how to ventilate icu patient dr mohammed bahzad mbbs.frcpc,fccp,fccm head of critical care...
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How To Ventilate ICU How To Ventilate ICU PatientPatient
Dr Mohammed Bahzad Dr Mohammed Bahzad MBBS.FRCPC,FCCP,FCCMMBBS.FRCPC,FCCP,FCCM
Head Of Critical Care Department Head Of Critical Care Department Mubarak Alkbeer HospitalMubarak Alkbeer Hospital
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AimsAims
Get oxygen inGet oxygen in Get carbon dioxide outGet carbon dioxide out Minimize adverse effectsMinimize adverse effects Maximize patient comfortMaximize patient comfort
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Case ACase A
60 kg male60 kg male Post operative – complicated wipel Post operative – complicated wipel
procedureprocedure No previous lung or heart diseaseNo previous lung or heart disease Still paralyzedStill paralyzed
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Make the ventilator fit the Make the ventilator fit the patientpatient
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ModeMode
Non-invasiveNon-invasive InvasiveInvasive
– Assist controlAssist control– Pressure controlPressure control– SIMVSIMV– (Pressure support)(Pressure support)
Pick a mode you understand and are Pick a mode you understand and are familiar withfamiliar with
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Assist controlAssist control
Set tidal volumeSet tidal volume Inspiratory-expiratory cyclingInspiratory-expiratory cycling
– Time cycledTime cycled Time is setTime is set Ventilator adjusts flow to deliver set tidal volume in Ventilator adjusts flow to deliver set tidal volume in
the set timethe set time
– Volume cycledVolume cycled
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Assist controlAssist control
Breaths:Breaths:– Ventilator initiated (control breaths)Ventilator initiated (control breaths)– Patient initiated (assist breaths)Patient initiated (assist breaths)– Set minimum frequencySet minimum frequency
Characteristics of each inspiration are the Characteristics of each inspiration are the samesame– Not affected by whether breath is control breath Not affected by whether breath is control breath
or an assist breathor an assist breath
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700 ml
-70
70 l/min
50 cmH2O
Assist controlAssist control
Pressure
Flow
Volume
T
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700 ml
-70
70 l/min
50 cmH2O
Assist controlAssist control
Pressure
Flow
Volume
T
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Assist controlAssist control
SetSet– Minimum respiratory rateMinimum respiratory rate
Patient’s spontaneous respiratory rate < set rate Patient’s spontaneous respiratory rate < set rate ventilator gives additional control breaths to make ventilator gives additional control breaths to make up differenceup difference
Patient’s spontaneous rate > set rate Patient’s spontaneous rate > set rate no control no control breathsbreaths
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Volume controlVolume control
SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume
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Volume controlVolume control
SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume– Inspiratory time or I:E ratioInspiratory time or I:E ratio– Inspiratory pause timeInspiratory pause time
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Volume controlVolume control
Longer inspiratory timeLonger inspiratory time– Improved oxygenationImproved oxygenation
Higher mean airway pressureHigher mean airway pressure Re-distributionRe-distribution
– Lower peak airway pressureLower peak airway pressure More time available to deliver set tidal volumeMore time available to deliver set tidal volume
Shorter inspiratory timeShorter inspiratory time– Less risk of gas trapping and PEEPLess risk of gas trapping and PEEPii
– Less effect on cardiovascular systemLess effect on cardiovascular system
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Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time
NomenclatureNomenclature
Time
Vol
ume
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Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time
NomenclatureNomenclature
Time
Vol
ume
Inspiratory flow time
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Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time
NomenclatureNomenclature
Time
Vol
ume
Inspiratory pause time
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Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time
NomenclatureNomenclature
Time
Vol
ume
Inspiratory time
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Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time
NomenclatureNomenclature
Time
Vol
ume
Inspiratory time Expiratory time
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Setting I:E, inspiratory flow time, Setting I:E, inspiratory flow time, pause timepause time
NomenclatureNomenclature
Time
Vol
ume
Respiratory cycle time
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I:E as a ratio & inspiratory pause time I:E as a ratio & inspiratory pause time as a percentageas a percentage
Time
Vol
ume
6 secs
1 2
10%
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I:E as a ratio & inspiratory pause time I:E as a ratio & inspiratory pause time as a percentageas a percentage
Time
Vol
ume
3 secs
1 2
10%
Respiratory rate
