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- 1. Non-invasive ventilation Updated. Dr Mohammed AL-Shamsi. R5
- 14. Peak- end expiratory pressure (PEEP)
- 20. Pressure Waveform CPAP 0
- 23. NIV - Changes in EPAP Pressure 5 cm Delta P 10 cm 10 cm 15 cm IPAP increased to 20 cm Delta P returned to 10 cm P R E S S U R E Decreasing delta pressure will usually result in lower Vt Delta pressure 5 cm EPAP increased to 10 cm
- 26. From Pressure Support to PAV Patient Effort Pressure PSV PAV
- 31. After POST, Start “Test Exhalation Port”
- 32. Follow steps on screen, block circuit, “Start Test”. Exhalation (castle) port
- 33. Exhalation port test in progress
- 34. Test Complete, press Monitoring to exit. Monitoring
- 35. Monitoring Parameters Mode Alarms Alarm Silence Alarm Reset 21% options SB IPAP 8 EPAP 3 Rate 12 Pt Data Display Area Scale Fz/ UnFz Mode/Messages ALARMS
- 36. To change Mode, press Mode, then parameter soft key to adjust, and then “Activate New Mode” soft key 1 2 3
- 37. To change settings, press Parameters – then soft key next to parameter and adjust with knob. Soft keys Knob
- 41. Initial IPAP/EPAP settings Start at 10 cm water/5 cm water Pressures less than 8 cm water/4 cm water not advised as this may be inadequate Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP and/or EPAP) Subsequent adjustments based on arterial blood gas values Increase IPAP by 2 cm water if persistent hypercapnia Increase IPAP and EPAP by 2 cm water if persistent hypoxemia Maximal IPAP limited to 20-25 cm water (avoids gastric distension, improves patient comfort) Maximal EPAP limited to 10-15 cm water FIO 2 at 1.0 and adjust to lowest level with an acceptable pulse oximetry value Back up respiratory rate 12-16 breaths/minute
- 55. NIPPV &COPD
- 62. CPAP or BiPAP ?
- 64. CPAP VS BIPAP Risk ratio of acute myocardial infarction
- 79. CPAP or PAV
- 91. THANK YOU FOR YOUR ATTENTION
Notes de l'éditeur
- The "pneumatic chamber" made by Wilhelm Schwake of Germany was a tank ventilator designed to be operated by the patient. while
- The 1876 Woillez "spirophore" tank ventilator. (Courtesy of the J.H. Emerson Company.)
- The rocking bed ventilator (J.H. Emerson Company, Cambridge, MA) used by a patient with poliomyelitis and no autonomous breathing tolerance since 1952.
- As the first step in an attempt to clarify criteria for use of the rocking bed rather than the respirator as an aid to breathing for patients with weakness of respiratory muscle function caused by poliomyelitis, ventilation studies were done on seven patients with pronounced weakness or paralysis of the respiratory muscles. Average tidal air volume was considerably less when the patient was on the rocking bed than when he was in the respirator.
- Iron lung polio ward at Rancho Los Amigos Hospital in 1953. Negative-pressure ventilators (“iron lungs”) Non-invasive ventilation first used in Boston Children’s Hospital in 1928 Used extensively during polio outbreaks in 1940s – 1950s
- In Boston, the nearby Emerson Company made available a prototype positive-pressure lung inflation device, which was put to use at the Massachusetts General Hospital, and became an instant success. Thus began the era of positive-pressure mechanical ventilation (and the era of intensive care medicine Positive-pressure ventilators Invasive ventilation first used at Massachusetts General Hospital in 1955 Negative pressure ventilators (Tank and Cuirass ventilators) were the only non-invasive methods of assisting ventilation for many years mainly for ventilating large number of victims of Polio during their acute illness. In 1980s it was recognized that delivery of continuous positive airway pressure by close fitting nasal masks for treatment of obstructive sleep apnea could also be used to deliver an intermittent positive pressure. This was followed by improvements in the interface and establishment of role of NIMV in patients of COPD. The use of NIMV has increased in last decade in various conditions to avoid complications of intubation.
- Figure 25.5 Thoracic CT images from a patient with ARDS showing resolution of atelectasis (recruitment) in response to PEEP. Images from Barbas CSV. Lung recruitment maneuvers in acute respiratory distress syndrome and facilitating resolution. Crit Care Med 2003;31(suppl):S265–S271. What is the goal of PEEP? Improve oxygenation Diminish the work of breathing Different potential effects What are the secondary effects of PEEP? Barotrauma Diminish cardiac output Regional hypoperfusion NaCl retention Augmentation of I.C.P.? Paradoxal hypoxemia PEEP increases the end expiratory lung volume (FRC) PEEP recruits collapsed alveoli and prevents recollapse Excessive PEEP has adverse effects - decreased cardiac output - barotrauma (pneumothorax, pneumomediastinum)
- I will start with oldest mode of niv which was used initeally to treat OSA in 1980. If peep isaplied to spontanously breathing pt is called cpap rosen How does CPAP work Decreases work of breathing Decreases FRC (in COPD) Increases FRC (in CHF) Decreases venous return Increased oxygenation (allows a drop in catecholamines) Decreases LV afterload (higher intrapulmonary pressure mean less stress on heart Recruit atelectatic alveoli
- Ipap increase tv andhence the alveolar ventilatio. So it has great impacton the decreaseing pco2 level and some impreovemnt on oxygenation. Epap is like peep, it imrove oxygenation by previnting alvolar collapse in exhelation and allow gas exchange even in exhelation, so it has great impact on oxgenation. Question, whatwil hepen of we increase epap without changing he ipap?
