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What Can We Do For The Patient? Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine
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Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Dec 16, 2015

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Page 1: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

What Can We Do For The Patient?

Dr Tristan GR DyerRCSEd Fellow in Pre-hospital Emergency Medicine

Page 2: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Aims

To discuss methods of ventilation To discuss mechanical ventilation To introduce some difficult patient

groups that make ventilation more challenging

To look at future tools to aid ventilatory strategies

Page 3: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

How Can We Ventilate The Patient?

Let the patient do it themselves! Manually Mechanically

Page 4: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Self-Ventilation

Deliver oxygen Work with the patient to optimise

their position Analgesia Therapeutic interventions (e.g.

drugs)

Page 5: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Indications for Ventilatory Support

Failure to Ventilate Failure to Oxygenate

Page 6: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Manual Ventilation

Page 7: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Manual Ventilation

Can be used with basic and advanced airway adjuncts.

BUT Ties operator up! Inaccurate tidal volumes. Tendency for operator to hyperventilate

(the patient!) May not be able to effectively ventilate

the patient. Risk of aspiration.

Page 8: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Predictors for Difficult Manual Ventilation

Page 9: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Mechanical Ventilation

Page 10: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

How does it work?

Intermittent application of positive pressure to the upper airway.

Inspiration – gas flows into alveoli until the alveolar pressure equals the upper airway pressure.

Expiration – positive airway pressure is removed/decreased so the gradient reverses and gas flows out of the alveoli.

Page 11: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Pre-hospital Mechanical Ventilation

Patient has to be anaesthetised or crash intubation.

BUT Delivers 100% FiO2

Accurate tidal volumes. Accurate respiratory rate. Alarms to warn of emergencies

developing. Allows inline capnography. Frees up the operator.

Page 12: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Modes of Ventilation

Controlled Mechanical Ventilation Assist-Control Ventilation Intermittent Mandatory Ventilation Pressure Support Ventilation Pressure Control Ventilation Inverse I:E Ratio Ventilation

Page 13: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Controlled Mechanical VentilationCMV

Page 14: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Patient Factors To Optimise Ventilation

Ensure adequate sedation and paralysis

Patient position Clear secretions Treat underlying pathology

Page 15: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Basic Settings

Respiratory Rate 10-12 breaths/min. Tidal Volume 6-8 ml/Kg.

Aim to balance adequate ventilation with risk of pulmonary barotrauma and volutrauma at inflation pressures of >35-40 cm H2O.

Lower mean airway pressures (<20-30 cm H2O) can help preserve cardiac output and V/Q relationships.

May build TV up to 10ml/Kg.

Page 16: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Advanced Ventilators

Page 17: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Allow for...

Page 18: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Positive End-Expiratory Pressure(PEEP)

Used to improve a symptomatic decrease in the Functional Residual Capacity that causes hypoxaemia.

Provided by an extra valve applied to the breathing circuit or within the ventilator.

Page 19: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Pulmonary Effects of PEEP

In patients with a reduced lung volume, PEEP stabilizes and expands

partially collapsed alveoli.

This... Increases FRC and tidal ventilation Improves lung compliance Corrects V/Q abnormalities

Page 20: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Adverse Pulmonary Effects

Worse at levels >20 cm H20. Barotrauma Worse with underlying lung disease,

high rate of breaths, large tidal volumes and young age.

Page 21: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Adverse Non-Pulmonary Effects

Transmission of elevated airway pressure to the contents of the chest.

Reduced cardiac output. Elevated central venous pressure.

Page 22: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

PEEP Settings

Starting PEEP 5-8 cm H2O used to compensate for the reduced FRC in anaesthetised patients.

Add in increments of 5 cm H2O up to 15 cm H2O.

Aim to improve oxygen saturations.

Page 23: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Lung Protective Strategy

Low Tidal Volume Low Airway Pressure Modest PEEP

Page 24: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Difficult Patient Groups

Page 25: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Trauma

Page 26: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.
Page 27: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Asthmatics

Page 28: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Pregnant

Page 29: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Bariatric

Page 30: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Elderly

Page 31: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Children

Page 32: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

The Future

Page 33: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Arterial Lines

Page 34: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

iSTAT

Page 35: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Portable Ultrasound

Page 36: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Inotropes

Page 37: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Any Questions?

Page 38: Dr Tristan GR Dyer RCSEd Fellow in Pre-hospital Emergency Medicine.

Summary

Discussed means of ventilation Focused on mechanical ventilation Talked about difficult patient groups Looked at future adjuncts that may

help with ventilatory support