Difficult ventilation Craig Hore Intensive Care ASH.

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Presentation transcript:

Difficult ventilation Craig Hore Intensive Care ASH

Check patient ETT and suction Tubing Examine – bronchospasm; tension pneumothorax; raised IAP Patient position Patient compliance with ventilator Sedation / NMJB

The ventilator

Protective ventilation

Lung protective strategy

A Randomised Controlled Trial Of Staircase Recruitment Manoeuvres, High PEEP And Low Airway Pressure (PHARLAP) Carol L. Hodgson, Alistair Nichol, David Tuxen, Jamie Cooper, Michael Bailey, Jenny Keating, Anne Holland, David Pilcher, Andrew Westbrook, Andrew Davies, and Andrew Hilton Permissive Hypercapnia Alveolar Recruitment Low Airway Pressure

Permissive Hypercapnia F i O 2 - aim SpO % Low tidal volume ~ 6ml/kg (ideal body weight) Accept PaCO 2 ≤ 70 (or pH ≥ 7.1)

Low Airways Pressure Pressure control mode vs volume control mode P plat ≤ 30 cmH 2 O P max ≤ 35 cmH 2 O

PEEP

The first point of the PEEP PV curve corresponds to the increase in EELV induced by PEEP (∆EELV). On this example, the recruitment induced by PEEP is measured at a pressure of 20cmH2OMathematical model of the pressure–volume (PV) curve. PV curves

Alveolar Recruitment

Staircase recruitment PCV 15 ± 3 Start at PEEP 10 cmH 2 O Step up: PEEP 20 / 30 / 40 for 2 mins Step down 2.5 cmH 2 O for 3 mins

Staircase recruitment Haemodynamically unstable Oxygenation worsens What PEEP to leave at?

Ask for help SRC Local intensivist MRU consultant ECMO