Has been proven to be of benefit in head injuries

9. Head Trauma Cerebral physiology Hyperventilation
ICP
CBF
Cerebral oxygenation : SJO2, PbrO2
Hyperventilation
Lung protective strategy
PEEP
Extubation

10. Hyperventilation in TBI
Chronic hyperventilation (PCO2 < 25) should be avoided
Prophylactic hyperventilation (PCO2 < 35) in the first 24 h should be avoided
May be necessary for a brief period with acute neurologic deterioration

11. Head Trauma + Lung protective strategy PEEP Extubation
Hypoventilation  PCO2   ICP 
No evidence of detrimental effect
Use protective ventilation
Observe ICP and CPP if PCO2▲
PEEP
ICP 
MAP 
Depends on compliance
Extubation
LOC
Cough
Tracheal secretions +

12. + Head Trauma Lung protective strategy PEEP
Hypoventilation  PCO2   ICP 
No evidence of detrimental effect
Use protective ventilation
Observe ICP and CPP if PCO2▲
PEEP
ICP 
MAP 
Depends on compliance +

13. Head Trauma
Extubation
LOC
Cough
Tracheal secretions

14. Hyperventilation & CBF

15. Head Trauma CBF and ICP with hyperventilation

16. Head Trauma
Extubation
LOC
Cough
Tracheal secretions

17. Intrathoracic Pressure (-3 cm H2O) Venous Return MAP (90)= CO X SVR
Decompressive Craniotomy
Decrease Oxygen Demand
Prevent seizure
Sedation
Treat pain
Barbiturate coma
Avoid hyperthermia
? hypothermia
ICP= 10
ICP =30
CSF Drainage
HOB > 30 degree
Head in neutral position
Vetriculostomy
Decrease Brain Water
Mannitol
Avoid D5%
Diuretics
Vasoconstriction
Pa co
CPP = MAP – ICP
Avoid ↑ Intrathoracic Pressure
Suppress Valsalva maneuvers
Suppress cough
↓ Mean airway pressure
Minimize use of PEEP
Treat distended abdomen
Maintain adequate MAP
Adequate CO
Use inotropic Agents
Adequate filling pressures
Avoid hypotensive agents
Treat infection abruptly
Intrathoracic Pressure (-3 cm H2O)
Venous Return
MAP (90)= CO X SVR

18. Underlying lung
disease
CMV (A/C), PCV or VC,
VT 4-8 mL/kg, FiO2 1, rate
20/min TI1s, PEEP 5 cm H2O
yes
CMV (A/C), PCV or VC,
VT 4-8 mL/kg, FiO2 1, rate
15/min TI1s, PEEP 5 cm H2O no
Titrate FiO2 for SpO2 ≥ 92%
PCO2
>45
↑ rate no
↓ rate
yes
↓ VT
Pplat > 30
<35
PaO2
35-45 no
yes
↑ PEEP
↓ FiO2
>100
FiO2
> 0.6
<70
yes
ICP < 20
70-100
FiO2 >
0.6 no
↑ FiO2
yes
<20
>20
ICP
More aggressive
Medical therapy
Slowly ↓ rate to
initial setting no
ICP
>20
↑ rate
Maintain
Ventilator
Setting
<20

19. Chest trauma Who Gets Admitted?
Sternal fractures mediastinal injury
Any 1th, 2nd, 3rd Rib fractures
> 1 Rib fracture in any region
Pulmonary contusion
Subcutaneous emphysema
Traumatic asphyxia
Flail segment
Arrhythmia or myocardial injury

20. Flail Chest

21. Flail chest

22. Flail Chest

24. BPF

25. BPF

26. BPF

27. Adverse effects of BPF in the ventilated patient
Incomplete lung expansion
Loss of TV
Inability to remove CO2
Loss of PEEP
Pleural space infection
Factitious ventilator cycling

28. Guidelines for ventilator management in the patient with BPF
Reduce MAP & RR
Wean patient completely if possible
Partial ventilatory support
low-rate SIMV or PSV
Minimize minute ventilation
Use of permissive hypercapnia
Avoid patient positions that increase the leak
Treat bronchospasm
Consider unconventional measures
Bronchoscopic techniques
HFV
ILV

29. Independent lung ventilation

30. Independent Lung Ventilation