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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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High Flow Nasal Cannula (HFNC)
• Humidified O
2
• Flow up to 60 L/min
• FiO2 up to 100%
• AGMP
19
Ozkowski et al. ERJ 2022;59:2101574.
Goligher et al. AJRCCM 2017;195(9).
Heated
/ Humidified Gas
Increased secretion clearance
Decreased
bronchoconstriction
Washout C02 Upper Airways
Decreased
dead space
High Nasal Insp. Flow
Decreased upper
airway resistance
Positive
Airway Pressure
Recruitment of atelectasis
(gives minimal PEEP ~ 5 cmH2O)
Decreased entrainment
ambient air
Increased FiO
2
Decreased work of breathing,
transpulmonary pressures
Decreased patient self
-induced lung
injury.
Proposed Benefits:
BONUS
Read on own
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20
HFNC Should Probably be Used For:
HFNC Should Probably
Not be Used For:
•
Hypoxemic resp failure (adults): HFNC
over Conventional O2 Therapy (COT) or
NIV
•
Patients taking Non-Invasive Ventilation
(NIV) breaks: HFNC over COT
•
Post extubation (non-surgical patients)
that are at a low/mod
risk of extubation
failure: HFNC over COT
•
Post-operative patient at low risk of
respiratory complications: HFNC or COT
•
Post-operative patient at high risk of
respiratory complications: HFNC or NIV
•
Post extubation for patients at a
high risk
of extubation failure: NIV over HFNC
(unless relative or absolute CI)
•
Acute hypercapnic resp failure
secondary to COPD (pH < 7.35): trial NIV
before HFNC
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Non-Invasive Ventilation
21
Mode
CPAP
– Continuous Positive
Airway Pressure
BiPAP
– Bi-Level Positive
Airway Pressure
What does the machine
provide?
Constant pressure throughout
expiration and inspiration (i.e.
PEEP or EPAP)
-
Expiratory Positive Airway
Pressure (EPAP = PEEP)
AND
-
Inspiratory Positive Airway
Pressure (IPAP)
Physiological Benefits
-
Reduced respiratory muscle
oxygen consumption
-
Recruitment of alveoli –
Improved V/Q matching
-
Reduced LV afterload
-
Reduced Preload
-
All the same as CPAP
AND
-
Increased alveolar ventilation
BONUS
Read on own
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22
NIV Should Definitely be Used For:
NIV Should Probably
Not be Used For:
•
BiPAP for mild-severe acidotic COPD patients (RR
>20-24, pH≤7.35, and PaCO
2
>45)
•
BiPAP/CPAP for Cardiogenic pulmonary edema*
(not cardiogenic shock and acute MI)
•
Treatment of post-extubation resp failure
•
Prevention of post-extubation resp failure if
not high risk
•
Hypercapneic COPD patients who are NOT
acidotic
NIV Should Probably be Used For:
•
Acute Respiratory Failure (ARF) if:
• Post-operative patients
(supra-diaphragmatic i.e. lung, abdominal, pelvic)
• Chest trauma
• Immunocompromised
• Palliative patients if dyspneic from terminal cancers
•
Prevention of post-extubation respiratory failure in high-risk patients (
High risk = >65yo + underlying cardiac disease or
respiratory disease)
•
Weaning from invasive mechanical ventilation if hypercapneic resp failure
No Recommendation for
i) Asthma exacerbation
ii) De novo respiratory failure-I.e
hypoxemia NYD, ARDS
iii) Acute Resp Failure due to viral
illness during pandemic
Eur Respir J 2017;50:1602426
*Also in pre-hospital setting
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Contraindications to NIV
• Facial surgery, facial trauma, airway
obstruction
• Decreased LOC (*relative)
• Inability to clear secretions
• Respiratory arrest
• Hemodynamic instability (reduces preload)
• Other Indication for intubation (e.g. airway
protection)
Intubating? Consider Video Laryngoscopy!
