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PITFALLS WITHPITFALLS WITH
MECHANICALMECHANICAL
Prof David V. Tuxen Prof David V. Tuxen Dept of Intens Care & Hyperbaric MedDept of Intens Care & Hyperbaric Med
The Alfred HospitalThe Alfred Hospital
he "passed away from an asthma attack" on Monday after paramedics worked to revive him for 50 minutes
Thunderstorm Asthma1. Jul 1983: Birmingham, England2. Nov 1987: Melb, Australia3. Nov 1989: Melb, Australia4. Jul 1994: London, England5. Oct 1997: Wagga Wagga, Australia6. Jun 2004: Naples, Italy7. Nov 2010: Melb, Australia8. Nov 2013: Ahvaz, Iran9. Nov 2016: Melb, Australia10.Dec 2016: Kuwait
Nov 2016: Melb, Australia>8500 ED presents 9 deaths – HC F 20 31 min OM M 18 15died in amb MP M 35
CL M - 70SL M 49
PITFALL 1Patient severe asthma required intubation and mech vent
(FIO2 0.5, RR 18, Vt 700 ml, PaO2 105, PaCO2 55, pH 7.23, Bic 22)
→ BP↓ 80 (CVP 16) → Fluid fill → BP↓ 95 (CVP 18) → Inotropes
What is the problem?
1.Hypovolaemia
2.Pneumothorax
3.Respiratory tamponade
4.LRTI with septic shock
5.Unsuspected cardiac disease
DYNAMIC HYPERINFLATION
GAS TRAPPING
LUNG
VOL.
(L)
Te
Vt
Vei
Normal/Stiff lungs
Obstructed lungs
Vtr
Tuxen & Oh. In Intensive Care Manual1989;192-201
SPONT vs MECH VENTILATION
Tuxen ARRD 1992;146:1136-42Tuxen ARRD 1987; 136: 872-9Spont Ventilation
NORMAL TLC
0
1
2
3
4
5
6
7
8
LUNGVOLUME
(L)
NORMAL FRC
Mech Ventilation
Dynamic HI Apnoea Tidal V.
FRC
Vtr
VT
Auto-PEEP
Pepe & Marini,ARRD 1982;126: 166
EFFECTS
of VE,
VT & R
Tuxen & Lane.Am Rev Respir Dis1987; 136: 872-879
(cm H2O)
10 16 26
0
1
2
3
4V TV EE
VEI
PIP
Pplat
LUNGVOL(L)
FRC
0
20
40
60
80
100
VT
VEVI
0.6 1.0
100
1.6 0.6 1.0
100
1.6 0.6 1.0
100
1.6
ACUTE SEVERE ASTHMA
Ve REQUIREDfor normal PaCO2/pH:
10-25 L/min
Ve SAFEfor VEI < 20ml/kg:
115 ml/kg/min(8 L/min)
HYPOTENSION in mostPNEUMOTHORAX in some >1/3 of MV MORTALITY
HYPOTENSION in mostPNEUMOTHORAX in some >1/3 of MV MORTALITY
PaCO2 50-90 , pH 7.0-7.3BUT NO HYPOTENSION PNEUMOTHORAX MORTALITY
PaCO2 50-90 , pH 7.0-7.3BUT NO HYPOTENSION PNEUMOTHORAX MORTALITY
ASTHMA - VENTILATOR Mx
1. SEDATE & minimal PARALYSE (NMBA)
2. HYPOVENTILATE: VE 115 ml/min/kg, VT <8 ml/kg, R 10-12 VI 80-100 L/min or Te ≥ 4 sec
3. ASSESS DHI (VEI, Pplat, PEEPi ), BP in apnea, blood gases
4. ADJUST VENTILATION BASED ON DHI (not PaCO2 / pH)
(DHI↑ → reduce rate, DHI↓ → increase R)Tuxen. ARRD1992;146 (5): 1136
Same patient, severe asthma, heavy sedation, and ventilated
FIO2 0.4, RR 12, VT 600 ml, VI 80 L/min PaO2 90, PaCO2 60, pH 7.23, Bic 24
BP 110, HR 95, CVP 8, Pplat 25, PEEPi 10
Nursing complain - repeated high pressure alarm (P limit 50 cmH20)
RMO - good air entry both sides, transient P limit ↑ → PIP 58 cmH20
RMO reduces VI to 40 L/min → PIP↓ 40 cmH20 → alarm stops. Calls you.
What should you do 1. Well done! (back to sleep)2. CXR3. VI back to 80 & ↑ PIP limit4. Restore VI to 80 & ↓ RR5. Other
PITFALL 2
EFFECTSEFFECTS
of Vof VEE &V &VII
Tuxen & LaneARRD1987; 136: 872
0
20
40
60
80
PIP
(cm H2O)
Pplat
LUNG
VOL
(L)
0
1
2
3
4VT
VEEVEI
FRCV I
V E
100 70
10
40 100 70
16
40 100 70
26
40
PITFALL 328 yo ♀ admit severe asthma - 2/7 slow improve on neb salbut & IV H’cort
Then deteriorates with increasing dyspnoea & wheeze
RR↑ 28 → 40, PEF↓ 120 → 80, PaO2 75, PaCO2 40, pH 7.42, Bic 25
Rx - contin neb salbut, aminophylline bolus+ 40 mg/hr, IV salbutamol 12 mcg/min, & Tx to ICU.
