![Page 1: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/1.jpg)
Emergency Ventilatory Management Emergency Ventilatory Management of theof the Critically Ill Critically Ill andand Injured:Injured:
Elemental or Detrimental?Elemental or Detrimental?
Presented at EMS TodayMarch 20, 2005
Presented at EMS TodayMarch 20, 2005
![Page 2: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/2.jpg)
Copyright 2005 Ray Fowler MD, FACEPCopyright 2005 Ray Fowler MD, FACEPRay Fowler MD, FACEP
www.utsw.wswww.utsw.wswww.utsw.ws
![Page 3: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/3.jpg)
That Brings Us to That Brings Us to TodayToday’’ s s
Sacred CowSacred Cow……
![Page 4: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/4.jpg)
the
A-B
-C’s
!
Wha
t Abo
ut th
e“B”
Par
t?
![Page 5: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/5.jpg)
Ass
iste
d B
reat
hing
with
PP
V
![Page 6: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/6.jpg)
Res
cue
Bre
athi
ng...
Is It
Rea
lly N
eces
sary
?
![Page 7: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/7.jpg)
Q: What are the Typical Teachings & Current National
Protocol Standards?
Q: What are the Typical Teachings & Current National
Protocol Standards?
A: 10-15 ml/kgTidal Volume &
15-20breaths/min Respiratory Rate
A: 10-15 ml/kgTidal Volume &
15-20breaths/min Respiratory Rate
![Page 8: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/8.jpg)
![Page 9: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/9.jpg)
Why
Do
We
Why
Do
We
Ven
tilat
e?V
entil
ate?
![Page 10: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/10.jpg)
Copyright 2005 Ray Fowler MD, FACEPCopyright 2005 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Oxygen-> lungs -> alveoli -> blood
muscles + organs
Oxygen
cells
Oxygen
Oxygen+
Glucose
energy
CO2
blood
lungs
CO2
breath
CO2
Oxygen and CO2Oxygen and CO2
![Page 11: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/11.jpg)
Copyright 2005 Ray Fowler MD, FACEPCopyright 2005 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Carbon dioxide physiology
Carbon dioxide physiology
CO2 + H2O H2CO3 H+ + HCO3-
![Page 12: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/12.jpg)
Copyright 2005 Ray Fowler MD, FACEPCopyright 2005 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Carbon dioxide physiology
Carbon dioxide physiology
• 0.03% concentration in air• Resting adult produces
2.5 mg/kg/min• In a 70 kg adult, that is about
175 mg per minute, or about 4% of a teaspoonful
• 0.03% concentration in air• Resting adult produces
2.5 mg/kg/min• In a 70 kg adult, that is about
175 mg per minute, or about 4% of a teaspoonful
![Page 13: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/13.jpg)
Copyright 2005 Ray Fowler MD, FACEPCopyright 2005 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Carbon dioxide physiology
Carbon dioxide physiology
• Transported in blood– 60-70% bicarbonate ion after
conversion in RBCs using carbonic anhydrase
– 20-30% bound to proteins (e.g., Hb)– 5-10% in physical solution (PCO2)
• Cleared by alveolar ventilation
![Page 14: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/14.jpg)
Copyright 2005 Ray Fowler MD, FACEPCopyright 2005 Ray Fowler MD, FACEPRay Fowler MD, FACEP
Alveoli: The Place Where Gas Exchange Happens
Alveoli: The Place Where Gas Exchange Happens
![Page 15: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/15.jpg)
OxygenationOxygenationvs.vs.
VentilationVentilationSaturating Red CellsSaturating Red Cells
vs.vs.
Clearing COClearing CO22
![Page 16: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/16.jpg)
OxygenationOxygenation
Air MovementAir Movementandand
Blood FlowBlood Flow
![Page 17: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/17.jpg)
THUS! CyanosisTHUS! Cyanosis……
An Air Movement ProblemAn Air Movement Problemoror
A Circulation ProblemA Circulation Problem
![Page 18: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/18.jpg)
![Page 19: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/19.jpg)
Wha
tW
hat ’’ s
an
Ade
quat
e T
idal
Vol
ume?
s an
Ade
quat
e T
idal
Vol
ume?
