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Italian perspectives: Helmet

C. B. E. D. A. Italian perspectives: Helmet. Latex-free transparent PVC Secured by 2 arm = pit braces (A) at two hooks (B) of the metallic ring (C) joining helmet with a soft collar (D) A seal connection (E) allows the passage of NGT. Courtesy of Dr Massimo Antonelli (Rome). Helmet.

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Italian perspectives: Helmet

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  1. C B E D A Italian perspectives: Helmet • Latex-free transparent PVC • Secured by 2 arm = pit braces (A) at two hooks (B) of the metallic ring (C) joining helmet with a soft collar (D) • A seal connection (E) allowsthe passage of NGT Courtesy of Dr Massimo Antonelli (Rome)

  2. Helmet InP = Inspiratory port; ExP = expiratory port; SC = sealed connector; BR= armpit braces

  3. Hypoxemic Hypercapnic Modes of Ventilation

  4. Mask CPAP in Hypoxemic Failure • Recruits lung units • improved V/Q matching > rapid correction of PaO2 & PaCO21 • increased functional residual capacity • decreased respiratory rate and WOB2 • Reduces airway resistance2 • Improves hemodynamics in pulmonary edema • decreases venous return • decreases afterload and increases cardiac index (in 50%)1-4 • decreases heart rate1-3 • Average requirement: 10cmH2O 1. Bersten NEJOM 1991 3. Rasanen AJC 1985 2. Lenique AJRCCM 1994 4. Bradley ARRD 1992

  5. Positive Negative  Pes  Pes Positive Negative CPAP in Congestive Heart Failure • LVPtm during systole • LVPtm = ventricular systolic pressure - extracardiac pressure (i.e., pericardial pr.) • Changes in Pes = changes in pericardial pr. • During inspiration > large negative intrathoracic pressure swings increase LVPtm and afterload • CPAP in CHF • Reduces systolic LVPtm by changing Pes from negative to positive • Lung inflation parasympathetic tone  sympathetic outflow  HR • Reduction in O2 consumption • Myocardial: systolic LVPtm x HR • Pulmonary: Pes x RR Naughton et al Circulation 1995; 91:1725

  6. COPD: Pathophysiology of ARF • Expiratory flow limitation • Dynamic hyperinflation • Respiratory muscle fatigue • Respiratory acidosis

  7. COPD: Dynamic Hyperinflation • Auto PEEP = inspiratory threshold load • Flattened diaphragm = reduced efficiency and endurance • shortening of the sarcomere length and decreased maximal force • reduced zone of apposition with the chest wall (expansion on insp.) • reduced blood supply

  8. COPD: Intrinsic PEEP • COPD patient stable • average PEEPi 2.4 ± 1.6 cm H2O1 • COPD patient with acute exacerbation • average PEEPi 6.5 ± 2.5 cm H2O2,3 • PEEPi = 43±5% total work by respiratory system4 • Increased O2 cost correlates with diaphr. flattening on CXR5 1. Dal Vecchio et al Eur Respir J 1990; 3:74 3. Brocard et al NEJOM 1990; 323: 1523 2. Appendini et al AJRCCM 1994; 149: 1069 4. Jubran et al AJRCCM 1995; 152: 129 5. Pitcher et al J Appl Physiol 1993; 74: 2750

  9. COPD: Management of ARF Etiology of ARFPharmacological Treatment • precipitating condition • bronchodilator, anti-inflammatory antibiotics, etc. Physiology of ARF Positive pressure • expiratory flow limitation  • causes bronchodilation • dynamic hyperinflation  • offsets intrinsic PEEP ( load) • respiratory muscle fatigue  • reduces diaphragmatic activity • respiratory acidosis  • increases VE ( Vt,  RR)

  10. Hypoxemic Hypercapnic Modes of Ventilation

  11. Auto PEEP 8 cm H2O Auto PEEP 8 cm H2O IT external PEEP 6 cm H2O atmospheric pressure Inspiratory Pressure 10 cm H2O Inspiratory Pressure 4 cm H2O • isotonic contraction to generate inspiratory flow and tidal volume COPD: Inspiratory Effort and PEEPi in COPD with ARF the inspiratory effort to lower alveolar pressure below ambient pressure is divided into two components: • isometric contraction to counterbalance PEEPi (inspiratory threshold load) Appendini et al. AJRCCM 1994; 149: 1069

  12. COPD: Mask CPAP in ARF • Offsets PEEPi1 •  acute COPD exacerbation: average PEEPi 6.5 + 2.5 cmH2O1 •  apply PEEP at 80-90% of PEEPi to avoid overdistention1 • Reduces transdiaphragmatic pressure2 • May improve Vt, VE, or PaCO24 •  no response within 30 min in 4 studies 1,2,5,6 •  delayed response (> 4 h) in clinical studies4 • Average CPAP requirement: 5 cmH20 1. Appendeni AJRCCM 1994 3. Martin ARRD 1982 5. Shivaram Resp 1987 2. Gottfried Chest 1987 4. De Lucas Chest 1993 6. Elliot BMJ 1994

  13. BMJ 2003; 326:185.

  14. Resetting responses to PaCO2 • In COPD, the ventilatory response to raised PaCO2 is decreased especially during sleep. • NPPV lowers nocturnal PaCO2 and resets the respiratory control centre to become more responsive to increased PaCO2 by increasing the neural output to the diaphragm and other respiratory muscles. • These patients are then able to maintain a more normal PaCO2 throughout the daylight hours without the need for mechanical ventilation.

  15. Hypoxemic Hypercapnic Modes of Ventilation

  16. Mask Inspiratory Pressure Support • Synchrony between patient effort and delivered assistance • NPPV with PSV is superior to (ABG and RMR) • spontaneous breathing1-5 • CPAP • Comparison to volume-cycled ventilation (COPD)6 • equally effective in improving gas exchange • better tolerated and lower incidence of complications • lower mask air leakage (lower peak mask pressure) 1. Appendeni AJRCCM 1994 3. Broachard NEJOM 1990 5. Ambrosino Chest 1992 2. Belman Chest 1990 4. Carrey Chest 1990 6. Vitacca ICM 1993

  17. spontaneous breathing PSV 12 cmH2O PSV 15 cmH2O Reduction Pes swings Positive Pes swings Asynchrony PAM synchrony Additional reduction Effect of Mask Pressure COPD patient with acute exacerbation Carrey et al. Chest 1990; 97:150

  18. Within 5 breathes Timing to Suppression of EMG Activity Initiation of NPPV Carrey et al. Chest 1990; 97: 150.

  19. Mask CPAP and PSV in COPDCritical Pdi max 5 cmH2O 10 cmH2O Seven COPD patients with acute exacerbation Nasal mask - 15 min. recordings Appendini AJRCCM 1994; 149: 1069

  20. Effects of CPAP and IPPV Hypercapnic vs Hypoxemic ARF Data obtained from: Ambrosino Chest 1992; Apprendini AJRCCM 1994; Brochard NEJOM 1990; Carrey Chest 1990; De Lucas Chest 1993; Elliot Anaesthesia 1994

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