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Non-Pulmonary Complications of Mechanical Ventilation.

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Presentation on theme: "Non-Pulmonary Complications of Mechanical Ventilation."— Presentation transcript:

1 Non-Pulmonary Complications of Mechanical Ventilation

2 Complications of Mechanical Ventilation Complications related to Intubation Mechanical complications related to presence of ETT Pulmonary complications Cardiovascular complications Biomedical complications Neurological complications Other complications

3 Four major concepts Know the patient Know the ventilator Put the ventilator between you and the patient Alive ill patients

4 MV complications Mechanicals Biophysical Inflammatory Cytokines Biochemical MedicationModesDisease

5

6 COMPLICATIONS RELATED TO AIRWAYS

7 Competence Confidence Unable to Open Mouth Trismus Small mouth Peri-oral scarring Fascial swealling Unable to insert laryngoscope Short neck Large chest Prominent upper incisors Small mandible Edema Unable to see glottis Fixed position of the head Small jaw Anterior larynx Obstructed by blood or vomit Unable to pass tube into trachea Fixed Unrecognizable glottis Too small glottis or sub-glottic diamete Vulnerability to complications Fixed Full stocmach Hypovolemia Hypotension Hypoxemia Hypercarbia Agitation Age and sex Trauma Endobronchial intubation Esophageal intubation Severe hypoxia Severe hypotension Death Environment No skilled help No specialized equipments Missing of defective equipment Poor positioning Difficult Intubation

8 Injuries to Face, Lips and Oro- pharynx Trauma to the lips and cheeks from tube ties Peri-oral herpes Injuries to the tongue especially if entrapped between the endotracheal tube and the lower teeth Pressure ulcers to the palate and oropharynx

9 Skin Avulsion Tongue Injury Lip Injury Periorbital herpes

10 Maxillary Sinus and Middle Ear Effusion Maxillary effusion –20% in patients intubated for > 7 days. –47% when the gastric tube is placed nasally –95% Secondarily infected maxillary effusion (45- 71% of effusions) Middle ear effusion (29%) with 22% of them become infected Hearing impairment that may contributes to the confusion and delirium in elderly population

11 Laryngeal Injuries Some degree of glottic injury is seen in 94% of patients intubated for 4 days or longer Erosive ulcers of vocal cords (posterior commissures) Swelling and edema of the vocal cords Granulomas (7% in patients intubated for 4 days or more)

12 Vocal Cords Ulcers Granulomas Vocal Cord Hematoma Vocal Cord Edema

13 Pharyngo-laryngeal Dysfunction Post-extubation discomfort (40% regardless of the duration) Hoarsness : edema, injury, disarticulate –52% in short-term intubation –70% in patients with prolonged intubation Slowing of the reflex swallowing mechanism and risk of aspiration –15.8% of patients who were intubated more than 4 days did not have a gag reflex Silent aspiration: Ventilator Associated Pneumonia –20% in young population –36% in older population

14 Tracheal Injuries Cuff pressure related tracheal mucosa ischemia Cuff pressure tracheal damage: tracheal ulceration, edema and sub-mucosal hemorrhage Tracheal dilatation: tracheomalacia Tracheal stenosis: –At the site of the cuff (50%) –At the site of the tracheostomy (35%) –Unclear (15%)

15 Tracheal Stenosis Glottic Stenosis Granuloma and Ulceration Tracheomalacia

16 Unplanned Extubation Self extubation (8%) and accidental extubation (1%) Longer ICU and hospital stay Increased ICU and hospital mortality

17 CARDIOVASCULAR COMPLICATIONS OF MECHANICAL VENTILATION Biomechanical effect

18 ExpInsp CVP Pressure (mmHg) Extrathoracic veins Right atrium ExpInsp CVP Pressure (mmHg) Extrathoracic veins Right atrium

19 Decreased Cardiac Output. Decreased Pressure Gradient for venous return and decrease RV preload PPV Decreased CO due to decreased RV filling Volume due to decreased venous return

20 -2 mm Hg 3 mm Hg 5 mm Hg 6 mm Hg 8 mm Hg 2 mm Hg Decreased Cardiac Output Decreased Right Atrial Distension PPV Decreased CO due to decreased RV filling Volume due to decrease RA compliance

21 Decreased BP PPV vs. Spontaneous Ventilation

22 Decreased BP PPV VS. Spontaneous Ventilation

23 Hypotension following MV

24 PPV increase CO and BP Ventricular interdependence: decrease CO during spontaneous breathing due to : increase RV filling volume with shifting the intra ventricular septum causing mechanic impedance for LV decreasing its compliance causing decrease CO and BP PPV improve the dynamic shape of the septum providing better LV compliance, better preload and thus better Stroke Volume and BP. Increase in Trans mural pressure of the great arteries in the thorax.

