1. PATRICK GERARD L. MORAL, M.D.

3. I NTUBATION Prevention of upper airway obstructionPrevention of upper airway obstruction Protection against aspirationProtection against aspiration Facilitating tracheobronchial toiletFacilitating tracheobronchial toilet Providing a closed system for mechanical ventilationProviding a closed system for mechanical ventilation Prevention of upper airway obstructionPrevention of upper airway obstruction Protection against aspirationProtection against aspiration Facilitating tracheobronchial toiletFacilitating tracheobronchial toilet Providing a closed system for mechanical ventilationProviding a closed system for mechanical ventilation

4. VENTILATORY FAILURE REDUCED CENTRAL DRIVE IMPAIRED INSPIRATORY MUSCLE PERFORMANCE EXCESSIVE RESPIRATORY WORKLOAD

5. O BJECTIVES To support pulmonary gas exchangeTo support pulmonary gas exchange –alveolar ventilation –arterial oxygenation To increase lung volumeTo increase lung volume To reduce or manipulate work of breathingTo reduce or manipulate work of breathing To support pulmonary gas exchangeTo support pulmonary gas exchange –alveolar ventilation –arterial oxygenation To increase lung volumeTo increase lung volume To reduce or manipulate work of breathingTo reduce or manipulate work of breathing P HYSIOLOGICAL

6. O BJECTIVES To reverse hypoxemiaTo reverse hypoxemia To reverse acute respiratory acidosisTo reverse acute respiratory acidosis To relieve respiratory distressTo relieve respiratory distress To prevent / reverse atelectasisTo prevent / reverse atelectasis To reverse ventilatory muscle fatigueTo reverse ventilatory muscle fatigue To permit sedation / neuromuscular blockadeTo permit sedation / neuromuscular blockade To decrease myocardial oxygen consumptionTo decrease myocardial oxygen consumption To reduce intracranial pressureTo reduce intracranial pressure To stabilize chest wallTo stabilize chest wall To reverse hypoxemiaTo reverse hypoxemia To reverse acute respiratory acidosisTo reverse acute respiratory acidosis To relieve respiratory distressTo relieve respiratory distress To prevent / reverse atelectasisTo prevent / reverse atelectasis To reverse ventilatory muscle fatigueTo reverse ventilatory muscle fatigue To permit sedation / neuromuscular blockadeTo permit sedation / neuromuscular blockade To decrease myocardial oxygen consumptionTo decrease myocardial oxygen consumption To reduce intracranial pressureTo reduce intracranial pressure To stabilize chest wallTo stabilize chest wall C LINICAL

7. 700 - 900 mL700 - 900 mL 15 LPM (self-inflating)15 LPM (self-inflating) augment VTaugment VT 700 - 900 mL700 - 900 mL 15 LPM (self-inflating)15 LPM (self-inflating) augment VTaugment VT A MBUBAG VENTILATION

8. M ODES Assist - ControlAssist - Control SIMVSIMV PSVPSV CPAPCPAP Servo-controlledServo-controlled Assist - ControlAssist - Control SIMVSIMV PSVPSV CPAPCPAP Servo-controlledServo-controlled

9. B ASIC V A = V T - V D V A = V E - V D V A = V T - V D V A = V E - V D VAVA VAVA VTVT VTVT

10. Hook to mechanical ventilator with the following set-up:Hook to mechanical ventilator with the following set-up: – mode: assist - control – VT: 500 mL – BUR: 15/ minute – FiO2: 100 % ABG 30 minutes after hooking to MVABG 30 minutes after hooking to MV In-line nebulization q 6In-line nebulization q 6 Hook to mechanical ventilator with the following set-up:Hook to mechanical ventilator with the following set-up: – mode: assist - control – VT: 500 mL – BUR: 15/ minute – FiO2: 100 % ABG 30 minutes after hooking to MVABG 30 minutes after hooking to MV In-line nebulization q 6In-line nebulization q 6 O RDERS

11. FiO2FiO2 100 %100 % dependent on target PaO2, hemodynamic status, MAP, PEEP leveldependent on target PaO2, hemodynamic status, MAP, PEEP level 100 %100 % dependent on target PaO2, hemodynamic status, MAP, PEEP leveldependent on target PaO2, hemodynamic status, MAP, PEEP level

12. O XYGEN CONTENT CaO2 = 1.34 mL x Hgb x SaO2 +.OO3 mL O2 x PaO2 1.34 mL x Hgb x SaO2 +.OO3 mL O2 x PaO2 CaO2 = 1.34 mL x Hgb x SaO2 +.OO3 mL O2 x PaO2 1.34 mL x Hgb x SaO2 +.OO3 mL O2 x PaO2

13. T IDAL VOLUME Physiologic: 5 - 7 mL / KgPhysiologic: 5 - 7 mL / Kg MV: 10 - 15 mL / KgMV: 10 - 15 mL / Kg alveolar distending pressure: 35 cm H 2 Oalveolar distending pressure: 35 cm H 2 O Physiologic: 5 - 7 mL / KgPhysiologic: 5 - 7 mL / Kg MV: 10 - 15 mL / KgMV: 10 - 15 mL / Kg alveolar distending pressure: 35 cm H 2 Oalveolar distending pressure: 35 cm H 2 O

