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Initial ventilator settings

Dr Chaitanya Vemuri Int.Med M.D Trainee. Initial ventilator settings. The choice of ventilator settings – guided by clearly defined therapeutic end points. In most of cases : primary goal is to correct abnormalities of arterial blood gas tensions Accomplished by

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Initial ventilator settings

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  1. Dr ChaitanyaVemuri Int.Med M.D Trainee Initial ventilator settings

  2. The choice of ventilator settings – guided by clearly defined therapeutic end points. • In most of cases : primary goal is to correct abnormalities of arterial blood gas tensions • Accomplished by • adjusting minute volume - to correct hypercapnea • oxygen supplementation – to correct hypoxemia Introduction

  3. Choice of inspired gas composition Means to ensure the machine’s sensing of patient’s demand Definition of machine’s mechanical output General aspects of ventilator management

  4. INITIATION

  5. Confirm indication for mechanical ventilation • Invasive / Non invasive • Check Connections & Circuit • Self test • Select mode • Set variables • Alarm settings • Connect to patient • Monitor and reassess

  6. Patient not breathing Patient breathing but not enough Patient breathing enough, but pt hypoxemic / hypercapneic Patient breathing with normal gas exchange, but working hard Airway protection indications

  7. LABORATORY CRITERIA CLINICAL CRITERIA OTHER CRITERIA Indications

  8. Blood gases : PaO2 < 55 mm Hg PaCo2 > 50 mm Hg pH < 7.32 PFT : Vital Capacity < 10 ml/Kg -ve inspiratory force <25cm H20 FEV 1 < 10 mL/Kg LABORATORY CRITERIA

  9. Apnea / Hypopnea Respiratory distress with altered mentation Clinically apparent increasing work of breathing unrelieved by other interventions Need for airway protection Clinical criteria

  10. Controlled hyperventilation ( eg head injury ) • Severe circulatory shock • THERE IS NO ABSOLUTE CONTRAINDICATION FOR MECHANICAL VENTILATION Other criteria

  11. Connections

  12. connections

  13. Connections

  14. To check : - leak - compliance - resistance of circuit - sensors • Needs to be done : - before connecting to patient - once in 2 weeks - whenever circuit is changed Self test

  15. Depends on : Patients requirement User comfort Availability Select mode

  16. For PO2 : adjust FiO2, PEEP For PCo2 : adjust TV , RR Basic principles

  17. Set variables

  18. Tailored to need of the patient SIMV / A/C – versatile modes for initial settings In pts with good resp drive & mild – mod resp failure – PSV MODE OF VENTILATION

  19. Initial TV : 5 – 8 ml/Kg of ideal bd wt Lowest values are recommended in presence of Obstructive airway ds & ARDS Goal : to adjust TV so that plateau pressures are less than 35 cm H20 Tidal volume

  20. 8 – 12 breaths per minute : pts not requiring hyperventilation for treatment of toxic/metabolic acidosis or intracranial injury Initial rate may be low ( 5 – 6 breaths per min ) in asthmatic pts where permissive hypercapnic technique is used Respiratory rate

  21. Lowest FiO2 that produces an Sp02 > 90 % PaO2 > 60 mm Hg is recommended Supplemental o2 therapy

  22. Normal I:E ratio to start is 1:2 Reduced to 1:4 or 1:5 in presence of obstructive airway disease in order to air trapping Inverse I:E – in ARDS Inspiration : expiration ratio

  23. 60 L/min is typically used Increased to 100 L/min : to deliver TVs quickly and allow for prolonged expiration in presence of obstructive airway ds INSPIRATORY FLOW RATE

  24. Titrated according to PEEP and BP • High PEEP ( > 10 H20 ) – pneumonia, ards • PEEP – reduces risk of atelectasis - increase no of open alveoli ( decrease V/Q mismatch ) - in CHF : decrease venous return • Physiological PEEP ( 3-5 cm H20 ) : to prevent decrease in FRC in normal lungs Positive end expiratory pressure ( peep )

  25. Set at -1 to -2 cm H20 NEWER VENTILATORS SENSE INSPIRATORY FLOW and thereby reduce work of breathing associated with ventilator triggering Sensitivity ( TRIGGER )

  26. Mode : Complete / Partial . VCV/PCV • Rate : titrate to Pco2 • Tidal Volume : 5 – 8 ml / Kg • Flow rate & Pattern : 4 – 8 times Minute Ventilation • I:E = 1:2 to 1:4 • FiO2 : titrate to O2 Saturation / Pa O2 • PEEP : titrate to PaO2 & BP • Trigger : Adjust to synchronize SET VARIABLES

  27. Fixed alarms : disconnection o2 sensor Set alarms : volume pressure rate apnea Alarm settings

  28. Patient • Monitor : pulse , bp , rr, spO2 • Ventilator • Abg • Volume • Pressure • Rate • Patient comfort / synchrony Monitor & reassess

  29. Ventilatory settings in various diseases

  30. For Paralysed pts : CMV or A/C mode For Non paralysed pts : SIMV mode Pts with normal resp effort mild resp failure : PSV mode

  31. Hypoxia corrected by High FiO2 • Increase Expiratory Flow Time to max : to prevent increase intrinsicPEEP • RR : 6 -8 breaths / min ( permissive hypercapnia ) • I : E : increased 1:2 Asthma & copd

  32. A/C mode Tidal Volume : 6 ml/Kg PEEP : 5 Ventilatory rate : 12 titrated to maintain Ph > 7.25 ards

  33. Respond well to positive pressure ventilation (opens alveoli, reduces preload) • Many benefit from trial of noninvasive CPAP / BiPAP • Intubated pts usually manage to oxygenate well • But PEEP can be increased to improve oxygenation and reduce preload Chf

  34. Thank you

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