4 hrs - increasing dyspnoea & distress, RR↑ 50, PEF 200, Chest - minimal wheezeGases: FIO2 0.4, PaO2 85, PaCO2 30, pH 7.36, Bic 16
What is going on?
LACTIC ACIDOSIS
Asthma + IV Salbutamol → LACTIC ACID IN 70 %
Se Lact 5.5 ± 2.5 (2-12)
2 Patterns Ambulance Salb. Bolus (500-750mcg /15-30min)
Hospital Salb. Infus (5-20 mcg/min)
Management Bolus <500 mcg, infus <10 mcg/min
Measure lactate if Bic <22 or decrease >2
Reduce or cease IV Salb. if lact too high
PITFALL 4
A 56 yo female with severe acute on chronic asthma required prolonged MV including high dose asthma Rx and 4 days paralysis.
After 10 days MV, airflow improved considerably BUT patient incapable of weaning - tachypnea & hypercapnia.
O/E: Severe limb weakness, hyporeflexia, sensation intact
What has happened??
Normal MuscleNormal Muscle
Necrotising MyopathyNecrotising Myopathy
EFFECTS OF VENTILATORY STRATEGIES
AdrenalineVentolin (ETT)PancuroniumAdrenaline x 2Bicarb (25 meq)Ca Gluconate
PITFALL 536 yo F - rapid asthma deterioration - emergency intubation & ventilation Vt 600 ml, R 12-14 /min
5 min - P 113, BP unrecordable, ECM commenced
15 min - pH 7.08, PCO2 96, PO2 36, Sat 46%, Bic 27 ECG 60 SR, pulseless, cyanosed, FD pupils, neck veins distended Pericardial tap unrewarding, CXR - no pneumo
25 min - ECM ceased
30 min - HR 120, BP 110, neck viens down
33 min - Re-ventilated : Vt 600 ml, R6-8 /min pH 7.04, PCO2 91, PO2 396, Sat 100%, Bic 27 Pupils reacting, BP maintained. Rosengarten, Tuxen. Anaes & Int Care 1990;19:118
SEVERE HYPOTENSION / EMD
Almost always due to excessive dynamic hyperinflation(May have secondary tension pneumothoraces)
Best management
1. Apnea test
2. Profound hypoventilation (RR 4-6)
3. Colloid fluid loading
MOST DIFFICULT MECH VENT
Eg Hypotension,high PIP despite RR<6, PaCO2 >100, pH <7.00
1. Adenaline, Mg, Ketamine
2. Bicarb, fluid load & more hypoventilation
3. Heliox (50:50)
4. Inhalational anaesthetic (halothane or isofluorane)
5. ECMO (should not be needed)
PITFALL 6
33 yo, 67 kg female with severe asthma – sedated, paralysed & MVRR 12, VT 600 ml, VI 80 L/minFIO2 0.4, PaO2 90, PaCO2 60, pH 7.23, Bic 24
MV stable then: PIP/Pplat↑ 35/20 → 48/33, BP↓105 → 90 , HR↑ 100 → 140O/E Reduced air entry on left, trachea ? shifted to right
What is the most appropriate 1st action (1 only) 1. Reduce RR 2. Urgent CXR3. Inotropes 4. Blind ICC(s)5. Colloid fluid loading 6. IC Jelco
ASTHMA CXR
PNEUMOTHORAX
CAUSES - DHI, CVC, Jelco’s (spontaneous is rare)
EFFECTS - PROPENSITY FOR TENSION due to AO→ Ipsilateral VE↓ → Contralateral VE↑→ Contralateral DHI↑ → RISK B/L PNEUM ↑
MANAGEMENT – Suspected → Reduce RR + urgent CXRSevere BP↓ → BLIND ICCALL ICC’s - BLUNT INSERTION
PNEUMOTHORAX
Most commonly due to excessive dynamic hyperinflation or CVC
Best management when clinically suspected 1. Reduce RR (protect 2nd lung)
2. No intercostal needles (unless in extremis)
3. Urgent CXR
4. Intercostal catheter with blunt dissection
Severe hypotension – urgent ICC (with blunt dissection)
CONCLUSION - Asthma MV
1. DHI – VE <8L/min, low Vt, High VI (↓Ti)
2. Accept high PIP (short Ti) – Pplat<25
3. Avoid Lactic acidosis – salbutamol dose
4. Avoid myopathy – minimize NMBA. Steroid Mx
5. Pneumothorax – reduce RR, avoid needles if poss
6. Hypotens/EMD – Apnea test, RR 4-6