14. B ASIC V A = V T - V D V A = V E - V D V A = V T - V D V A = V E - V D VAVA VAVA VDVD VDVD mechanical anatomic alveolar

15. C ARDIAC OUTPUT hyperinflation Increased pulmonary vascular resistance Increased RV afterload Decreased RV output Decreased LV preload Decreased LV output

16. PPV

17. 4 to 20 / minute4 to 20 / minute 8 to 12 / minute8 to 12 / minute dependent on:dependent on: –delivered VT –metabolic rate –target PaCO2 –level of spontaneous ventilation 4 to 20 / minute4 to 20 / minute 8 to 12 / minute8 to 12 / minute dependent on:dependent on: –delivered VT –metabolic rate –target PaCO2 –level of spontaneous ventilation R ESPIRATORY RATE

18. 40 to 100 L/ minute40 to 100 L/ minute determined by level of spontaneous breathing effortdetermined by level of spontaneous breathing effort 40 to 100 L/ minute40 to 100 L/ minute determined by level of spontaneous breathing effortdetermined by level of spontaneous breathing effort F LOW RATE

19. Inspiratory time: 0.8 to 1.2 sInspiratory time: 0.8 to 1.2 s I:E 1:2 to 1:1.5I:E 1:2 to 1:1.5 Inspiratory time: 0.8 to 1.2 sInspiratory time: 0.8 to 1.2 s I:E 1:2 to 1:1.5I:E 1:2 to 1:1.5 I NSPIRATORY TIME / I:E RATIO

20. Respiratory rate: 20 / minute Respiratory rate: 20 / minute 60 seconds / 20 = 3 seconds = T tot at an I:E ratio of 1:2: T I = 1 second T E = 2 seconds Respiratory rate: 20 / minute Respiratory rate: 20 / minute 60 seconds / 20 = 3 seconds = T tot at an I:E ratio of 1:2: T I = 1 second T E = 2 seconds I NSPIRATORY TIME / I:E RATIO

21. Respiratory rate: 30 / minute Respiratory rate: 30 / minute 60 seconds / 30 = 2 seconds = T tot at an I:E ratio of 1:1: T I = 1 second T E = 1 second Respiratory rate: 30 / minute Respiratory rate: 30 / minute 60 seconds / 30 = 2 seconds = T tot at an I:E ratio of 1:1: T I = 1 second T E = 1 second I NSPIRATORY TIME / I:E RATIO

22. -0.5 to 1.5 cm H20-0.5 to 1.5 cm H20 most sensitive level that prevents self- cyclingmost sensitive level that prevents self- cycling -0.5 to 1.5 cm H20-0.5 to 1.5 cm H20 most sensitive level that prevents self- cyclingmost sensitive level that prevents self- cycling S ENSITIVITY

23. High pressureHigh pressure Low pressureLow pressure High pressureHigh pressure Low pressureLow pressure P RESSURE ALARMS

24. Low pressureLow pressure –check connections between tubings and patient –deflated cuff –extubation Low pressureLow pressure –check connections between tubings and patient –deflated cuff –extubation P RESSURE ALARMS

25. High pressureHigh pressure –bronchoconstriction –airway obstruction –barotrauma –right main bronchus obstruction –kinked endotracheal tube High pressureHigh pressure –bronchoconstriction –airway obstruction –barotrauma –right main bronchus obstruction –kinked endotracheal tube P RESSURE ALARMS

26. Cascade humidifierCascade humidifier heats carrier gas to 37 Cheats carrier gas to 37 C holds 44 mg H20 / L gasholds 44 mg H20 / L gas water replacementwater replacement increases volume and decreases viscosity of the sputumincreases volume and decreases viscosity of the sputum Cascade humidifierCascade humidifier heats carrier gas to 37 Cheats carrier gas to 37 C holds 44 mg H20 / L gasholds 44 mg H20 / L gas water replacementwater replacement increases volume and decreases viscosity of the sputumincreases volume and decreases viscosity of the sputum H UMIDIFICATION

27. Chest radiographChest radiograph Arterial blood gasArterial blood gas OximetryOximetry CapnographyCapnography Chest radiographChest radiograph Arterial blood gasArterial blood gas OximetryOximetry CapnographyCapnography A NCILLARY

28. BarotraumaBarotrauma Oxygen toxicityOxygen toxicity Patient-ventilator asynchronyPatient-ventilator asynchrony CardiovascularCardiovascular RenalRenal GastrointestinalGastrointestinal BarotraumaBarotrauma Oxygen toxicityOxygen toxicity Patient-ventilator asynchronyPatient-ventilator asynchrony CardiovascularCardiovascular RenalRenal GastrointestinalGastrointestinal C OMPLICATIONS