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Ventilators and abg s

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Ventilators and ABG’s

Philip L. Kalarickal, M.D., M.P.H.


Objectives
Objectives

Review and understand Intubation criteria

Understand basic ventilator settings and mechanisms

Understand how to monitor a patient on a ventilator

A systematic review of ABG analysis

Understand the physiology of ventilation and oxygenation.


Patient in er
Patient in ER

  • 55 y.o. Male

  • CC: SOB and cough

  • Vitals: Ht: 5’10”, Wt: 70kg

    • T: 38.7 RR: 35 HR: 105 BP: 140/95

    • Pox: 90% on 100% NRBM

  • What do you do?


Intubation criteria
Intubation Criteria

1.

2.

3.

4.

5.


Intubation criteria1
Intubation Criteria

1. Hypoxemia: PaO2 < 60mmHg on >.6 FiO2

2.Hypercarbia: PaCO2 > 60mmHg

3. RR > 30

4. GCS <8

5. Hemodynamic instability - Pressors


You intubate the patient successfully. The respiratory tech turns to you and says, “What vent settings do you want doc?”

What settings need to be programmed into the ventilator?

1.

2.

3.

4.

5.


You intubate the patient successfully. The respiratory tech turns to you and says, “What vent settings do you want?”

What settings need to be programmed into the ventilator?

1. Mode

2. Tidal volume

3. RR

4. FiO2

5. PEEP


Initial vent settings
Initial Vent Settings

Mode:

TV:

RR:

FiO2:

PEEP:


Initial vent settings1
Initial Vent Settings

Mode:

2 basic modes – pressure control & volume control. TV depends on lung compliance. Usually pick SIMV or PRVC

TV:

5-7 cc/kg IBW

RR:

start at 20. Can adjust based off of ABG

FiO2:

start at 1.0. Can adjust based off of ABG

PEEP:

start at 5cm H2O


Ok the patient is on the vent now what
Ok, the patient is on the vent. Now what?

How do we assess patients on vents?

1.

2.


Abg s
ABG’s

1.

2.

3.

4.

5.

6.


Abg s1
ABG’s

1. pH: 7.35 – 7.45

2. PaCO2: 35-45 mmHg

3. PaO2: 80-100 mmHg

4. HCO3-: 22-28 mEq/dL

5. BE: -2 - +2

6. Sat: 97 – 100%


You get your first gas
You get your first gas….

7.30/55/200/24/0/100

What do you think?

What do you want to do?


Acid/Base

Ventilation

Oxygentation


Acid base
Acid/Base

Look at pH to determine primary process

Then look at PaCO2 and HCO3- to determine relative contribution of Respiratory and Metabolic components to acid/base disturbance and the degree of compenation.


Ventilation
Ventilation

  • Measured by PaCO2

  • ***Oxygentation and Ventilation are independent processes***

  • Ventilation is a function of MV

    • MV= TV x RR

    • Usually by RR rather than TV

  • This patient has an elevated PaCO2. He is hypoventilating (retaining CO2).

  • We should increase RR


Ventilation1
Ventilation

  • You ask the Resp Tech to increase RR to 24 and check an ABG in an hour

  • The repeat gas is:

    7.40/40/200/24/0/100

  • Now what?

  • Have we addressed oxygenation yet?

    • What do you think about the PaO2 of 200mmHg?


Oxygenation
Oxygenation

  • How do we assess oxygenation?

    1.

    2.

  • What is PaO2? What does PaO2 mean?

  • It is the pressure of oxygen that is dissolved in plasma

  • It contributes very little to oxygen delivery

  • CaO2 = 1.34 x Hb x sat + .003(PaO2)

  • Helps assess how well oxygen exchange occurs at the alveolus

  • You need to compare it to PAO2.


P a o 2
PAO2

PAO2 = [(Patm – PH2O)FiO2] – (PaCO2/0.8)

Because oxygen and carbon dioxide are small molecules, there should be almost perfect gas exchange across the alvelous to pulmcapp.


P a o 21
PAO2

  • Example: on 100% oxygen,

  • PAO2 = [(760-47)x 1] – (40/0.8)

    = 710 – 50

    = 650mmHg

  • Rule of Thumb: PaO2 should be about 5x O2%

    • Ex: on 100% O2, PaO2 should be approx 500mmHg

  • Now what do you think about the PaO2 of 200 mmHg on our ABG?

  • If we have an unexpected result, we should correlate it clinically.



Ok we know we have a problem with oxygenation now what
Ok, we know we have a problem with oxygenation, now what? across the alveolus?

  • How do we improve oxygenation?

  • 2 ways:

    • Increase FiO2

    • Increase PEEP

  • Are there any drawbacks to PEEP?

  • Yes-

    • Barotrauma

    • Inhibits venous return


Effect of increased peep example
Effect of Increased PEEP- example across the alveolus?

  • “Best” PEEP – the level of PEEP at which you improve oxygenation the most without significant effects on venous return

In this example, 9cm H2O is the “Best” PEEP


Oxygenation1
Oxygenation across the alveolus?

  • Ok, we’ve improved oxygenation via PEEP and hope to improve it further with anitbiotics for his pneumonia.

  • Now what?

  • Are we happy with his FiO2?

  • Are there problems with high FiO2?

    1.

    2.


Oxygenation2
Oxygenation across the alveolus?

You should wean FiO2 to minimum to maintain sats > 95% (PaO2 > 80)

Why?


Oxygenation3
Oxygenation across the alveolus?

  • Problems with high FiO2

    • “oxygen toxicity” – due to oxygen free radicals that may cause alveolar damage

    • Risk factor – FiO2 > .6 for greater than 24 hours

  • High FiO2 is not safe for patients

    • Saturation is a relatively insensitive measure of oxygenation (sats won’t drop until PaO2 is less than 80-100)


  • Low FiO2 allows you to know your PaO2 within a narrow range across the alveolus?without drawing an ABG.

    • Ex:

      • Pt. on 100% O2 with sats 100%

        • The lowest PaO2 can be is 80 mmHg

        • The highest PaO2 can be is 500-600mmHg

      • Pt on 30% O2 with sats 100%

        • The lowest PaO2 can be is 80 mmHg

        • The highest PaO2 can be is 150 mmHg


  • Low FiO2 will allow you to identify problems earlier across the alveolus?

    • A patient on 30% O2 will desat sooner than a patient on 100% O2

    • In other words, 100% O2 will “mask” a problem

      3. If a patient is on a low FiO2 you can increase to 100% to buy time to make a diagnosis and treat.


Now you know almost everything you need to know about vents and abg s
Now you know across the alveolus?almost everything you need to know about Vents and ABG’s

  • Intubation Criteria

  • Basic ventilator settings

  • Assessing patients on vents

    • Pulse oximeter

    • ABG’s

  • Analyzing ABG’s

    • Acid/Base

    • Ventilation

    • Oxygenation


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