Tuesday, September 7, 2010

Trouble shooting vents - to initiate

Managing your patient on a ventilator can be a big and at stressful task for someone starting their residency.....an intern! Eventhough it is easy to get help from the resident or the attending or the respiratory therapists....its better to go through some of the basic stuffs. We will try to keep this simple and easy to use .....especially with algorithms.So this is not going to be fully explanatory...but will serve the purpose.

Lets start with initiating ventilators.The first thing to be chosen is the mode of ventilation. The common mode used in most of the hospitals is assist control ventilation, whereby we set the desired tidal volume...and is delivered to the pt irrespective of whether the ventilator or the pt initiates the breath.
The parameters we determine (or we set on the ventilator) are
1. Tidal volume (usually around 8-10cc/kg or less in case of ARDS)
2. Respiratory rate (usually these pts were tachypneic before intubation..so start with 5-10breaths less than what they were doing...and then titrate)
3. FiO2 - start with 100% FiO2
4. Positive end expiratory pressure(PEEP) - start with 5 cm of H2O

Common types of waveforms that you may want for your patient when setting the ventilator- Square waveform( more exhalation time...useful for eaxmple in status asthmaticus) and decelerating waveform (useful in ARDS).

Now you have initiated the ventilation/oxygenation for the patient. Do a chest Xray immediately to look for ETT placement and expansion of both lungs (which you should have checked by auscultation beforehand)

Get an ABG in 15 - 30 min to determine if any change is needed with regards to the oxygenation(FiO2 & PEEP) or ventilation (Tidal volume & respiratory rate) or both. You are all set. Have a look at this nice algorithm from Cleveland clinic.(This is available in your Mass Gen hand book or Washington Manual).
Hope this helps...and we will discuss about some common issues in ventilator management, subsequently.


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