Sait Modes Of Mechanical Ventilation

Front 1

Indications for mechanical ventilation

Back 1

Apnea
Sever hypoxemia
Impending ventilatory failure
Acute ventilatory failure

Front 2

MIP (cmH20)

Back 2

-80 -- -10 Critical 0 -- -20

Front 3

VC (ml/kg)

Back 3

65 - 75 Critical <10

Front 4

Vt (ml/kg)

Back 4

5-8 Critical <5

Front 5

RR (bpm)

Back 5

12-22 Critical >35

Front 6

MV (L/min)

Back 6

5-6 Critical

Front 7

vd/vt

Back 7

0.25 - 0.4 Critical >0.6

Front 8

Pa02/Fi02

Back 8

350-450 Critical <200

Front 9

IBW male (kg)

Back 9

50+2.3(H-60)

Front 10

IBW female (kg)

Back 10

45.5 + 2.3(H-60)

Front 11

Predicted PH if C02 >40

Back 11

7.4 - ([C02 - 40]*0.006)

Front 12

Predicted PH if C02 < 40

Back 12

7.4 + ([40 - C02]*0.01)

Front 13

ARDS if

Back 13

Pa02/Fi02 < 200

Front 14

Ti =

Back 14

Vt/flow (in L/s)

Front 15

in PC Paw =

Back 15

Ti/TCT * (pip-peep) + peep

(In VC it's same except
1/2(pip-peep))

Front 16

Compliance

Back 16

Vt/Pplat-peep

Normal is 50-170 ml/cmh20

Front 17

Resistance

Back 17

(pip-Pplat)/Flow (L/s)

Normal is 0.6-2.4 cmH20/L/s

Front 18

Autopeep

Back 18

Suspect if shortened Te, ^MV, or air trapping. Do expiratory hold then AutoPEEP = TotalPEEP – PEEPset

Front 19

CMV (VC without pause) TLC

Back 19

T: pt(flow)/time
L: Flow
C: Volume/Flow

Front 20

CMV (VC with pause) TLC

Back 20

T: pt(flow)/time
L: Volume'/Flow
C: Time

Front 21

SIMV-VC+ PS Mandatory or assisted breaths TLC

Back 21

T: pt(flow)/time
L: Volume/Flow
C: Time/Volume

Front 22

SIMV-VC+ PS Spontaneous breaths TLC

Back 22

T: pt(flow)
L: Pressure
C: Flow

Front 23

CMV-PC

Back 23

T: pt(flow)/time
L: Pressure
C: Time

Front 24

SIMV-PC +PS

Back 24

T: pt(flow)/time
L: Pressure
C: Tims (Flow if spontaneous)

Front 25

CMV-PRVC

Back 25

T: pt(flow)/time
L: Pressure
C: Time

Front 26

SIMV PRVC

Back 26

T: pt(flow)/time
L: Pressure
C: Time

Front 27

Pressure Support

Back 27

T: pt(flow)
L: Pressure
C: Flow

Front 28

Other names for PRVC

Back 28

39. CMVAutoflow, SIMVAutoflow, APV-CMV, APV-SIMV, A/C VC+, SIMV (VC+). Newer classification proposals refer to it as “Adaptive Pressure Control”.

Front 29

Describe the indications for CPAP in the neonate.

Back 29

Abnormalities on physical exam (ie. Tachypnea, retractions, grunting, nasal flaring, pale or cyanosis, agitation), inadequate ABGs (exhibited by PaO2  50 mmHg on FiO2 > 0.6 but adequate VE shown by pH  7.25 and PaCO2  50 mmHg), poorly expanded and/or infiltrated lungs on CXR and, a condition responsive to CPAP (RDS, Pulmonary edema, atelectasis, apnea of prematurity, recent extubation, TTNB, tracheal malacia…)

Front 30

Describe the contraindications for non-invasive ventilation in the neonate.