- As we discussed on the previous slide, EPAP is adjusted to increase oxygenation. If EPAP is increased without a corresponding increase in IPAP, the Delta pressure decreases, conversely if EPAP is lowered without lowing IPAP pressure Delta pressure increases. The IPAP pressure is what is set, and it is not PEEP compensated, in other words, IPAP pressure does not increase with increases in EPAP pressure. As you can see on the the blue waveform, EPAP pressure is 5 cm and IPAP pressure is 15 cm, resulting in a Delta pressure of 10 cm. On the yellow waveform, we can see that the EPAP pressure was increased to 10 cm to facilitate an increase in oxygenation. The Delta pressure therefore decreases to 5 cm, this may result in increased CO 2 as tidal volume will likely decrease. On the red waveform we can see that the IPAP pressure was increased by 5 cm, the same amount the EPAP pressure was increased, thus restoring the Delta pressure of 10 cm. Keep in mind that any increase or decrease in the EPAP pressure may need to be accompanied by an equal increase or decrease in IPAP pressure to maintain the same Delta pressure if desired. Also rom this iure we can say that if you increase thepeep by 2 to improve the oxygenation, we should increase he ps by at least same incremets otherwise we will decrease the Vt and impairing ventilation .
- PAV is a new mode of ventilation that is fundamentally different from the volume and pressure ventilation we practice today. In PAV the ventilator generates a pressure change, then creates airflow that move volume into the lungs. So far nothing special. But unlike conventional ventilation, the pressure is not preset by the physician but is generated in proportion to patient’s effort. With PAV, the machine is able to respond and to adapt to changes in patient breathing pattern and effort.
- BiPAP® Vision .1 -Assemble the circuit with exhalation port proximal to the patient. A bacterial filter and oxygen analyzer should be placed between the machine’s patient interface port and the patient circuit. If using the O2 module, connect to a 50psi O2 source. 2 -Plug electrical cord in A/C outlet. Press START on the back of the machine. The Vision will perform a self-test as indicated by the display screen, “System Self-Test in Progress. 3 -Perform the “Test Exh Port”, second button from top, left of screen. 3.1 Occlude circuit with thumb throughout the test. 3.2 Press START TEST, top button, right of screen. This tests the leak of the circuit. 4 -Assess appropriateness of physician’s orders and set ventilatory parameters accordingly. Initial settings as well as changes to ventilatory parameters must be accompanied by a physician order. 5 -Select the proper mode by first selecting the mode button at the bottom of screen. 5.1 Choose CPAP or S/T mode, top button, right side of screen, per physician’s order. 5.2 Activate view mode by pressing the “Activate View Mode” button, bottom right of screen. 6- Select the “parameters” button below the screen. 6.1 Choose a parameter from the left and right sides of screen. Press the soft button for the parameter of choice. Once it is highlighted, spin knob clockwise to increase value, and counter clockwise to decrease value in the parameter block. Repress the button for that particular parameter to activate the new value. NOTE: Consult the BiPAP® Vision Ventilatory Support System Clinical Manual for specific information on the modes of operation and set parameters. 7 -Connect the patient’s properly fitted mask or airway adapter to the BiPAP Vision Circuit, and then apply the mask to the patient. 8- Select “alarms” button, below the screen. Set values for Hi Pressure, Lo Pressure, Lo Pressure Delay, Apnea, Lo MinVent, Hi Rate, and Lo Rate as appropriate for the patient.
- Analyzes leak rate of exhalation port If successful – the value of “Pt. Leak” will be displayed If unsuccessful – “Tot. Leak” will be displayed
- Orofacial masks (cautions, disadvantages) Claustrophobic Hinder speaking and coughing Risk of aspiration with emesis Nasal masks (general advantages) Best suited for more cooperative patients Better in patients with a lower severity of illness Not claustrophobic Allows speaking, drinking, coughing, and secretion clearance Less aspiration risk with emesis Generally better tolerated Nasal masks (cautions, disadvantages) More leaks possible (eg, mouth-breathing or edentulous patients) Effectiveness limited in patients with nasal deformities or blocked nasal passages
- -there are so many different protocol, no standard protocol. These different protocol are never been compared .
- Why not to start with alow pressure?
- It is imprtant to set with he pt for he first hour or so after initiatiobn of the therapy to provide support and monitor the pt.
- Standard of care level A evidence
- Fig. 34.1 Risk ratio of acute myocardial infarction in the studies comparing nIPSV (noninvasive pressure support ventilation) versus nCPAP (noninvasive continuous positive airway pressure). (Note: In their study, Rusterholtz and coworkers used proportional assisted ventilation [PAV] and not pressure support ventilation)
- One metaanalysis compared efficasy and savity of bibap vesus cpap in treatment of acpe showed. Puplshed in j of ritical care in 2006 هى
- No intubation or mortality benefit. 14 Patients with CPAP and noninvasive ventilation (BiPAP) did have more rapid resolution of symptoms and correction of gas exchange abnormalities and pH compared with the oxygen group. No difference was noted between CPAP and noninvasive ventilation (BiPAP).
- study found no differences between PAV and CPAP in patients with acute respiratory failure subsequent to CPE. There was no evidence of increased risk for myocardial infarction in patients with PAV. Since the implementation of NIV in the prehospital setting and emergency departments is now widely developed, CPAP, an easy to use, relatively cheap method of NIV, remains Changes in physiological parameters were similar in the two groups.the gold standard in these patients.
- Most asthmatic patients do not present with acute respiratory failure
- Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 1999