Reading the Ventilator Like An ECG
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Own the ventilator! Irma Bilgrami lays down a framework for analysis of ventilator settings and waveforms to enhance your daily practise.
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Reading the Ventilator Like An ECG
- 1. Reading the Ventilator Like An ECG
- 3. Course in mechanical ventilation Advanced course in ventilator waveform analysis Respiratory physiology
- 4. WHAT IS NORMAL- in brief HAVE A SYSTEM- like an ECG CASE STUDIES
- 5. What is normal??? Ventilators Alarms Ventilator graphics
- 6. PRESSURE FLOW VOLUME VENTILATOR GRAPHICS WAVEFORMS LOOPS Pressure vs volume Flow Vs Volume
- 8. Time Time Time Pressure Mode Volume Pressure Flow Inspiration Expiration Flow wave form = Decelerating Affected by changes in compliance/ resistance Pressure waveform= rectangular Not affected by change in compliance/ resistance
- 9. VOLUME mode Descending Ramp Flow Pattern THIS TALK
- 10. Have a System
- 11. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings
- 12. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt Oxygen Saturations End Tidal CO2 Trace Haemodynamics
- 13. B) Technical qualityReport ECG findingsDesc ribe Inter pret Patient Assessme nt Know your ventilator ..and the alarms
- 14. C) Report Ventilator findingsReport ECG findingsDesc ribe Inter pret Patient Assessme nt 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ?
- 15. 3) Report Ventilator findings VOLUME mode Volume set, pressure variable Pressure mode Pressure set, volume variable 1) Mode?
- 16. 2) Parameters set 3) Report Ventilator findings Volume Respiratory rate Inspiratory Flow Rate Inspiratory Time FIO2 PEEP 2) Parameters achieved Peak Pressure Volume-expiratory I:E ratio achieved
- 17. 3) Information from waveforms/ manoeuvres 3) Report Ventilator findings
- 18. Influenced by Compliance Resistance Flow pattern Values Pattern Curve meet baseline VOLUME MODE Values Pattern Peak pressure
- 19. ?Problem with airway resistance or lung compliance HIGH AIRWAY PRESSURES
- 20. Inspiratory Hold Manoeuvre Assess Plateau Pressure HIGH PLATEAU PRESSURES Low compliance Gas trapping
- 21. Expiratory Hold Manoeuvre Assess Auto-PEEP
- 22. Values PIFR Values Pattern Expiratory flow reaches baseline well before expiratory time has ended AUC PEFR Pattern VOLUME MODE Set by the user Decelerating Square Not affected by change in lung characteristics
- 24. 4) Interpretation? C) Report Ventilator findings Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance
- 25. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
- 26. If you change the ventilator settings REASSESS the patient
- 28. New Admissions overnight Matt: Drug overdose Rosa: Severe pneumonia Ms Smith: Asthma
- 29. Morning Ward Round Matt 24yr old man Drug overdose
- 30. 24year old man Benzodiazepine overdose Currently intubated/ ventilated Weight 70 kg (predicted body weight) History
- 31. Examination
- 32. Examination INFUSIONS: Propofol 100mg/hour PHYSICAL EXAM ETT Size 8.5 Minimal secretions Unremarkable exam
- 33. Investigations
- 34. Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
- 35. MODE Parameters set The Ventilator Parameters achieved
- 36. Information from waveforms The Ventilator
- 37. INTERPRETATION IS VENTILATION SAFE? IS OXYGENATION SAFE? Other ISSUES? Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance I:E ratio of 1:1
- 38. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
- 39. Morning Ward Round ROSA 36yr Lady Pneumonia
- 40. PROBLEM WITH LUNG COMPLIANCE? Lung parenchyma Pleura Chest wall
- 41. PRESSURE TIME CURVE Volume mode Values Pattern Increased PIP Same shape. Higher pressures Values Pattern Expiratory limb back to baseline
- 42. FLOW TIME CURVE Volume mode Values Pattern Increased Expiratory flow rate Flow pattern normal Area under curve same in both Curve finishes earlier Values Pattern No Change