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Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate
Time
Vol
ume
6 secs
2 secs 4 secs
0.5 s
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Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate
Time
Vol
ume
3 secs
2 secs
0.5 s
Respiratory rate withoutchanging Inspiratory time orinspiratory flow
1 sec
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Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate
Time
Vol
ume
3 secs
2 secs
1.5 s
inspiratory flow1 sec
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Absolute inspiratory time, inspiratory Absolute inspiratory time, inspiratory flow time as a function of flow rateflow time as a function of flow rate
Time
Vol
ume
3 secs
1 sec
0.5 s
Absolute inspiratory time2 sec
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Time
Vol
ume
3 secs
2 secs
0.5 s
Respiratory rate withoutchanging inspiratory flow orinspiratory pause time
1 sec
Inspiratory flow time as a function of Inspiratory flow time as a function of flow rate, absolute pause timeflow rate, absolute pause time
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Inspiratory flow time as a function of Inspiratory flow time as a function of flow rate, absolute pause timeflow rate, absolute pause time
Time
Vol
ume
3 secs
1 sec
0.5 s
inspiratory flow2 sec
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Inspiratory flow time as a function of Inspiratory flow time as a function of flow rate, absolute pause timeflow rate, absolute pause time
Time
Vol
ume
3 secs
0.8 sec
0.3 s
inspiratory pause time2.2 sec
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Volume controlVolume control
SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume– Inspiratory time or I:E ratioInspiratory time or I:E ratio
Directly/indirectlyDirectly/indirectly
– Inspiratory pause timeInspiratory pause time Directly/indirectlyDirectly/indirectly
– PEEPPEEP
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Assist controlAssist control
AdvantagesAdvantages– Relatively simple to setRelatively simple to set
– Guaranteed minimum Guaranteed minimum minute ventilationminute ventilation
– Rests muscles of Rests muscles of respiration (if properly respiration (if properly set)set)
DisadvantagesDisadvantages– Not synchronizedNot synchronized– Patient may “lead” Patient may “lead”
ventilatorventilator– Inappropriate triggering Inappropriate triggering
may result in excessive may result in excessive minute ventilationminute ventilation
lung compliance lung compliance alveolar pressure with risk alveolar pressure with risk of barotraumaof barotrauma
– Often requires sedation to Often requires sedation to achieve synchrony. achieve synchrony.
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Pressure controlPressure control
Pressure preset assist/control ventilationPressure preset assist/control ventilation Similar to volume control except pressure is Similar to volume control except pressure is
presetpreset
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PEEP
PC above PEEP
Pre
ssure
Flow
Time
Time
Time
Volu
me
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PEEP
PC above PEEP
Pre
ssure
Flow
Time
Time
Time
Volu
me
Normal inspiratory time Short inspiratory time
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Pressure controlPressure control
AdvantagesAdvantages– Relatively simpleRelatively simple
– Avoids high inspiratory Avoids high inspiratory pressurespressures
– Rests muscles of Rests muscles of respirationrespiration
– Improved oxygenationImproved oxygenation
DisadvantagesDisadvantages– Not synchronizedNot synchronized
– Inappropriate triggering Inappropriate triggering may may excessive minute excessive minute ventilationventilation
– Change in lung compliance Change in lung compliance or resistance or resistance change in change in tidal volumetidal volume
– Often requires sedationOften requires sedation
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Pressure supportPressure support
NomenclatureNomenclature– Inspiratory assistInspiratory assist– Assisted spontaneous breathingAssisted spontaneous breathing
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Pressure supportPressure support
PEEP
PS above PEEP
Pre
ssu
reFl
ow
Volu
me
Maximum inspiratory
flowSet % of maxinspiratory flow
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Pressure supportPressure support
AdvantagesAdvantages– Simple to setSimple to set– Avoids high inspiratory Avoids high inspiratory
pressurespressures– Better patient-Better patient-
ventilator synchronyventilator synchrony– Unloads respiratory Unloads respiratory
musclesmuscles
DisadvantagesDisadvantages– No apnoea back-up in No apnoea back-up in
older ventilatorsolder ventilators
– Change in lung Change in lung compliance or compliance or resistance resistance change in change in tidal volumetidal volume
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Pressure supportPressure support
Pressure support of 3.5-14.5 cmHPressure support of 3.5-14.5 cmH22O O required to overcome the additional work required to overcome the additional work of breathing due to breathing through ETT of breathing due to breathing through ETT and demand valveand demand valve
Patients who require pressure support of < Patients who require pressure support of < 6 cmH6 cmH22O can probably be extubatedO can probably be extubated
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SIMV (& pressure support)SIMV (& pressure support)