![Page 20: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/20.jpg)
IT DEPENDS ON THE IT DEPENDS ON THE CLINICAL SITUATION!!CLINICAL SITUATION!!
![Page 21: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/21.jpg)
10 m
l per
kg
(Int
ubat
ed, N
o P
EE
P, N
o D
iffus
e Lu
ng In
jury
)
![Page 22: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/22.jpg)
Ven
tilat
ion
Ven
tilat
ion
Tid
al V
olum
eT
idal
Vol
ume
xx RR
RR
![Page 23: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/23.jpg)
““ Ven
tilat
ion
Ven
tilat
ion
””
ME
AN
SM
EA
NS
RA
TE
!!R
AT
E!!
![Page 24: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/24.jpg)
How
Fas
t H
ow F
ast
Sho
uld
You
S
houl
d Y
ou
Bre
athe
The
m?
Bre
athe
The
m?
![Page 25: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/25.jpg)
Need to VentilateNeed to Ventilate
••COCO2 2 Production Production (depends upon O(depends upon O2 2 CConsumption onsumption
&& Venous ReturnVenous Return))
![Page 26: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/26.jpg)
Hig
h V
entil
ator
y D
eman
d...
Hig
h V
entil
ator
y D
eman
d...
![Page 27: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/27.jpg)
But Also:But Also:in very low flow statesin very low flow states
Oxygen ConsumptionOxygen ConsumptionBecomes Dependent Becomes Dependent onon
Oxygen Delivery...Oxygen Delivery...
![Page 28: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/28.jpg)
For
Exa
mpl
e, C
PR
Cas
es...
![Page 29: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/29.jpg)
Cardiac ArrestCardiac Arrest•• Little OLittle O 22 Delivery Delivery
& Consumption& Consumption
•• Little COLittle CO 22 Production Production & Venous Return& Venous Return
...Little Need to Ventilate...Little Need to Ventilate
![Page 30: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/30.jpg)
0%
20%
40%
60%
80%
100%
120%
OO22 DeliveryDelivery( ml/min/kg )( ml/min/kg )
10 20 30 40
OO22MetabolizedMetabolized
(% of (% of baseline)baseline)
![Page 31: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/31.jpg)
0%
20%
40%
60%
80%
100%
120%
A
B
OO22 DeliveryDelivery( ml/min/kg )( ml/min/kg )
10 20 30 40
COCO22ProductionProduction
(% of baseline)(% of baseline)
![Page 32: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/32.jpg)
8 br
eath
s / m
in
Car
diac
Arr
est…
.
…Li
ttle
CO
2 E
xcre
tion
![Page 33: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/33.jpg)
CP
R
Pul
ses
Ret
urn
![Page 34: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/34.jpg)
Take HomeTake Home……
Ventilation Ventilation
Should Match Should Match PerfusionPerfusion……
![Page 35: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/35.jpg)
The
“C
PR
Dile
mm
a”
![Page 36: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/36.jpg)
Chest Compressions Chest Compressions & &
Coronary Perfusion PressureCoronary Perfusion Pressure5:15:1 RatioRatio
15:2 Ratio
20 mmHg20 mmHg
20 mmHg20 mmHg
40 mmHg40 mmHg
![Page 37: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/37.jpg)
In Video Study of Lay Individuals Recently Taught 15:2 CPR ….
In Video Study of Lay Individuals Recently Taught 15:2 CPR ….
“Reality” CPR “Reality” CPR
…Took 15-16 Seconds to Deliver the2 Breaths
…Took 15-16 Seconds to Deliver the2 Breaths
![Page 38: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/38.jpg)
Is There Evidence Is There Evidence That We Can That We Can
Breathe Less Often?Breathe Less Often?