Back 30

The need for intubation and ventilation! This includes conditions such as nasal obstruction, choanal atresia, cleft palate and TE fistula; severe cardiovascular instability/impending arrest, unstable respiratory drive manifesting as apneas with brady’s and desat’s or ventilatory failure (PaCO2 > 60 with pH < 7.25). Also, untreated congenital diaphragmatic hernia, history of recent GI surgery and bronchiolitis.

Front 31

severe refractory hypoxemia in adults?

Back 31

we look at PF ratios (< 200 critical), A-a gradient (>350 critical), and PaO2/PAO2 (<0.15 critical)

Front 32

severe refractory hypoxemia In neonates?

Back 32

PaO2 < 50 mmHg despite use of CPAP and supplemental oxygen (with FiO2 > 0.6)

Front 33

adult VT target?

Back 33

VT 6-10 mL/kg (if no lung pathology select the higher side of this, if some lung patho is present use the lower side). Use 5-7 mL/kg if needing a lung protective strategy.

Front 34

Adult RR target?

Back 34

Frequency 10-18 (initial setting typically 12-14 bpm but set to get goal MV of ~100 mL/kg.

Front 35

Adult Blood Gas target?

Back 35

For the adult patient the normal goal ranges for ABGs:
Normal blood gas values for ventilation (ie. pH 7.35-7.45, PaCO2 35-45 mmHg)
PaO2 60-100 mmHg
Saturations 90%

Front 36

Neo Vt target?

Back 36

VT : 4-6 mL/kg for neonates > 28 weeks and 4 mL/kg for neonates < 28 weeks

Front 37

Neo RR target?

Back 37

Frequency 40-60 bpm (on the lower range for term “healthy” babies, on the upper range the more premature they are.)

Front 38

Neo Pressure target?

Back 38

PIP set to get the desired VT. If no VT monitoring then can estimate by looking for inflation to the 9th rib on inspiration (on CXR). Note that in neonates PIPs should be kept to < 25-30 cmH2O (if unable to maintain ABGs at this then consider HFO)

Front 39

Neo Insp. time target?

Back 39

PIP set to get the desired VT. If no VT monitoring then can estimate by looking for inflation to the 9th rib on inspiration (on CXR). Note that in neonates PIPs should be kept to < 25-30 cmH2O (if unable to maintain ABGs at this then consider HFO)

Front 40

Neo Blood gas goal?

Back 40

The normal goal ranges for ABGs in the neonates are a pH ≥ 7.25, PaCO2 40-50 for > 28 weeks and 45-55 for < 28 weeks (permissive hypercapnia is the goal!), and SpO2 85-94%.

Front 41

When ventilating a neonatal patient, the goal SpO2 would be

Back 41

85-94%

Front 42

Normal neonatal lung compliance is

Back 42

1-2 mL/cmH2O

Front 43

Normal airway resistance of a spontaneously breathing adult is:

Back 43

0.6-2.4 cmH2O/L/s

Front 44

When ventilating an adult COPD patient, which of the following strategies are considered:

Back 44

Setting low RR and short inspiratory times

Front 45

When ventilating a patient with an acute traumatic brain injury which of the following would be appropriate

Back 45

Targeting low-normal PaCO2

Front 46

Hyaline Membrane Disease (HMD/RDS)
strategy

Back 46

Set PEEP for appropriate recruitment (CXR)
Permissive hypercapnia
VT ~ 4 mL/kg
Goal pH ≥ 7.25
Peak pressures should be < 25-30 cmH2O

Front 47

Persistent Pulmonary Hypertension (PPHN)
strategy

Back 47

New trend is target low/normal PaCO2 (35-40) with pH 7.40-7.45
Hyperoxygenate to PaO2 > 100 mmHg and higher SpO2
Nitric oxide therapy
To meet these goals consider:
Conventional mechanical ventilation
HFO
HFJV
ECMO

Front 48

Cyanotic Heart Defects
Usually require a PDA for survival
Eg. Transposition, Tetralogy of Fallot, Hypoplastic left heart

Back 48

Target ABGs:
Rule of 40’s:
pH 7.40, PaCO2 40’s, PaO2 40’s
SpO2 70-80%
 These mimic in-utero conditions and maintain a PDA

