2. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

3. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

4. Trauma to the lips and cheeks from tube ties Avulsion of skin due to adhesive tape Injuries to the entrapped tongue Pressure ulcers to the palate and oropharynx Perioral herpes

9. 3-4 cm

11.  Secure ET tube in place, note the number  Sedate patient with appropriate MAAS  Avoid accidental, or self extubation

12. Laceration and hematoma in the left vocal fold during direct laryngoscopy. Exam performed with rigid telescope

13. Bilateral intubation granulomas inserted in the vocal apophasis. Exam performed with rigid telescope. Ulcerated lesion in the posterior glottic commissure soon after extubation. Exam performed with rigid telescope.

14. diffuse posterior erythema, edema and piled-up mucosa of inter-arytenoid area

15. Risk of aspirationRisk of mechanical complications

16. Prince J S et al. Radiographics 2002;22:S215-S230

17. Tracheal stenosis (exam performed with flexible nasofibroscope) Glottic stenosis (exam performed with rigid telescope).

19. Tracheal collapse of more than 50% during expiration is diagnostic of tracheomalacia

20. The AnapnoGuard system detects air leakage from the lungs by measuring the CO 2 level above the cuff. Detection of high CO 2 levels above the cuff represents leakage

22.  Air inflation of the tube cuff until the airflow heard escaping around the cuff during positive pressure breath ceases.  Place a stethoscope over larynx. Indirectly assesses inflation of cuff.  Slowly withdraw air (in 0.1-mL increments) until a small leak is heard on inspiration.  Remove syringe tip, check inflation of pilot balloon

23. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

24.  64 year old male with history of COPD who presented with severe respiratory distress and required to be intubated and placed on CMV, VT of 650 ml and a rate of 24/min.  Immediately post intubation, his systolic blood pressure dropped from 132 mm Hg to 73 mm Hg.

26. PPV vs. Spontaneous Ventilation 0 5 3 -3 120 0 10

27. 0 5 3 -3 110 0 8

28.  No effect in Normal individual with PEEP less than 10 cmH2O  Major effect in patients with Dynamic Hyperinflation such as asthma and COPD, and in pre-existing pulmonary hypertension  Small changes in PVR can cause considerable hemodynamic compromise secondary to acute increase in PVR  Avoid air trapping in these patients

29.  Decreased cardiac output, decreased venous return  Observe for: ▪ Decreased BP ▪ Restlessness, decreased LOC ▪ Decreased urine output ▪ Decreased peripheral pulses ▪ Slow capillary refill ▪ Increasing Tachycardia

30. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

31. Overdistention Volutrauma Repeated recruitment and collapse Atelectetrauma Inflammatory mediators Bio trauma High-pressure induced lung damage Barotrauma FiO2 Oxygen toxic effect

32. Atelectrauma: Repetitive alveolar collapse and reopening of the under- recruited alveoli Volutrauma: Over-distension of normally aerated alveoli due to excessive volume delivery *Dreyfuss: J Appl Physiol 1992 Cytokines, complement, prostanoids, leukotrienes, O 2 - Proteases Biotrauma

33. Pinsp = 40 mbar

34. “Stretch” “Shear” Airway Trauma

40. Volume Pressure Zone of Overdistention “Safe” Window Zone of Derecruitment and Atelectasis Injury  Overdistension  Edema fluid accumulation  Surfactant degradation  High oxygen exposure  Mechanical disruption  Derecruitment, Atelectasis  Repeated closure / re-expansion  Stimulation inflammatory response  Inhibition surfactant  Local hypoxemia  Compensatory overexpansion

41. Diseased Lungs Do Not Fully Collapse, Despite Tension Pneumothorax And they cannot always be fully “opened” Dimensions of a fully Collapsed Normal Lung

42. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

43.  Absorptive atelectasis  O2/ N2 = 21/ 79 >>>>>> 50/ 50  Accentuation of hypercapnia  Chronic respiratory failure:  PCO2 with  PO2  Damage to airways  Bronchopulmonary dysplasia  Diffuse alveolar damage Carbon dioxide Water vapour Oxygen Nitrogen

45.  PEEP  Alveolar recruitment maneuvers  Alternative modes of ventilation  Inverse-ratio, APRV, HFV, …..  Inhaled nitric oxide (iNO)  Extracorporeal membrane oxygenation (ECMO)  Diuresis  if pulmonary edema is possible  Bronchopulmonary hygiene  if secretions are prominent  Augmentation of antioxidants??

46. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

48.  VAP – ventilator associated pneumonia  >48 hours on vent  Combination of: ▪ CXR changes ▪ Sputum changes ▪ Fever, ↑ WBC ▪ positive sputum culture  Occurs secondary to micro-aspiration of upper airway secretions

49.  No 1 risk factor is endotracheal intubation  Factors that related to cross contamination:  Poor adherence to infection control standards  Factors that enhance colonization of the oropharynx &/or stomach:  Poor oral hygiene  Conditions favoring aspiration into the respiratory tract or reflux from GI tract:  Supine position  NGT placement  Re-Intubation and self-extubation  Surgery of head/neck/thorax/upper abdomen  GERD  Coma/ depressed Glascow coma scale

67.  HOB at 30-45º CDC Guideline for Prevention of Healthcare Associated Pneumonias 2004 ATS / IDSA Guidelines for VAP 2005  45o head-up tilt is the goal in all patients unless contraindicated  No benefit of semi-recumbency ~30o over standard care ~10o  Supine position is harmful

70.  Elevation of the head of the bed 30-45o  Use 15-30o for neonates and small infants, otherwise 30-45o  Daily sedation vacations (minimize duration of intubation)  Daily assessment of readiness to extubate  Peptic ulcer disease (PUD) prophylaxis  Oral care protocol (chlorhexidine)  DVT prophylaxis option

71.  Dravulovic et al. Lancet 1999;354:1851-1858

72. NHSN 50 th Percentile 4.1

73. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

76.  Elevation of the head of the bed 30-45o  Use 15-30o for neonates and small infants, otherwise 30-45o  Daily sedation vacations (minimize duration of intubation)  Daily assessment of readiness to extubate  Peptic ulcer disease (PUD) prophylaxis  Oral care protocol (chlorhexidine)  DVT prophylaxis option

77. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

78.  Fighting the ventilators  Inconsistent tidal volume  Increase work of breathing  Barotraumas and thoracic air leak  Insufficient gas exchange  Disturbances in the cerebral blood flow

79. Airway complicationsHemodynamic disturbancesVentilator associated lung injury: VILIOxygen toxicityVentilator associated pneumoniaPulmonary emboliPatient ventilator asynchronySleep disturbance

80. 0 100 200 300 100 Stage 1 Stage 2 Stage 3 Stage 4 REM Non REM Age 40 MV Sleep Time (minutes)

81. 81012141618202202468 Stage 1 Stage 2 Stage 3 Stage 4 REM

82. 81012141618202202468 Stage 1 Stage 2 Stage 3 Stage 4 REM

83.  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)  Opioids ( ↓ REM, ↓ deep NREM)  Neuromuscular blocking drugs

85.  لا تبقِ نظام الإنذار مكتوماً.  لا تتجاهل الإنذار حتى لو كنت تعلم سببه أو كان ليس شيئاً مهماً.  ضع المريض في وضعية مشابهة لوضعية فولر أو أخفض منها لزيادة راحة المريض وتسهيل التنفس.

86. Thank you