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Mechanical Ventilation in Special Conditions. Mechanical Ventilation: Outline Head injury Chest Trauma Bronchopleural Fistula.

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Presentation on theme: "Mechanical Ventilation in Special Conditions. Mechanical Ventilation: Outline Head injury Chest Trauma Bronchopleural Fistula."— Presentation transcript:

1 Mechanical Ventilation in Special Conditions

2 Mechanical Ventilation: Outline Head injury Chest Trauma Bronchopleural Fistula

3 Traumatic Brain Injury

4 Prevalence of extracerebral organ dysfunction in TBI

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

6 Cerebral Compliance Curve 50 Cerebral Blood Flow CPP PaO 2 PaCO

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 1.Causes cerebral vasoconstriction 2. Decreases cerebral blood flow 3. Decreases cerebral blood volume 4. Increases ICP 5. Has been proven to be of benefit in head injuries

9 Head Trauma Cerebral physiology –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 –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 –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 ▼ICP ►CBF◄

16 Head Trauma Extubation –LOC –Cough –Tracheal secretions

17 Intrathoracic Pressure (-3 cm H 2 O) CPP = MAP – ICP MAP (90)= CO X SVRVenous Return ICP= 10 ICP =30 Maintain adequate MAP Adequate CO Use inotropic Agents Adequate filling pressures Avoid hypotensive agents Treat infection abruptly Avoid ↑ Intrathoracic Pressure Suppress Valsalva maneuvers Suppress cough ↓ Mean airway pressure Minimize use of PEEP Treat distended abdomen CSF Drainage HOB > 30 degree Head in neutral position Vetriculostomy Decrease Oxygen Demand Prevent seizure Sedation Treat pain Barbiturate coma Avoid hyperthermia ? hypothermia Decrease Brain Water Mannitol Avoid D5% Diuretics Vasoconstriction Pa co Decompressive Craniotomy

18 Underlying lung disease Titrate FiO2 for SpO2 ≥ 92% no ↓ rate yes ↓ V T yes ICP < 20 no ↑ FiO FiO2 > 0.6 ↑ rate <20 >20 ICP More aggressive Medical therapy Slowly ↓ rate to initial setting no ICP yes ↑ PEEP CMV (A/C), PCV or VC, V T 4-8 mL/kg, FiO 2 1, rate 20/min T I 1s, PEEP 5 cm H 2 O yes CMV (A/C), PCV or VC, V T 4-8 mL/kg, FiO 2 1, rate 15/min T I 1s, PEEP 5 cm H 2 O no >45 ↑ rate PCO2 ↓ FiO 2 >100 >20 yes FiO2 > 0.6 <70 Maintain Ventilator Setting <20 no Pplat > 30 <35 PaO

19 Chest trauma Who Gets Admitted? Sternal fractures mediastinal injury Any 1th, 2 nd, 3 rd 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

23

24 BPF

25

26

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

31


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