1/17/2012 1 Understanding Mechanical Understanding Mechanical Ventilation and its Implications for Ventilation and its Implications for Physical Therapy Intervention Physical Therapy Intervention 1 Jennifer M. Zanni, PT, DScPT Clinical Specialist, Johns Hopkins Hospital Lecturer, Johns Hopkins University Objectives Objectives • Identify types of airways and indications • Identify common modes of ventilation and describe the assistance that each mode provides • Interpret common alarms associated with mechanical ventilation and indicate actions • Describe possible complications associated with mechanical ventilation 2 Objectives Objectives • Discuss and synthesize common weaning parameters and methods • Describe treatment strategies for mobilizing the patient requiring mechanical ventilation • Discuss current literature regarding rehabilitation of patients requiring mechanical ventilation 1/17/2012 3 Why is mechanical ventilation Why is mechanical ventilation required required ? • One of the most common indications for using mechanical ventilation is to decrease the work of the respiratory musculature and improve arterial oxygenation • Patients in acute respiratory failure can have 4- 6x the normal inspiratory effort • Careful selection of vent support and settings is crucial and needs to be individualized to each patient Tobin, MJ. NEJM, Vol. 344, No. 26, June 28, 2001 4 Why is mechanical ventilation Why is mechanical ventilation required required ? • In a study of 1638 patients (8 countries) who required mech vent: – Acute Respiratory Failure (66%) • ALI/ARDS, heart failure, pneumonia, sepsis, trauma, surgery complications – Coma (15%) – Acute on chronic COPD (13%) – Neuromuscular disorders (5%) Esteban, A et al. Am J Respir Crit Care Med. 2000;161:1450-8. Tobin, MJ. NEJM, Vol. 344, No. 26, June 28, 2001 5 Why is mechanical ventilation Why is mechanical ventilation required required ? • Impending or existing respiratory failure – Failure to oxygenate – Failure to Ventilate – Or combination of the two • Airway protection
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Zanni CSM 2012 Handout[1] · disorders (ALI/ARDS) causing pulm edema and stiffness in the lungs, making them difficult to ventilate Tobin, MJ. NEJM, Vol. 344, No. 26, June 28, 2001
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1/17/2012
1
Understanding Mechanical Understanding Mechanical
Ventilation and its Implications for Ventilation and its Implications for
Jennifer M. Zanni, PT, DScPTClinical Specialist, Johns Hopkins HospitalLecturer, Johns Hopkins University
ObjectivesObjectives
• Identify types of airways and indications
• Identify common modes of ventilation and describe the assistance that each mode provides
• Interpret common alarms associated with mechanical ventilation and indicate actions
• Describe possible complications associated with mechanical ventilation
2
ObjectivesObjectives
• Discuss and synthesize common weaning
parameters and methods
• Describe treatment strategies for mobilizing
the patient requiring mechanical ventilation
• Discuss current literature regarding
rehabilitation of patients requiring mechanical
ventilation
1/17/2012 3
Why is mechanical ventilation Why is mechanical ventilation
requiredrequired??
• One of the most common indications for using mechanical ventilation is to decrease the work of the respiratory musculature and improve arterial oxygenation
• Patients in acute respiratory failure can have 4-6x the normal inspiratory effort
• Careful selection of vent support and settings is crucial and needs to be individualized to each patient
Tobin, MJ. NEJM, Vol. 344, No. 26, June 28, 2001
4
Why is mechanical ventilation Why is mechanical ventilation
requiredrequired??
• In a study of 1638 patients (8 countries) who required mech vent:
– Acute Respiratory Failure (66%)
• ALI/ARDS, heart failure, pneumonia, sepsis, trauma, surgery complications
– Coma (15%)
– Acute on chronic COPD (13%)
– Neuromuscular disorders (5%)
Esteban, A et al. Am J Respir Crit Care Med. 2000;161:1450-8.
Tobin, MJ. NEJM, Vol. 344, No. 26, June 28, 2001
5
Why is mechanical ventilation Why is mechanical ventilation
requiredrequired??