![Page 39: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/39.jpg)
Sanders, Sanders, et alet al•• 15:215:2 ((e.g.,e.g.,standard CPRstandard CPR))
•• 50:550:5 ((e.g.,e.g.,Great BritainGreat Britain))
•• CCCC ((chest compressionschest compressionsonlyonly))
•• 4 4 minmin CC CC onlyonly; ; thenthen 100:2100:2Porcine model of four different CPR techniquesAnnals of Emergency Medicine, Dec. 2002, pp 553-62Porcine model of four different CPR techniquesAnnals of Emergency Medicine, Dec. 2002, pp 553-62
![Page 40: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/40.jpg)
Neurological Outcomes...Neurological Outcomes...•• 4 4 minmin CC CC onlyonly; ; thenthen 100:2100:2
----Did Significantly Better thanDid Significantly Better than
15:215:2 (e.g., standard CPR)(e.g., standard CPR)
•• CCCC (chest compression only) (chest compression only)
----Did Much WorseDid Much WorseAnnals of Emergency Medicine, Dec. 2002, pp 553-62Annals of Emergency Medicine, Dec. 2002, pp 553-62
![Page 41: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/41.jpg)
Neurological Outcomes...Neurological Outcomes...•• CONCLUSIONCONCLUSION : In this experimental model of : In this experimental model of
bystander CPR, the group receiving bystander CPR, the group receiving compressions only for 4 minutes followed by a compressions only for 4 minutes followed by a compressioncompression--ventilation ratio of 100:2 achieved ventilation ratio of 100:2 achieved better better neurologicneurologic outcome than the group outcome than the group receiving standard CPR and CCreceiving standard CPR and CC--CPR. CPR. Consideration of alternative chest compressionConsideration of alternative chest compression--ventilation ratios might be appropriate.ventilation ratios might be appropriate.
Annals of Emergency Medicine, Dec. 2002, pp 553-62Annals of Emergency Medicine, Dec. 2002, pp 553-62
![Page 42: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/42.jpg)
Sources of Sources of Ventilation:Ventilation:
•• Active Positive Pressure Active Positive Pressure
•• Chest CompressionsChest Compressions
•• GaspingGasping ((AgonalAgonal Breaths)Breaths)
![Page 43: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/43.jpg)
Stopping to Breathe...Stopping to Breathe...
...Interrupts...InterruptsChest CompressionsChest Compressions
![Page 44: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/44.jpg)
Idea
lC
PR
Idea
lC
PR
Rea
lC
PR
Rea
lC
PR
71%
19%
58%
42%
![Page 45: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/45.jpg)
Normal BreathingNormal Breathing……•• Generates Negative IntraGenerates Negative Intra--
thoracic Pressurethoracic Pressure•• Pulls Lungs Open in a Pulls Lungs Open in a Specific Specific
ArchitectureArchitecture•• Enhances Venous Return Enhances Venous Return and and
Cardiac PreloadCardiac Preload
![Page 46: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/46.jpg)
Ass
iste
d B
reat
hing
with
PP
V
![Page 47: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/47.jpg)
PPVPPV……•• Generates Positive Generates Positive
IntrathoracicIntrathoracic PressurePressure•• Pushes Lungs Open in a Pushes Lungs Open in a
MaldistributiveMaldistributive MannerManner•• Diminishes Venous Return Diminishes Venous Return
and Cardiac Preloadand Cardiac Preload
![Page 48: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/48.jpg)
PPV PPV Cardiovascular EffectsCardiovascular Effects
•• Obstructive Lung DiseaseObstructive Lung Disease•• HypovolemiaHypovolemia•• Circulatory CompromiseCirculatory Compromise
Worsened By...Worsened By...
![Page 49: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/49.jpg)
![Page 50: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/50.jpg)
So
Let’s
S
tudy
It!!
It’s
Not
Roc
ket
Sci
ence
!!
![Page 51: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/51.jpg)
![Page 52: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/52.jpg)
Dispatch Assisted CPR Instructions
Compressions Alone
vs
Standard ABC’s
![Page 53: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/53.jpg)
Com
pres
sion
sA
lone
14.7
%vs
Sta
ndar
d
AB
C’s
10.4
%
Sur
viva
l...
![Page 54: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/54.jpg)
But
Doe
s T
his
App
ly to
Chi
ldre
n?T
hink
Hyp
oxia
!!
![Page 55: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/55.jpg)
How About How About Hypovolemic Hypovolemic
Patients?Patients?
Depends!Depends!
![Page 56: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/56.jpg)
<---Breaths
Measuring Coronary Perfusion Pressure
Ventilated Pigs with Moderate Hemorrhage
![Page 57: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/57.jpg)
Rate: 6 breaths x min-1 (2nd measurement)
one respiratory cycle= 10 sec.
