Presentation of Dr. Lluis Blanch at 10th Pulmonary Medicine Update Course, Cairo, Egypt. Pulmonary Medicine Update Course is organized by Scribe : www.scribeofegypt.com

1. Lluís Blanch M.D., Ph.D. Consultant Critical Care Scientific Director Corporació Parc Taulí Universitat Autónoma de Barcelona Sabadell, Spain. Cairo 3 - 4 February 2010 Under Appreciated Signs in Ventilator Monitoring 10th Pulmonary Medicine Update Course

2. Relationship of PaO 2 to True Shunt for Three Values of FiO 2 30 %

3. The definitions of ARDS and ALI require the use of standard ventilator settings to ensure that patients with consistent levels of lung injury are properly classified as having ARDS or ALI In 170 pts meeting ARDS criteria (PaO 2 /FiO 2 < 200 mmHg ) diferent combinations of FiO 2 & PEEP at VT 7 ml/kg were obtained in Day 0 and in Day 1. PaO 2 /FiO 2 156 mmHg PaO 2 /FiO 2 247 mmHg PaO 2 /FiO 2 370 mmHg

4. Am J Respir Crit Care Med 2002; 165: 165-170

5. Relationship between RM-induced changes in PaO 2 /FiO 2 & Qva/Qt in ARDS Am J Respir Crit Care Med 2002; 165: 165-170 r=-0.85 p<0.01 Patients

6. Normal Volumetric Capnogram Fletcher R, Jonson B, Cumming J, Brew J. Br J Anest 1981;53:77-88 Blanch L, Romero PV, Lucangelo U. Minerva Anesthesiol 2006;72:577-85 Exhaled Volume PCO 2 Phase I Phase II Phase III PaCO 2 PetCO 2 Effective Alveolar Ventilation

7. Verschuren F et al Intensive Care Med 2004; 30:2129-2132 Volumetric Capnography as a Bedside Monitoring of Thrombolysis in Major Pulmonary Embolism

8. Crit Care Med 2006;34:1202-8 Odds Ratio of Survival J Trauma 2007;62:1330-8

9. Components of Exhaled Tidal volume Using a Capnogram Physiologic dead space sub-divided into anatomic dead space and alveolar dead space VD phys /VT = PaCO 2 -P E CO 2 PaCO 2

10. Bidani A, et al. JAMA 1994; 272:957-962 An increase in dead space represents an impaired ability to excrete CO 2 Target V E in ARDS . Physiologic Consecuences of High V D /V T at Different V E .

11. Nuckton TJ et al. N Engl J Med 2002; 346:1281. Observed Mortality According to the Quintile of Dead-Space Fraction in 179 Patients with ARDS Mechanisms: 1- Injury of pulmonary capillaries by thrombotic and inflammatory factors. 2- Obstruction of pulmonary blood flow in pulmonary circulation. 3- Lung areas with high V/Q ratio (impaired CO 2 excretion)

12. Exhaled Volume PCO2 Phase I Phase II Phase III PaCO2 PetCO2 Effective Alveolar Ventilation

13. Prognostic Value of Volumetric Capnography Indices in Patients with ALI/ARDS receiving Mechanical Ventilation The difference between VAE/VT-48h and VAE/VT-adm (ΔVAE/VT) show SS of 73% and SP of 93% with LR 10.2 and area under ROC curve of 0.83. Physiologic dead space after 48h predicted survival (p = 0.02) with an area under ROC curve of 0.75, LR of 8.8, SS 63% and SP 93%. Lucangelo U et al. Chest 2008;133:62-71 V AE /V T adm-48h 0.83 (0.67-0.93) 0.2 0.4 0.5 0.6 0.7 0.3 Adm 48 h 24 h * * ns p<0.05 V AE /V T S D SS 73% SP 93%

14. Volumetric Capnography & Lung Recruitment Blanch L, Lucangelo U. Capnography and adjuncts to mechanical ventilation. New York, Cambridge University Press 2004; 163-174.

15. Volumetric Capnography in Patients with Acute Lung Injury: Effect of PEEP on CO 2 Slope Blanch L et al. Eur Respir Dis 1999;13:1048. CONTROL ALI ARDS

17. tachycardia intercostal recession supresternal & supraclavicular recession sternomastoid activity diaphoresis & nasal flaring cyanosis tachypnea abdominal paradox Tobin MJ. Principles and Practice of MV. 1994. Dissynchrony between Patient & Ventilator

18. Paw VT CO 2 ECG Assist Control Ventilation . Double Cycling V .

19. Pressure support ventilation Double Cycling Paw CO 2 Pes V .

20. Mancebo J. Assist-control ventilation. In: Principles and practice of mechanical ventilation. 2 nd ed. Tobin MJ, Ed. Mc Graw-Hill. New York, 2006, pp 183-200

22. ECG Paw VT Pes Pressure support ventilation Dyssynchronies V .

23. Pressure support ventilation Dyssynchronies Pes CO 2 Paw V .

24. Intensive Care Med. 2006 Oct;32(10):1515-22.