SIMV almost always combined with SIMV almost always combined with pressure supportpressure support
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SIMVSIMV
Patient receives a minimum number of Patient receives a minimum number of mandatory breathsmandatory breaths
Able to breath in between these breathsAble to breath in between these breaths– ± pressure support breaths± pressure support breaths
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SIMVSIMV
Pressure
Flow
PEEP
Time
Trig Trig
Time
Mandatory breath
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SIMVSIMV
Pressure
Flow
PEEP
Time
Trig Trig
Time
Pressure support breath
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Mandatory breathsMandatory breaths
Volume control breathsVolume control breaths– Set tidal volumeSet tidal volume
Pressure control breathsPressure control breaths– Set pressureSet pressure
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Mandatory breathsMandatory breaths
Synchronized with patients inspiratory Synchronized with patients inspiratory effortsefforts
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TriggeringTriggering
Effect of triggering depends on its timingEffect of triggering depends on its timing– Close to time that a mandatory breath is due Close to time that a mandatory breath is due
(during SIMV period)(during SIMV period) ⇒⇒synchronized mandatory breathsynchronized mandatory breath
– Other times (during spontaneous period)Other times (during spontaneous period) ⇒⇒pressure support breathpressure support breath
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SIMV period
T T
Spontaneous period
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SIMV period Spontaneous period
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SettingsSettings
FFiiOO22
SIMV rateSIMV rate– =mandatory breath rate=mandatory breath rate
SIMV period (some ventilators)SIMV period (some ventilators) Tidal volume (or inspiratory pressure)Tidal volume (or inspiratory pressure) I:E ratioI:E ratio Pressure supportPressure support PEEPPEEP
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Volume controlVolume control
SetSet– Minimum respiratory rateMinimum respiratory rate– Tidal volumeTidal volume– Inspiratory time or I:E ratioInspiratory time or I:E ratio
Directly/indirectlyDirectly/indirectly
– Inspiratory pause timeInspiratory pause time Directly/indirectlyDirectly/indirectly
– PEEPPEEP
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SIMV & PSSIMV & PS
AdvantagesAdvantages– Better patient-Better patient-
ventilator synchronyventilator synchrony
– Guaranteed minimum Guaranteed minimum minute ventilationminute ventilation
DisadvantagesDisadvantages– Complicated modeComplicated mode
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What mode?What mode?
Largely apnoeic patientLargely apnoeic patient– Control of minute ventilation importantControl of minute ventilation important
Assist controlAssist control
– Control of peak pressure importantControl of peak pressure important Pressure controlPressure control
Intermittent spontaneous breathsIntermittent spontaneous breaths– SIMVSIMV
Regular spontaneous breaths, improving conditionRegular spontaneous breaths, improving condition– Pressure supportPressure support
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Case ACase A
60 kg male60 kg male Post operative – complicated wipel Post operative – complicated wipel
procedureprocedure No previous lung or heart diseaseNo previous lung or heart disease Still paralyzedStill paralyzed
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54
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
!
12-25 15:32
Charles Gomersall 2003
ModeVolume Control
AutomodeAdmitpatient
Nebulizer Status
Additionalvalues
Set ventilation mode Volume control Automode
Ti =1.33 s (33%)
Tidal volume
500
Resp. Rate
12
PEEP
5
O2 conc.
100
I:E
1:2.0
T. pause
10
T. Insp. rise
5
Trigger sensitivity
V
Basic I:E Trigger
.
Cancel Accept
.
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AssessAssess
Chest movementChest movement Breath soundsBreath sounds SaturationSaturation
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pH 7.23
PaCO2 8.1 kPa (61 mmHg)
PaO2 54.9 kPa (413 mmHg)
HCO3- 26 mmol/l
Base excess +3
Saturation 100%
)V-(V xRR nventilatio Alveolar DT
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Increasing alveolar ventilationIncreasing alveolar ventilation
Increase tidal volumeIncrease tidal volume
Increase respiratory rateIncrease respiratory rate– Increase risk of gas trappingIncrease risk of gas trapping
Flow x resistance(Volume/compliance) + PEEP
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58
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
!
12-25 15:32
Charles Gomersall 2003
ModeVolume Control
AutomodeAdmitpatient
Nebulizer Status
Additionalvalues
Basic I:E Trigger
.Additionalsettings
700 ml
-70
70 l/min
50 cmH2O
RecordingPpeak
Pplat
Pmean
PEEP
RR
O2
Vee
I:E
MVe
MVi
VTi
VTe
34
28
12
5
12
100
0
1:2.0
6.0
6.1
501
471
Moderately high Pplat
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59
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
!
12-25 15:32
Charles Gomersall 2003
ModeVolume Control
AutomodeAdmitpatient
Nebulizer Status
Additionalvalues
Set ventilation mode Volume control Automode
Ti =1.33 s (33%)
Tidal volume
500
Resp. Rate
15
PEEP
5
O2 conc.
50
I:E
1:2.0
T. pause
10
T. Insp. rise
5
Trigger sensitivity
V
Basic I:E Trigger
.
Cancel Accept
.