25 Cyclic BP effects is related to Volume status Ventilation on sick individual Cyclic changes in Gas exchange and partial pressures

26 Effect of Changing Lung Volume on Pulmonary Vascular Resistance Pulmonary vascular Resistance Lung Volume Total pulmonary vascular resistance Intra-alveolar vaso-compressionHypoxic vasoconstriction RVTLCFRC

27 Hemodynamic effects of mechanical Insuflation. End of inspiration Maximum of SBP, PP, Aortic velocity End of inspiration Maximum of SBP, PP, Aortic velocity End of inspiration Minimum of SBP, PP, Aortic velocity End of inspiration Minimum of SBP, PP, Aortic velocity Inc. LV ejection Inc. LV ejection Dec. LV ejection Dec. LV ejection

28 Effect of Lung Volume No effect in Normal individual with PEEP less than 10 cmH2o Major effect in patients with Dynamic Hyperinflation such as asthmatic and COPD, and in pre-existing pulmonary hypertension Small changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVR Avoid gas trapping in these patient Know the patient, Know the ventilator

29 Alveolar pressure and Gas exchange Dead Space PaO2 Oxygen Transport

30 Pleural pressure Venous Return V/Q Matching LV afterload Work of Breathing Fully Spontaneous Partial Ventilator support Fully Controlled Effects of PPV on hemodynamic Magnitude of Effect

31 Bradycardia and intra-arteriolar vasodilatation Reflex Arrhythmias, Bradycardia Intra arteriolar Vasodilatation

32 Effect of Preload on Cardiac Output Left Ventricular Preload Cardiac Output Normal cardiac function Congestive heart failure

33 BIOCHEMICAL EFFECT OF MECHANICAL VENTILATION Systemic inflammatory effect

34 Inflammatory Biochemical injury Local and systemic Inflammation cascade

35 Micro vascular, Alveolar Fracture Hotchkiss et all Critical care Med, 2002 Prot for Gas and Bacteria

36 Biochemical effect of MV Pro- Inflammatory Cytokines during PPV

37 NEUROLOGICAL FUNCTIONS DURING MECHANICAL VENTILATION Psychogenic effect

38 Acute Effects Vasoconstriction secondary to hypercapnia Decreased intra-cerebral blood volume and intracranial pressure PEEP reduces cerebral perfusion pressure by decreasing venous return and increasing intracranial pressure –20-25% of is transmitted to the central venous pressure in a normal compliant lung –>20% is transmitted in patients with decreased lung compliance

39 Stage 1 Stage 2 Stage 3 Stage 4 REM Non REM Age 40 MV Sleep Time (minutes)

40 Stage 1 Stage 2 Stage 3 Stage 4 REM Normal Sleep Pattern

41 Stage 1 Stage 2 Stage 3 Stage 4 REM Hyponogram for a Patient on Mechanical Ventilation

42 Mechanisms by which mechanical Ventilation Disrupt Sleep Noise disruption –Ventilator alarm: inappropriate threshold Delayed alarm inactivation –Humidifier alarms Disruption by nursing interventions –Airway suction –Nebulizer delivery Ventilation-related pharmacological disruption –Benzodiazepines (↓REM, ↓deep NREM) –Oipoids (↓REM, ↓deep NREM) –Neuromuscular blocking drugs Ventilator mode –Pressure support ventilation

43 GASTROINTESTINAL EFFECTS OF MECHANICAL VENTILATION Systemic inflammatory and low perfusion effects

44 GI Effects of PPV

45 GI Effects of MV

46 Esophagus, Stomach and Small Intestine Erosive esophagitis (30-50% of patients ventilated >48 hours) –NG tube –Poor lower esophageal sphincter tone and reflux –Opiates and adrenergic agonists –Duodenogastroesophageal reflux through the action of trypsin Upper gastrointestinal hemorrhage: –Stress –Decreased gastric mucosal protection secondary to a fall in splanchnic blood flow Decreased motility of stomach and small intestine

47 Liver and Gallbladder Reduction in portal venous flow secondary to the fall in cardiac output Increased hepatic arterial flow “ hepatic arterial buffer response” Normal total hepatic perfusion Hepatic engorgement Venous ischemia and elevation of serum transaminases and hyperbilirubinemia Reduction in drug clearance secondary to reduction of hepatic blood flow

48 Large Bowel Constipation Abdominal distension

49 RENAL FUNCTIONS DURING MECHANICAL VENTILATION Systemic inflammatory and ischemic effects

50 Renal Effects of MV The usual renal response to reduction of cardiac output and mean arterial pressure Reduction in urine output secondary to a fall in the transmural pressure of the right atrium that results in reduction of the secretion of atrial naturitic peptide and the activation of renin-angiotensin-aldosterone system and pituitary vasopressin secretion

51 Acute Effects Vasoconstriction secondary to hypercapnia Decreased intra-cerebral blood volume and intracranial pressure PEEP reduces cerebral perfusion pressure by decreasing venous return and increasing intracranial pressure –20-25% of is transmitted to the central venous pressure in a normal compliant lung –>20% is transmitted in patients with decreased lung compliance

52 ASYNCHRONY WITH MECHANICAL VENTILATION Patient, Mode, and Operator effects

53 Asynchrony with the Ventiaitor Fighting the ventilators Inconsistent tidal volume Increase work of breathing Barotraumas and thoracic air leak Insufficient gas exchange Disturbances in the cerebral blood flow

54 Ventilation complications Mode specific Mode Specific Complications

55 Summery: MV complications ProcedureMechanical Ventilation Mechanical Ventilation and Disease Mechanical Ventilation, Disease, and Operator


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