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Mechanical Ventilation Strategies and Considerations in Respiratory Failure, Exams of Medical Sciences

The University of Texas Medical BranchMedical Sciences

A comprehensive overview of the key concepts and recommendations related to mechanical ventilation in patients with respiratory failure. It covers a wide range of topics, including the causes and management of respiratory failure, the use of neuromuscular blocking agents, sedation strategies, spontaneous breathing trials, ventilation modes, extubation criteria, and specific considerations for patients with ards and covid-19. The document delves into the rationale and evidence behind various ventilation interventions, highlighting the importance of individualized approaches to optimize patient outcomes. It serves as a valuable resource for healthcare professionals involved in the management of critically ill patients requiring mechanical ventilation.

Typology: Exams

2023/2024

Available from 08/27/2024

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D&M 3: Module 5: mech vent
Type 1 respiratory failure - correct answer Acute hypoxemic respiratory failure
Occurs with alveolar flooding and subsequent ventilation-perfusion mismatch and intrapulmonary
shunt physiology
Flooding may be due to pulmonary edema, lung injury, pneumonia, or alveolar hemorrhage
Syndrome defined by an acute onset of <1 week of bilateral opacities on chest imaging, not fully
explained by cardiac failure or fluid overload
-characterized as V/Q shunt mismatch requiring PEEP
History of mechanical ventilation of ARDS and lung injury overview - correct answer May
propagate lung injury, repeated stretching and overdistention of injured alveoli and further worsen
injury
-termed ventilator induced volutrauma
Led to a multicenter RCT for ventilation strategies
-12ml/kg IBW vs 6 ml/kg IBW
Study showed a decreased mortality for low tidal voluem group
Type II respiratory failure - correct answer Hypercapneic respiratory failure
Consequence of alveolar hypoventilation and inability to eliminate CO2 effectively
Mechanisms
-impaired CNS drive to breathe
-impaired strength with failure of neuromuscular function
-increased loads on the respiratory system
Causes of diminished CNS drive to breathe - correct answer Drug overdose
Brainstem injury
Sleep-disordered breathing system
Severe hypothyroidism
Causes of reduced reduced respiratory strength due to neuromuscular transmission - correct
answer Mysathenia gravis
Guillan barre
amyotrophic lateral sclerosis
pf3
pf4
pf5
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D&M 3: Module 5: mech vent

Type 1 respiratory failure - correct answer Acute hypoxemic respiratory failure Occurs with alveolar flooding and subsequent ventilation-perfusion mismatch and intrapulmonary shunt physiology Flooding may be due to pulmonary edema, lung injury, pneumonia, or alveolar hemorrhage Syndrome defined by an acute onset of <1 week of bilateral opacities on chest imaging, not fully explained by cardiac failure or fluid overload

  • characterized as V/Q shunt mismatch requiring PEEP History of mechanical ventilation of ARDS and lung injury overview - correct answer May propagate lung injury, repeated stretching and overdistention of injured alveoli and further worsen injury
  • termed ventilator induced volutrauma Led to a multicenter RCT for ventilation strategies
  • 12ml/kg IBW vs 6 ml/kg IBW Study showed a decreased mortality for low tidal voluem group Type II respiratory failure - correct answer Hypercapneic respiratory failure Consequence of alveolar hypoventilation and inability to eliminate CO2 effectively Mechanisms
  • impaired CNS drive to breathe
  • impaired strength with failure of neuromuscular function
  • increased loads on the respiratory system Causes of diminished CNS drive to breathe - correct answer Drug overdose Brainstem injury Sleep-disordered breathing system Severe hypothyroidism Causes of reduced reduced respiratory strength due to neuromuscular transmission - correct answer Mysathenia gravis Guillan barre amyotrophic lateral sclerosis

Causes of respiratory muscle weakness - correct answer Myopathies Electrolyte derangements Fatigue Respiratory system load classifications - correct answer Resistive loads

  • ie. bronchospasms Reduced lung compliance
  • alveolar edema, atelectasis, intrinsic PEEP Reduced chest wall compliance
  • pneumothorax, pleural effusion, abdominal distention Decreased minute ventilation
  • sepsis, PE with increased dead space Mainstays of therapy for hypercapneic respiratory failure - correct answer Directed at reversing underlying causes of ventilatory failure Avoiding intubation in some patients, NIPPV if possible Type III respiratory failure - correct answer Atelectasis Most commonly referred to as postoperative respiratory failure due to it commonly occuring postop Treatment includes chest PT, frequent changes in position, upright positioning, pain control Type IV respiratory failure - correct answer Metabolic demands Most often occurs due to hypoperfusion of respiratory muscles in shock Respiratory muscles consume <5% of cardiac output In patients with shock, respiratory muscles may consume up to 40% of cardiac output
  • due to redistribution secondary to pulmonary edema, lactic acidosis, and/or anemia Intubation and mechanical ventilation can allow redistribution of cardiac output to other vital organs

Most AC modes are in volume control, where the operator sets a specific tidal volume and respiratory rate, PEEP, and FiO