- 43. HISTORY Rosa, 36 year old lady with respiratory failure 2’ to Community acquired pneumonia Day 1 ICU Weight= 80 Kg (Predicted body weight) History
- 44. EXAM
- 45. INFUSIONS: Morphine 10mg/hr Midazolam: 10mg/hr Noradrenaline : 5 mcg/min EXAM PHYSICAL EXAM ETT Size 8 Purulent secretions Coarse creps , reduced air entry
- 46. Investigations PHYSICAL EXAM ETT Size 8 Purulent secretions Coarse creps , reduced air entry ABG pH 7.33 PaCo2 57 PaO2 65 HCO3 24 BE 0 Sats 85%
- 47. Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
- 49. Information from waveforms FT The Ventilator Increase Peak pressure ? Plateau pressure Increase Expiratory flow rate
- 50. Inspiratory pause Expiratory pause
- 51. INTERPRETATION Severe respiratory failure with P/F ratio of 65 Poor lung compliance, with high plateau pressures IS VENTILATION SAFE? IS OXYGENATION SAFE? Other ISSUES? Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance
- 52. MANAGE Patient MANAGE Ventilator Position Sedate / Paralyse Fluid balance Lung protective ventilation Optimum PEEP Consider rescue treatments
- 53. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
- 54. Morning Ward Round Ms Smith 35yr old Exacerbation of Asthma
- 55. PROBLEM WITH Resistance? ET tube Increased airways resistance
- 56. PRESSURE TIME CURVE Increased Airway Resistance Values Pattern Increased PIP Rapid rise in PIP. Then tapers down Values Pattern Expiratory limb back to baseline VOLUME MODE
- 57. Values Pattern FLOW TIME CURVE Increased Airway Resistance Values Pattern Decreased Expiratory flow rate Increased expiratory time Rises to zero baseline just before next breath VOLUME MODE
- 58. FLOW TIME CURVE Auto-PEEP Values Pattern Decreased Expiratory flow rate Increased expiratory time Does not reach baseline AUC exp< inp VOLUME MODE Values Pattern No Change
- 60. 35 year old lady with respiratory failure 2’ to exacerbation of Asthma Currently intubated Weight 80kg (Predicted body weight) History
- 61. Examination
- 62. Examination INFUSIONS: Morphine 10mg/hr Midazolam: 10mg/hr Noradrenaline : 2 mcg/min PHYSICAL EXAM ETT Size 8.5 Trachea midline B/L expiratory wheeze
- 63. Investigation
- 64. Ventilator What mode Parameters set and achieved Oxygenation Ventilation Interpretation Waveforms
- 66. Information from waveforms The Ventilator Increase Early Peak pressures DECREASE Expiratory flow rate INCREASE Expiratory time
- 67. Inspiratory pause Expiratory pause Raised Peak pressure Plateau pressure normal No intrinsic PEEP P cmH20 Time
- 68. INTERPRETATION IS VENTILATION SAFE? IS OXYGENATION SAFE? Other problems? Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance INCREASED AIRWAY RESISTANCE NO gas trapping
- 70. Emergency buzzer
- 71. PHYSICAL EXAM Trachea midline Diminished breath sounds
- 72. Parameters achieved Parameters set MODE Volume mode F 18, TV 500, Flow 70, FiO2 35%, PEEP 0 Peak pressure 55, I:E 1:4, Volume 430
- 74. Expiratory pause
- 75. INTERPRETATION IS VENTILATION SAFE? IS OXYGENATION SAFE? Other Problems? Gas trapping Safe ventilation? TV 6-8ml/kg Pplat<30 Safe oxygenation? FiO2<60% Other problems: Low Compliance High Resistance Dyssynchrony Equipment
- 76. MANAGE Patient MANAGE Ventilator Disconnect patient Consider and correct Hypovolemia, Pneumothorax Disconnect patient. Decreased RR Increase Insp flow rate Prolonged I:E
- 77. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
- 78. Read Ventilator – daily patient assessment Have a System
- 80. Modes of Ventilation Loops Dyssynchrony Waveform abnormalities PEEP/ Recruitment
- 81. A) Patient AssessmentReport ECG findingsDesc ribe Inter pret Patient Assessme nt B) Technical quality C) Report Ventilator findings 1) Mode? 2) Parameters set and achieved? 4) Interpretation? 3) Information from waveforms/ manoeuvres ? Safe ventilation? Safe oxygenation? Other problems
