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STEFANO NAVA

STEFANO NAVA. Clinical importance of respiratory mechanics ISTANBUL 8 May 2010. Fondazione Maugeri-IRCCS-Pavia Pneumologia Riabilitativa e Terapia Intensiva Respiratoria. Problems. Diagnosis Need for mechanical ventilation Settings of mechanical ventilation

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STEFANO NAVA

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  1. STEFANO NAVA Clinical importance of respiratory mechanics ISTANBUL 8 May 2010 Fondazione Maugeri-IRCCS-Pavia Pneumologia Riabilitativa e Terapia Intensiva Respiratoria

  2. Problems • Diagnosis • Need for mechanical ventilation • Settings of mechanical ventilation • Patient/ventilator interaction • Weaning from mechanical ventilation

  3. How do we breathe ?

  4. espiration Flow Pdi Pga Pes inspiration Pdi= Pga – (-Pes) = Pdi= Pga + Pes + _

  5. Diagnosis

  6. Case report • 47 yrs old lady with a 2-yr history of CHF (actually NYHA class II) EF=41% • Fatigue and orthopnea in the last 12 months • 3 recent ER admission for shortness of breath and increased secretions • PFT= FEV1=64% pred VC=32% pred • Mean SaO2 during visit= 92-94%

  7. Despite NO echographic signs of CHF worsening, she was treated 2 times as CHF decompensation- Third time she see a pulmonologist, that diagnosed COPD exacerbation (since she was a former smoker)- Admitted to our Unit where she underwent respiratory mechanics

  8. Sitting inspiration Flow Volume Paw Pes Pga Pdi 320 ml - 5 cmH20 1 cmH20 6 cmH20

  9. Supine inspiration Flow Volume Paw Pes Pga Pdi 150 ml - 15 cmH20 - 14 cmH20 1 cmH20

  10. Which associated pathology ? • Scleroderma • Idiophatic Pulmonary Fibrosis • Severe “intermittent” asthma • Sjogren syndrome • Amiotrophyc Lateral Sclerosis

  11. ALS=Diaphragm paralysis (i.e. inward abdominal movement during inspiration in supine position) may be one of the first symptom

  12. Need for MV

  13. Another case • 71 yrs old man with a long-lasting COPD story • On LTOT since 2 yrs • Last ABG before admission= pH=7,38 PaCO2=41 PaO2=65 in oxygen • In the last couple of days worsening of secretions and dyspea • ABG at admission: pH= 7,34 PaCO2= 46 PaO2=59 in oxygen

  14. Friday afternoon 16,30 • On call the previous weekend • Looking forward to watching the defining game of the season on TV • Choice of starting medical therapy and being home, showered and in front of the TV by 1900 • or trying NIV, maybe failing and getting home, just in time to see the credits

  15. Respiratory mechanics was performed

  16. Pdi per breath is 50% of the maximal inspiratory pressure Flow Pdi Pga Pes 18 cmH20 9cmH20 MIP Tidal Breathing

  17. Can this guy breathe alone for long ?

  18. From Sherer and Monod, 1956 30 * * * * 20 * * * Time limit (min.) * * * * * 10 * * * * * * * * * * * * * * * * 0 100 0 50 Force (% of Force max.)

  19. = normal 100% = stable COPD = ARF 50% Ti/Tot 0.15 Fatigue treshold 50% 0 100% Pdi/Pdimax

  20. Not likely to go very far….

  21. Weakness Hyperinflation FORCE Elastance PEEPi Resistance LOAD

  22. Ventilator Bronchodilators FORCE LOAD

  23. Setting of MV

  24. We seat in front of a ventilator

  25. Apparently there is nothing wrong on what you see on the ventilator

  26. But if you could see the neural activity of the patient…..

  27. Or be more more careful…..

  28. You could find out that there is sometimes a problem

  29. Conclusions Only 3 of 19 patients (16%), with I/E were weaned. This is in contrast to a weaning success rate of 57%, of those patients without I/E I/E appeared to result from: high auto-PEEP high Pressure Support severe pump failure.

  30. If you measured PEEPi with the balloon-catheter technique set the appropriate amount of external PEEP

  31. US= the usual ventilator settings PHYS= the ventilator settings according the recording of respiratory mechanics

  32. Patient/ventilator interaction

  33. Weaning from mechanical ventilation

  34. “Passive” mechanics

  35. Elevated static compliance STRONG indicator of weaning failure

  36. “Active” mechanics

  37. Weaning success vs weaning failure

  38. 100% 50% Ti/Tot TTdi 0.15 Fatigue treshold 50% 0 100% Pdi/Pdimax

  39. The case of post-surgical patients

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