Mechanical ventilation in special conditions
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Mechanical Ventilation in Special Conditions. Mechanical Ventilation: Outline. Head injury Chest Trauma Bronchopleural Fistula. Traumatic Brain Injury. Prevalence of extracerebral organ dysfunction in TBI. Cerebral Compliance Curve. CPP= MAP-ICP. Intracranial pressure. CPP.

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Mechanical ventilation outline
Mechanical Ventilation: Outline

Head injury

Chest Trauma

Bronchopleural Fistula




Cerebral compliance curve
Cerebral Compliance Curve

CPP= MAP-ICP

Intracranial pressure

CPP

Intracranial volume


Cerebral compliance curve1
Cerebral Compliance Curve

PaCO2

CPP

PaO2

Cerebral Blood Flow

50

100

150


Head injury mv monitoring
Head Injury: MV Monitoring

Peak alveolar pressure, airway pressure, auto-PEEP

PaCo2 end tidal PCO2

Intracranial pressure

Jugular venous oxygen saturation

Pulse oximetry

Heart rate and systemic blood pressure


Hyperventilation in traumatic brain injury
Hyperventilation in Traumatic Brain Injury

Causes cerebral vasoconstriction

Decreases cerebral blood flow

Decreases cerebral blood volume

Increases ICP

Has been proven to be of benefit in head injuries


Head trauma
Head Trauma

  • Cerebral physiology

    • ICP

    • CBF

    • Cerebral oxygenation : SJO2, PbrO2

  • Hyperventilation

  • Lung protective strategy

  • PEEP

  • Extubation


Hyperventilation in tbi
Hyperventilation in TBI

Chronic hyperventilation (PCO2 < 25) should be avoided

Prophylactic hyperventilation (PCO2 < 35) in the first 24 h should be avoided

May be necessary for a brief period with acute neurologic deterioration


Head trauma1
Head Trauma

+

  • Lung protective strategy

    • Hypoventilation  PCO2   ICP 

    • No evidence of detrimental effect

    • Use protective ventilation

    • Observe ICP and CPP if PCO2▲

  • PEEP

    • ICP 

    • MAP 

    • Depends on compliance

  • Extubation

    • LOC

    • Cough

    • Tracheal secretions


Head trauma2
Head Trauma

+

  • Lung protective strategy

    • Hypoventilation  PCO2  ICP 

    • No evidence of detrimental effect

    • Use protective ventilation

    • Observe ICP and CPP if PCO2▲

  • PEEP

    • ICP 

    • MAP 

    • Depends on compliance


Head trauma3
Head Trauma

  • Extubation

    • LOC

    • Cough

    • Tracheal secretions



Head trauma cbf and icp with hyperventilation
Head TraumaCBF and ICP with hyperventilation

►CBF◄

▼ICP


Head trauma4
Head Trauma

  • Extubation

    • LOC

    • Cough

    • Tracheal secretions


Mechanical ventilation in special conditions

Decompressive Craniotomy

  • CSF Drainage

  • HOB > 30 degree

  • Head in neutral position

  • Vetriculostomy

ICP =30

  • Decrease Brain Water

  • Mannitol

  • Avoid D5%

  • Diuretics

  • Decrease Oxygen Demand

  • Prevent seizure

  • Sedation

  • Treat pain

  • Barbiturate coma

  • Avoid hyperthermia

  • ? hypothermia

ICP= 10

Vasoconstriction

Pa co2 25-30

CPP = MAP – ICP

  • Avoid ↑ Intrathoracic Pressure

  • Suppress Valsalva maneuvers

  • Suppress cough

  • ↓ Mean airway pressure

  • Minimize use of PEEP

  • Treat distended abdomen

  • Maintain adequate MAP

  • Adequate CO

  • Use inotropic Agents

  • Adequate filling pressures

  • Avoid hypotensive agents

  • Treat infection abruptly

Intrathoracic Pressure (-3 cm H2O)

Venous Return

MAP (90)= CO X SVR


Mechanical ventilation in special conditions

CMV (A/C), PCV or VC,

VT 4-8 mL/kg, FiO2 1, rate

20/min TI1s, PEEP 5 cm H2O

CMV (A/C), PCV or VC,

VT 4-8 mL/kg, FiO2 1, rate

15/min TI1s, PEEP 5 cm H2O

yes

no

Titrate FiO2 for SpO2 ≥ 92%

Pplat > 30

PCO2

no

↑ rate

↓ rate

<35

>45

yes

35-45

↓ VT

no

FiO2

> 0.6

<70

PaO2

>100

↓ FiO2

70-100

yes

FiO2 >

0.6

ICP <

20

no

yes

↑ FiO2

More aggressive

Medical therapy

yes

no

>20

↑ PEEP

ICP

ICP

<20

Maintain

Ventilator

Setting

<20

Slowly ↓ rate to

initial setting

Underlying lung

disease

>20

↑ rate


Chest trauma who gets admitted
Chest traumaWho Gets Admitted?

Sternal fractures mediastinal injury

Any 1th, 2nd, 3rd Rib fractures

> 1 Rib fracture in any region

Pulmonary contusion

Subcutaneous emphysema

Traumatic asphyxia

Flail segment

Arrhythmia or myocardial injury









Guidelines for ventilator management in the patient with bpf
Guidelines for ventilator management in the patient with BPF

  • Reduce MAP & RR

  • Wean patient completely if possible

  • Partial ventilatory support

    • low-rate SIMV or PSV

  • Minimize minute ventilation

  • Use of permissive hypercapnia

  • Avoid patient positions that increase the leak

  • Treat bronchospasm

  • Consider unconventional measures

    • Bronchoscopic techniques

    • HFV

    • ILV