DEVICE trial 2023 Prekker NEJM
• Video Laryngoscope (VL) vs Direct Laryngoscope (DL) for 1
st
pass rate in intubation
• Setting: ED or ICU
• Higher 1
st
pass rate with VL
• Subgroups favored DL if >100 prior intubations or < ¼ prior intubations with VL
POST-Operative Patients
OK to proceed with NIV if indicated
(even if upper GI or thoracic surgery including
esophageal - get blessing of surgeon if concern for
anastomotic leak)
↓ reintubation ↓ invasive ventilation days
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Basic Modes of Mechanical Ventilation
24
Mode
Type of Breath
Independent
variable
Dependent
variable
Best For
Notes
Volume Assist/
Control
Assist or
Control
Tidal Volume
(preset)
Peak inspiratory
Pressure & Plateau
Pressures
Lung Protection
Post intubation with
Low GCS pts
Control tidal volume
for lung protection;
can get breath
stacking
Pressure assist/
Control
Assist or
Control
Pressure
Adequate tidal
volumes
Comfortable for patient;
Used for decreased lung
compliance
Control pressures to
avoid barotrauma &
breath stacking
Pressure Support
Supported
Pressure
Adequate tidal
volumes
Patient comfort, used
for weaning
All breaths initiated
by pt.
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Ventilator Hacks
How to ê PaCO2
How to é SpO2
(PaO2)
Example of “Vent
Orders”
25
é RR
é tidal volume
(minute ventilation = RR * Vt)
é FiO2
é PEEP
é Inspiratory time
Affect O2 delivery: é cardiac output, é Hb
ê O2 consumption: treat fever, agitation
Stop pulm vasodilators (eg nitroprusside)
RR 10-12, VT 6-8ml/kg (6 if ARDS)
PEEP 5-20, PC 5-25
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Lung and Airway Pressures
• Peak inspiratory pressures (PIP)
– Reflects airway resistance + lung compliance
– Ta rg et <35cm H2O
• Plateau pressure (Pplat)
– The pressure in the lungs when no air is moving,
reflects lung compliance
– This is the pressure that the alveoli are seeing
– Ta rg et <30 cm H2O in any v ent ed pa tient
• >30 = risk of barotrauma causing pneumothorax/lung
injury
– May be confounded by chest wall restriction (ie.
Obesity)
• Positive End Expiratory Pressure (PEEP)
– Pressure at end of respiratory cycle
– Increases solubility of gas (oxygen)
– Splits airways, decreases work of breathing
• Driving pressure: Pplat – PEEP (target < 15)
OR tidal volume/static compliance
26
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MCQ #2 –2023
A 56 year old male presents with ARDS secondary to
acute smoke inhalation during a condominium fire.
He is intubated on arrival to the ED and transferred
to the ICU. He is diagnosed with ARDS and his ABG
PaO2 on day 3 is 87, despite deep sedation, INO and
paralysis. His vent settings are as follows: ACVC Vt
4ml/kg, PEEP 14, FiO2 100%, pPlat 30, driving
pressure 14.
• What is the next best step?
a) Give methylprednisolone 125 mg daily
b) Reduce PEEP to 10 and repeat an ABG
c) Diurese with Lasix 40 mg IV BID
d) Place patient in prone positioning for 16 hrs
27
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ARDS: New Updated Criteria 2023 (updates in red)
MILD
MODERATE
SEVERE
Timing
Within 1 week of known clinical insult or worsening respiratory symptoms
Pulmonary edema
Not cardiogenic pulmonary edema or due to intravascular volume overload
Chest Imaging
Bilateral infiltrates on CXR or CT
Or on LUNG ULTRASOUND by trained professional
*not explained by nodules, pleural effusions or atelectasis
Hypoxemia
PaO2/FiO2 **
(**no requirement for
PEEP in resource limited
countries)
201
-300 with
NIV/CPAP PEEP
≧ 5 or
HFNC >30l/min
101
-200
PEEP
≧ 5
≦
100
PEEP
≧ 5
Hypoxemia SpO2/FiO2
≦
315 with SpO2 ≦ 97%
28
1. Riviello, Am J Respir Crit Care med 2016;193:52-9. 10.1164/rccm.201503-0584OC
2. Mathay et al., Am J Respir Crit Care Med, 2023, 10.1164/rccm.202303-0558WS.
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