Rate: 12 breaths x min-1
one respiratory cycle = 5 sec
s
Time-Averaged Coronary Perfusion Pressure = Area Under the Curve (in Pink)
RR = 6 / min RR = 12 / min
![Page 58: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/58.jpg)
![Page 59: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/59.jpg)
AufderheideAufderheide Study Study of Paramedicsof Paramedics
•• Averaged Averaged 3737±± 44 breaths/minbreaths/min
•• ReRe--trained at 12 / mintrained at 12 / min
•• Averaged Averaged 2222±± 33 breaths/minbreaths/min
![Page 60: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/60.jpg)
CONCLUSIONS:Despite seemingly adequate training,
professional rescuers consistently hyperventilated patients
during out-of-hospital CPR.
CONCLUSIONS:Despite seemingly adequate training,
professional rescuers consistently hyperventilated patients
during out-of-hospital CPR.
![Page 61: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/61.jpg)
And on the Road And on the Road to the to the
22nd Century...22nd Century...
![Page 62: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/62.jpg)
…P
hren
icN
erve
Pac
emak
er?
![Page 63: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/63.jpg)
![Page 64: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/64.jpg)
Insp
irato
ryIm
peda
nce
Thr
esho
ld V
alve
-12
cm
H2O
![Page 65: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/65.jpg)
HB
OC
HB
OC
-- 201
201
![Page 66: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/66.jpg)
![Page 67: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/67.jpg)
Let
Let ’’
s do
a
s do
a
Cas
e S
tudy
Cas
e S
tudy
![Page 68: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/68.jpg)
Case #1Case #1……
•• 24 24 yoyo Male, Involved in MVCMale, Involved in MVC•• Altered MSAltered MS•• PERLA PERLA (but sluggish),(but sluggish),ThrashingThrashing•• 80/60, HR 130, pale80/60, HR 130, pale
![Page 69: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/69.jpg)
Case # 1Case # 1……
•• Chest wall tenderChest wall tender•• Diminished BS on Right, dullDiminished BS on Right, dull•• Tender abdomenTender abdomen
![Page 70: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/70.jpg)
Case # 1Case # 1……
•• Sick or not sick?Sick or not sick?•• REAL SICK, or REAL SICK, or kindakinda sick?sick?
![Page 71: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/71.jpg)
Remember!!Remember!!Normal BreathingNormal Breathing……
•• Generates Negative Generates Negative IntrathoracicIntrathoracic PressurePressure
•• Pulls Lungs Open in a Pulls Lungs Open in a Specific ArchitectureSpecific Architecture
•• Enhances Venous Return Enhances Venous Return and Cardiac Preloadand Cardiac Preload
![Page 72: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/72.jpg)
SO?????SO?????
How to assist How to assist ventilation ventilation
on this guy??on this guy??
![Page 73: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/73.jpg)
MoribundMoribund Trauma Pt.Trauma Pt.
•• Little OLittle O 22 Transport Transport && ConsumptionConsumption
•• Little COLittle CO 22 Production Production && Venous ReturnVenous Return
Little Need to VentilateLittle Need to Ventilate
![Page 74: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/74.jpg)
And ThereAnd There’’ s a Key s a Key Problem...Problem...
Positive Pressure Breaths Positive Pressure Breaths CanCanImpair Cardiac Output...Impair Cardiac Output...
...in the Face of Severe ...in the Face of Severe Circulatory CompromiseCirculatory Compromise
![Page 75: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/75.jpg)
Moribund Trauma Moribund Trauma PatientPatient
•• Adequate Adequate Tidal VolumeTidal Volume
•• BreathBreath q 7 q 7 -- 10 seconds10 seconds
![Page 76: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/76.jpg)
Tha
nk y
ouT
hank
you
for
your
kin
dfo
r yo
ur k
ind
atte
ntio
n!!
atte
ntio
n!!
![Page 77: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/77.jpg)
ww
w.U
TS
W.w
sw
ww
.UT
SW
.ws
![Page 78: Emergency Ventilatory Management of the Critically Ill ...doctorfowler.com/www/lectures/emstoday2005ventilation.pdf · Rate: 6 breaths x min-1 (2 nd measurement ) one respiratory](https://reader035.vdocument.in/reader035/viewer/2022081409/6077361e737be0644345328f/html5/thumbnails/78.jpg)