Category Archives: Respiratory

Mechanical Ventilation – Basic to Advanced (Masterclass)

Talks

  • Controlled MV settings: basics
  • How to assess respiratory mechanics at the bedside
  • Strategies to set PEEP and to achieve lung recruitment

Revisiting the basics of mechanical ventilation with a nice quiz at the end…

Highly recommend https://www.youtube.com/youvent   – great (free), short videos on mechanical ventilation

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Recruitment Manoeuvres: 3 ways of doing it ….

  • sustained inflation
  • pressure controlled ventilation
  • incremental (decremental) PEEP trial

The ART trial highlighted the potential dangerous of recruitment manoeuvres. It’s effect may be dependant on determining which patients have recruitable lungs in the first place….

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@luigi_ICM  suggests that an assessment of potential lung recruitability MUST be performed prior to RM.

 

Do you know your respiratory mechanics equation??

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Master Class: Beyond BASIC mechanical ventilation: From the essentials to advanced respiratory support #EuAsia18

The twitter feed can be found here

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The physiology of ARF

Consideration of oxygenation and ventilation as separate components

Effects of MV

  • Increase VA/Q
  • Decrease elastic workload
  • Decrease resistive workload

Acute Respiratory Distress Syndrome: Advances in Diagnosis and Treatment (2018) – https://www.ncbi.nlm.nih.gov/pubmed/29466596

Comparison of definitions – https://www.ncbi.nlm.nih.gov/pubmed/23370917

Phases of ARDS

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The principles of controlled mechanical ventilation

Ventilator detects flow and pressure (sensors)

P(open alveolar) = P(resistance of the airway) + P(elastic resistance of the alveoli)

Modes – volume vs pressure (hybrid = pressure regulated volume controlled ventilation)

Volume controlled ventilation

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Pressure drop between peak and plateau pressure is reflective of airway resistance

Pressure controlled ventilation

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Which mode of ventilation is ‘better’ does not matter as there is no difference in plateau pressure BUT could/should square vs decelerated flow (may contribute to a difference)

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Hybrid modes may have share the benefits of both (constant Vt + decelerated flow)

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EXCELLENT RESOUCE – https://www.youtube.com/youvent

 

The correct strategy for ARDS

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The standard of care of patients with ARDS: ventilatory settings and rescue therapies for refractory hypoxemia – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4828494/

Higher vs lower positive end-expiratory pressure in patients with acute lung injury and acute respiratory distress syndrome: systematic review and meta-analysis – https://www.ncbi.nlm.nih.gov/pubmed/20197533

Open Lung Approach for the Acute Respiratory Distress Syndrome: A Pilot, Randomized Controlled Trial. https://www.ncbi.nlm.nih.gov/pubmed/26672923

There was a discussion on Stress/Strain which I admit I don’t consider regularly…..

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Support therapy in ARDS

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Aetiologies, diagnostic work-up and outcomes of acute respiratory distress syndrome with no common risk factor: a prospective multicentre study: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5476531/

Daily Sedation Interruption in Mechanically Ventilated Critically Ill Patients Cared for With a Sedation Protocol: A Randomized Controlled Trial: https://jamanetwork.com/journals/jama/fullarticle/1380160

Sedation summary

  • Keep pt awake/light
  • If deep sedation required – avoid benzos
  • Protocol-based

Volatile sedation in the intensive care unit: A systematic review and meta-analysis https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5728884/

Proning – http://www.nejm.org/doi/pdf/10.1056/NEJMoa1214103

 

Steroids and other adjuvant therapies

Effect of Prolonged Methylprednisolone Therapy in Unresolving Acute Respiratory Distress Syndrome: A Randomized Controlled Trial: https://jamanetwork.com/journals/jama/fullarticle/187709

Exploring the heterogeneity of effects of corticosteroids on acute respiratory distress syndrome: a systematic review and meta-analysis. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4056095/

Prolonged glucocorticoid treatment is associated with improved ARDS outcomes: analysis of individual patients’ data from four randomized trials and trial-level meta-analysis of the updated literature http://icmjournal.esicm.org/journals/abstract.html?v=0&j=134&i=0&a=4095_10.1007_s00134-015-4095-4&doi=

Salbutamol: Inhalation therapies in acute respiratory distress syndrome – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5537120/

Surfactant: Exogenous natural surfactant for treatment of acute lung injury and the acute respiratory distress syndrome. https://www.ncbi.nlm.nih.gov/pubmed/19713451

NAC: Effects of N-acetylcysteine treatment in acute respiratory distress syndrome: A meta-analysis  –https://www.ncbi.nlm.nih.gov/m/pubmed/28928799/

New(ish)

  • Neutrophil esterase inhibitors
  • Granulocyte macrophage CSF
  • Interferon
  • Stem cells

ARDS: challenges in patient care and frontiers in research: http://err.ersjournals.com/content/27/147/170107

 

 

 

EDIC 1 refresher course: Respiratory and airways management #LIVES2017

The second session to prepare for the EDIC exam was the B of ABC (breathing!)

First the “Australian in Vienna” Associate Prof Corke talked through NIV and high flow – an innovation we’re seeing more and more of across ICUs and indeed the rest of the hospital (?and beyond) See twitter thread for more detail:

Then followed a great talk from Gavin Joint – how to manage a patient that doesn’t wean quickly from mechanical ventilation? – Again detail in this twitter thread:

Claude Guérin then performed a run through of ARDS – what it is, what treatments are available:

Then the session closed with a talk on managing minute volume in COPD and a set of interactive MCQs – for which you have to be here to use the app and vote and practice!  Great prep for an exam, and a good basis for the next few days of more cutting edge talks.