  • inspiratory flow rate is set Can be pressure controlled
  • Resulting tidal volume varies based on lung compliance
  • Tidal volume/minute volume must be monitored as there is no assurance of delivery PCV is often used to limit peak airway and lung distending pressures in conditions where high pressures can cause harm such as ARDS or after thoracic surgery Pressure support ventilation - correct answer Similar to PCV, except there is no mandatory ventilation or set mechanical rate
  • ventilator support is entirely patient triggered and controlled Clinicians set the FiO2, PEEP, and inspiratory pressure Mostly used for patients transitioning off of mechanical ventilation Important criteria for indicating a patient may be ready for extubation - correct answer Underlying disease process has improved Awake and largely off sedatives FiO2 < 50% PEEP < SaO2 >88% Stable hemodynamics Manageable respiratory secretions and cough If met, SBT can follow Spontaneous breathing trial procedure - correct answer Positive pressure is set to a minimum to compensate for ET tube resistance
  • 5 - 7 Patient breaths spontaneously for 30-120 minutes Passing an SBT has >70% liklihood of successful extubation Risk factors for failing SBT - correct answer Age > CHF

COPD

APACHE >

BMI >

Significant secretions

2 comorbidities 7 days on mech vent Patients with these risk factors can be transitioned on NIPPV or highflow nasal cannula Indications for mechanical ventilation - correct answer RR > Reduced max inspiratory pressure or vital capacity Minutes ventilation <3 or > PaO2 < 55 PaCO2 > 55 AaDO2 on 100% FiO2 > 450 Low Rox index Hacor score Initial SBT recommendations in acutely hospitalized patients on mechanical ventilation for more than 24 hours (Mechanical vent liberation recs) - correct answer Should begin with pressure support of at least 5-8 cm/H2O vs without

  • ie. T-piece or CPAP Sedation recommendations in acutely hospitalized patients on mechanical ventilation for >24 hours (Mechanical vent liberation recs) - correct answer Protocols to minimize sedation in these patients is recommended Recommendations for extubation of high risk patients who have received mechanical ventilation for >24 hours and have passed a SBT (Mechanical vent liberation recs) - correct answer Recommended to extubate to NIV
  • ie. high flow nasal cannula High risk patients include those with hypercapnic respiratory failure, COPD, CHF, or other serious comorbidities Should acutely hospitalized adults who have been mechanically ventilated for more than 24 hours be subjected to protocolized rehabilitation directed toward early mobilization or noprotocolized attempts at early mobilization? - correct answer Recommended to provide protocolized rehabilitation directed at early mobilization to decrease mechanical ventilation days and increase the liklihood of ambulation at discharge

Has been shown to increase undesirable outcomes including significantly higher mortality Conditional recommendations for mechanical ventilation interventions in patients with ARDS - correct answer High PEEP in patients with moderate-severe ARDS Recruitment maneuvers in patients with moderate-severe ARDS Additional evidence is required for the use of extracorporeal membrane oxygenation in severe ARDS High vs lower PEEP in ARDS patients - correct answer High PEEP may improve alveolar recruitement, reduce stress/strain, and reduce atelectrauma However, places patient at high risk for overdistention, increased shunt, and higher pulmonary vascular resistance leading to cor pulmonale Evidence

  • Best method for setting PEEP is uncertain when adjusting to oxygenation
  • Alternative strategies include titrating PEEP to plateau pressures Should patients with ARDS receive recruitment maneuvers? - correct answer Rationale
  • increased lung weight from alveolar edema
  • atelectasis exacerbates lung injury during mech vent due to reduced size of lung available to ventilation
  • stress is induced in alveolar units due to cyclical tidal recruitment/derecruitment Higher PEEP and RMs can reduce atelectasis and increase end-expiratory lung volumes
  • intended effect is to open collapsed lung and increase participating alveolar units Evidence
  • RMs have been shown to be significantly associated with lower mortality and higher oxygenation Suggested for conditional recommendation to provide recruitment maneuvers in ARDS patients ECMO recommendations in ARDS patients - correct answer Limited evidence Trials to date have found no significant differences in mortality Additional evidence i required to make a definitive recommendation for the use of ECMO

There are additional studies underway for ECMO internationally as well as studies evaluating the effects of ECCO2R in combination with lower tidal volumes and the effect on severe ARDS Goals of oxygenation in patients with COVID on mechanical ventilation - correct answer 92-96%

  • <92% and >96% are associated with harmful adverse effects Patients with darker skin pigmentation may be subject to occult hypoxemia (<88%) despite SPO

92% Darker skin pigmentation and hypoxia - correct answer Patients with darker skin pigmentation may be subject to occult hypoxemia (<88%) despite SPO2 >92% transcutaneously COVID 19 and non-mechanical ventilation - correct answer HFNC

  • Recommended to begin oxygen therapy with HFNC in COVID 19 patients with hypoxemic respiratory failure who do not have an indication for endotracheal intubation If failing HFNC, NIVPPV can be used
  • not preferential due to aerosolizing nature of BiPAP Awake prone positioning in non-mechanically ventilated COVID patients - correct answer Trial recommended in patients who do not meet criteria for intubation with HFNC
  • may improve oxygenation and prevent the patient from progressing to requiring intubation Not recommended for refractory hypoxemia in patients who otherwise have indications for intubation
  • should not be used as a substitute for intubation/mechanical ventilation General mechanical ventilation considerations in COVID patients - correct answer Low tidal volume ventilation
  • ie. 4-8 ml/kg predicted body weight Targeting plateau pressures to <30 cm/H2O Conservative fluid strategy over liberal Recommended to NOT use inhaled nitric oxide PEEP and prone positioning in COVID patients with moderate-severe ARDS - correct answer Recommended to use a higher PEEP strategy over lower In patients with refractory hypoxemia, prone positioning 12-16 hours a day is recommended