1. Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine

2.  To discuss methods of ventilation  To discuss mechanical ventilation  To introduce some difficult patient groups that make ventilation more challenging  To look at future tools to aid ventilatory strategies

3.  Let the patient do it themselves!  Manually  Mechanically

4.  Deliver oxygen  Work with the patient to optimise their position  Analgesia  Therapeutic interventions (e.g. drugs)

5.  Failure to Ventilate  Failure to Oxygenate

7.  Can be used with basic and advanced airway adjuncts. BUT  Ties operator up!  Inaccurate tidal volumes.  Tendency for operator to hyperventilate (the patient!)  May not be able to effectively ventilate the patient.  Risk of aspiration.

10.  Intermittent application of positive pressure to the upper airway.  Inspiration – gas flows into alveoli until the alveolar pressure equals the upper airway pressure.  Expiration – positive airway pressure is removed/decreased so the gradient reverses and gas flows out of the alveoli.

11.  Patient has to be anaesthetised or crash intubation. BUT  Delivers 100% FiO 2  Accurate tidal volumes.  Accurate respiratory rate.  Alarms to warn of emergencies developing.  Allows inline capnography.  Frees up the operator.

12.  Controlled Mechanical Ventilation  Assist-Control Ventilation  Intermittent Mandatory Ventilation  Pressure Support Ventilation  Pressure Control Ventilation  Inverse I:E Ratio Ventilation

14.  Ensure adequate sedation and paralysis  Patient position  Clear secretions  Treat underlying pathology

15.  Respiratory Rate 10-12 breaths/min.  Tidal Volume 6-8 ml/Kg.  Aim to balance adequate ventilation with risk of pulmonary barotrauma and volutrauma at inflation pressures of >35-40 cm H 2 O.  Lower mean airway pressures (<20-30 cm H 2 O) can help preserve cardiac output and V/Q relationships.  May build TV up to 10ml/Kg.

18.  Used to improve a symptomatic decrease in the Functional Residual Capacity that causes hypoxaemia.  Provided by an extra valve applied to the breathing circuit or within the ventilator.

19. In patients with a reduced lung volume, PEEP stabilizes and expands partially collapsed alveoli. This...  Increases FRC and tidal ventilation  Improves lung compliance  Corrects V/Q abnormalities

20.  Worse at levels >20 cm H 2 0.  Barotrauma  Worse with underlying lung disease, high rate of breaths, large tidal volumes and young age.

21.  Transmission of elevated airway pressure to the contents of the chest.  Reduced cardiac output.  Elevated central venous pressure.

22.  Starting PEEP 5-8 cm H 2 O used to compensate for the reduced FRC in anaesthetised patients.  Add in increments of 5 cm H 2 O up to 15 cm H 2 O.  Aim to improve oxygen saturations.

23.  Low Tidal Volume  Low Airway Pressure  Modest PEEP

38.  Discussed means of ventilation  Focused on mechanical ventilation  Talked about difficult patient groups  Looked at future adjuncts that may help with ventilatory support