- 82. 8th Alfred Advanced Mechanical Ventilation Conference (AAMVC) Waveforms Workshop & Physiotherapy Meeting Wednesday, 16 July, 2014 - Friday, 18 July, 2014
- 83. References Critical Care Medicine Tutorials http://www.ccmtutorials.com/rs/mv/ Puritan Bennett™ , 840 Ventilator, User’s Pocket Guide http://www.covidien.com/imageServer.aspx/doc228227.pdf?contentID=26430&contentt ype=application/pdf Curves and loops in mechanical ventilation http://www.draeger.net/media/10/08/41/10084127/rsp_curves_and_loops_booklet_90 97339_en.pdf http://lifeinthefastlane.com/education/ccc/pressure-vs-time-graph/ Oh's Intensive Care Manual, 6e Andrew D Bersten, Neil Soni
Editor's Notes
- Provide a system for reading the ventilator Reading the ventilator is just not about the waveforms Interpret findings in context of the clinical situation
- Pragmatic talk. My system for incorporating information from vent in patient assessment Case based discussions Test your knowledge NOT: mechanical vent/ waveform/ modes of ventilation
- DISCLAIMER
- Assess your patient… with specific attention to …
- Assess your patient… with specific attention to …
- Assess your patient… with specific attention to …
- Resistance and flow PATTERN affect the peak pressure Compliance and affect the plateau pressure
- Change shape
- Assess your patient… with specific attention to …
- Predicted body weight based on gender and height
- Interactions between flow/ IE ratios
- Flow: exp limb meet baseline just before next breath ? Secondary to I:E= 1:1
- Parameters + Waveforms Safe ventilation= No Safe oxygenation= No Other complications: Severe respiratory failure with P/F ratio of 65 Poor lung compliance, with high plateau pressures
- Assess your patient… with specific attention to …
- Also important to exlude problems with pelura and chest wall
- Same shape Hgher
- Predicted body weight based on gender and height
- Predicted body weight based on gender and height
- Predicted body weight based on gender and height
- Predicted body weight based on gender and height
- Predicted body weight based on gender and height
- Interactions between flow/ IE ratios
- Parameters + Waveforms Safe ventilation= No Safe oxygenation= No Other complications: Severe respiratory failure with P/F ratio of 65 Poor lung compliance, with high plateau pressures
- Lung protective ventilation TV 6ml/kg (PBW) Increase RR, permissive hypercapnia Aim pH >7.2 Pplat<30 Oxygenation aims Sats>88% Consider rescue treatments
- Assess your patient… with specific attention to …
- I am expecting lady with COPD to have bronchospasm--- leading to high resistnce and Pressure. In this setting impotant to exclude other causes of high P- ETT
- The gas takes a long time to leave patients lungs
- The gas takes a long time to leave patients lungs
- Predicted body weight based on gender and height
- Predicted body weight based on gender and height
- Interactions between flow/ IE ratios
- Parameters + Waveforms Safe ventilation= No Safe oxygenation= No Other complications: Severe respiratory failure with P/F ratio of 65 Poor lung compliance, with high plateau pressures
- Dynamic hyperinflation The phenomenon that occurs when a new breath begins before the lung has reached the static equilibrium volume is called dynamic hyperinflation.[1]
- To qunatify degree of autopeep
- Parameters + Waveforms Safe ventilation= No Safe oxygenation= No Other complications: Severe respiratory failure with P/F ratio of 65 Poor lung compliance, with high plateau pressures
- Lung protective ventilation TV 6ml/kg (PBW) Increase RR, permissive hypercapnia Aim pH >7.2 Pplat<30 Oxygenation aims Sats>88% Consider rescue treatments
- Assess your patient… with specific attention to …
- Assess your patient… with specific attention to …
- Assess your patient… with specific attention to …