• Impending or existing respiratory failure
– Failure to oxygenate
– Failure to Ventilate
– Or combination of the two
• Airway protection
1/17/2012
2
Failure to VentilateFailure to Ventilate
• Hypercapnic Respiratory Failure
– Caused by disorders of CNS, neuromuscular
systems, chest wall or airways
– Increased PaCO2 > 50 mmHg
– s/s include tachypnea, agitation, cyanosis, and
decreased mental status
7
Failure to OxygenateFailure to Oxygenate
• Hypoxic Respiratory Failure• Inadequate exchange of gases at the alveolar level,
as seen in ARDS
• Decreased PaO2 (<50 mmHg)
– Can occur despite normal ventilation
– Occurs at pulm-alveolar interface due to pulm
edema or fibrosis
– Reduced diffusing capacity and V/Q mismatch
8
Failure to OxygenateFailure to Oxygenate
A big challenge in mech ventilation are in alveolar-filling
disorders (ALI/ARDS) causing pulm edema and stiffness
• Bailey, P.P., Miller, R.R., 3rd, & Clemmer, T.P. (2009, Oct). Culture of early mobility in mechanically ventilated patients. Crit Care Med, 37(10 Suppl):S429-35.
• Clini, E & Ambrosino, N. (2005, Sep). Early physiotherapy in the respiratory intensive care unit. Respiratory Medicine, (9):1096-104.
• Ciesla, N. D. (2004). Physical therapy associated with respiratory failure. In DeTurk, W.E and Cahalin, L.P (Eds.), Cardiovascular and Pulmonary Physical Therapy (pp. 541-587). New York: McGraw-Hill.
• Dean, E. (2008). Mobilizing patients in the ICU: Evidence and principles of practice. Acute Care Prospectives, Vol. 17(1).
Additional References
• Fessler, H.E. & Hess, D.R. (2007). Respiratory controversies in the critical care setting. Does high-frequency ventilation offer benefits over conventional ventilation in adult patients with acute respiratory distress syndrome? Respiratory Care. 2007. 52, (5), 595-605.
• Frownfelter, D. (1987). Chest Physical Therapy and Pulmonary Rehabilitation. (pp. 729-744). St. Louis: Mosby.
• Frowley PM and Habashi, NM. Airway Pressure Release Ventilation: Theory and Practice. AACN. 2001;Vol 12(2), 234-246.
Additional References
• Hopkins, R.O., & Spuhler, V.J. (2009, Jul-Sep). Strategies for promoting early activity in critically ill mechanically ventilated patients. ACCN Adv Crit Care, 20(3):277-289.
• Irwin, S and Tecklin, JS. (2004). Cardiopulmonary Physical Therapy: A Guide to Practice, (4th ed.). St Louis: Mosby.
• Perme, C., & Chandraskekar, R.K. (2008). Managing the patient on mechanical ventilation in ICU: Early mobility and walking program. Acute Care Prospectives,Vol17(1).
• Sadowsky, H.S. Monitoring and life support equipment. In E.A. Hillegass and H.S. Sadowsky, Essentials of cardiopulmonary physical therapy. (pp. 509-533). 2001; Philadelphia: Saunders.
Additional References
• Stawicki, S.P., Goval, M., & Sarani, B. (2009, Jul-Aug). Frequency oscillatory ventilation (HFOV) and airway pressure release ventilation (APRV): a practical guide. J Intensive Care Med, 24(4):215-29. Epub 2009 Jul 17.
• Tobin, MJ. (2001, June 28) Advances in mechanical ventilation. NEJM, 344(26) Yosefy, C., Hay, E., & Ben-Barak, A. (2003). BiPAP ventilation as assistance for patients presenting with respiratory distress in the department of emergency medicine. American Journal of Respiratory
Medicine. 2(4), 343-7.
• Zanni, J.M., & Needham, D.M. (2010, May). Promoting early mobility and rehabilitation in the intensive care unit. PT in Motion, 32-39