Front 49

Meconium Aspiration Syndrome (MAS)
Strategy

Back 49

Surfactant replacement therapy (+/-)
Lung protective strategy
Appropriate VT’s
Mild hyperventilation (low/normal CO2) and hyperoxygenation to treat concurrent PPHN
Peak pressures should be < 30 cmH2O
Watch for hyperinflation
For more severe cases consider NO, HFO, HFJV, ECMO

Front 50

Congenital Diaphragmatic Hernia
strategy

Back 50

Resuscitation:
Intubate immediately (avoid BVM); gastric tube
Use 100% O2 from beginning (not R/A)
Connect to vent ASAP
Ventilation Strategy:
“Gentle ventilation”: AVOID vigorous chest rise
Preserve spontaneous efforts (ie. Minimal sedation)
Permissive hypercapnia
Avoid high pressures (pnuemothorax a strong marker for mortality)
HFO and NO considered;
ECMO in severe cases (often decided antenatally)

Front 51

TPTV TLC

Back 51

Time-triggered, pressure-limited (and flow-limited), time-cycled breath

Front 52

APRV
Phigh
Plow
Thigh
Tlow

Back 52

PHIGH: set at current plateau pressure, should be kept < 35 cmH2O
PLOW: set at 0 cmH2O
To minimize exp. resistance and maximize expiratory flows
THIGH: minimum of 4 sec
TLOW: 0.5 to 1.0 s (0.8 s a good place to start)

Front 53

Weaning APRV

Back 53

The goal is to arrive at straight CPAP:
Wean PHIGH in increments of 2-3 cmH2O
Lengthen THIGH in 0.5-2.0 s increments
Should be in straight CPAP at pressures of 12 cmH2O and then CPAP is weaned
Once at CPAP ~ 6-12 patient is extubated
Rate of weaning depends on the severity of the ALI/ARDS

Front 54

PAV TLC

Back 54

patient triggered, pressure-limited proportionally-targeted?, flow-cycled

Front 55

What mode could be used for Patients with abnormalities in R and C
Obstructive disease, restrictive disease, combined…?

Back 55

PAV

Front 56

A-a Gradient (on 100%)

Back 56

Normal 25-65
Critical >350

Front 57

PaO2/PAO2
normal

Back 57

Normal 0.75-0.95
Critical < 0.15

Front 58

MAP =

Back 58

(Pip-Peep)*Ti
-------------------- + PEEP
TCT

Front 59

Neo Blood gas goals
if Neo < 28 weeks

Back 59

>7.25/45-55/50-70/85-94%

Front 60

Neo Blood gas goals
if Neo > 28 weeks

Back 60

>7.25/40-50/50-70/85-94%

Front 61

Permissive Hypercapnia used in:

Back 61

PH >7.25
Used in ARDS, COPD, Asthma.
Babies with RDS, BPD,PIE, Congenital diaphragmatic hernia.

Front 62

Low/Normal C02 targetted for babies with...

Back 62

PPHN, Meconium (MAS)

Front 63

Tobin AKA and the formula is:
Critical number is

Back 63

RSBI RR/Vt (in liters)

Critical is <105

Front 64

Discontinue SBT if

Back 64

RR > 38
Tobin > 105
Sweating, anxiety
Sp02 < 90% for 5 mins
HR > 140 or 20% change
Systolic BP < 90 or >180
New Dysrythmia or MI

Front 65

Wean in this order

Back 65

PIP
RR
Fi02
PEEP

Front 66

Wean PIP to _____ before weaning RR

Back 66

Wean Pip < 15 cmH20
Tidal volumes about 4 ml/kg

Front 67

Wean RR to ______

Back 67

Wean RR to < 10-15 bpm in 5 bpm increments

Front 68

Wean Fi02 down to ____

Back 68

Down to < 0.40 before weaning PEEP

Front 69

Wean PEEP to

Back 69

Wean PEEP to 3-5 cmH20