Resp rate
FiO2
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Case ACase A
Patient starts to wake upPatient starts to wake up Triggering ventilator frequentlyTriggering ventilator frequently
– some breath stackingsome breath stacking Change to pressure support modeChange to pressure support mode
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61
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
!
12-25 15:32
Charles Gomersall 2003
ModeVolume Control
AutomodeAdmitpatient
Nebulizer Status
Additionalvalues
Set ventilation mode Pressure support
PS above PEEP
15
PEEP
5
O2 conc.
40
T. Insp. rise
5
Insp. cycle off
5
Trigger sensitivity
V
Basic I:E Trigger
.
Cancel Accept
.
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Other settingsOther settings
Trigger sensitivityTrigger sensitivity sensitivity preferablesensitivity preferable
Flow triggering generally more sensitive than Flow triggering generally more sensitive than pressure triggeringpressure triggering
flow or flow or pressure pressure sensitivity sensitivity
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AssessAssess
Chest movementChest movement Respiratory rate & effortRespiratory rate & effort SaturationSaturation
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Respiratory rateRespiratory rate Tidal volumeTidal volume SynchronySynchrony Blood gasesBlood gases
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
ModeVolume Control
AutomodeAdmitpatient
Nebulizer Status
.
40
AssessAssess Ppeak (cmH2O)
2040
Pmean 12PEEP
RR (b/min)
O2 (%)46
MVe (l/min)
7.18.5
VTi 701VTe 693
Additionalsettings
Additionalvalues
5
10
34
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Case BCase B
72 year old, 60 kg man with history of 72 year old, 60 kg man with history of asthmaasthma
Presents with severe bilateral pneumoniaPresents with severe bilateral pneumonia
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Pressure control modePressure control mode FiOFiO22 1.0 1.0
Insp pressure 10 above PEEP 5Insp pressure 10 above PEEP 5 RR 20RR 20 I:E= 1:2I:E= 1:2
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
ModePressure Control
AutomodeAdmitpatient
Nebulizer Status
.
100
Case BCase B Ppeak (cmH2O)
1540
Pmean 12PEEP
RR (b/min)
O2 (%)100
MVe (l/min)
4.18.5
VTi 201VTe 193
Additionalsettings
Additionalvalues
5
20
94
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Pressure control modePressure control mode FiOFiO22 0.6 0.6
Insp pressure 20 above PEEP 5Insp pressure 20 above PEEP 5 RR 20RR 20 I:E= 1:2I:E= 1:2
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
ModePressure Control
AutomodeAdmitpatient
Nebulizer Status
.
60
Case BCase B Ppeak (cmH2O)
2540
Pmean 12PEEP
RR (b/min)
O2 (%)66
MVe (l/min)
8.18.5
VTi 501VTe 493
Additionalsettings
Additionalvalues
5
20
54
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Case BCase B
pH 7.43
PaCO2 5.1 kPa (38 mmHg)
PaO2 6.9 kPa (52 mmHg)
HCO3- 22 mmol/l
Base excess
-2
Saturation 84%
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Look for causes of desaturationLook for causes of desaturation
Chest movementChest movement Breath soundsBreath sounds Ventilator malfunctionVentilator malfunction CXRCXR
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Options ?Options ? FiOFiO22
inspiratory pressure inspiratory pressure inspiratory timeinspiratory time PEEPPEEP
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
ModePressure Control
AutomodeAdmitpatient
Nebulizer Status
.
60
Improving oxygenationImproving oxygenation Ppeak (cmH2O)
2540
Pmean 12PEEP
RR (b/min)
O2 (%)66
MVe (l/min)
8.18.5
VTi 501VTe 493
Additionalsettings
Additionalvalues
5
20
54
Mean alv pre
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Options ?Options ? FiOFiO22
inspiratory pressureinspiratory pressure inspiratory timeinspiratory time PEEPPEEP
Startbreath
O2
breathsExp.hold
Insp.hold
Mainscreen
Menu
Quickstart
Alarmprofile
Save Trends
i
ModePressure Control
AutomodeAdmitpatient
Nebulizer Status
.
60
Improving oxygenationImproving oxygenationPpeak (cmH2O)
2540
Pmean 12PEEP
RR (b/min)
O2 (%)66
MVe (l/min)
8.18.5
VTi 501VTe 493
Additionalsettings
Additionalvalues
5
20
54
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Re-assessRe-assess
Pulse oximetryPulse oximetry Arterial blood gasArterial blood gas
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SummarySummary
Chose the mode that fits the patientChose the mode that fits the patient Set the ventilator to achieve your aimsSet the ventilator to achieve your aims Often more than one way to achieve your Often more than one way to achieve your
aimsaims– Select the method with the least adverse effectsSelect the method with the least adverse effects
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Thank You