Ovid: Oxford Handbook Of Critical Care - Qums.ac.ir
Editors: Singer, Mervyn; Webb,Andrew R.Title: Oxford Handbook ofCritical Care, 2nd EditionCopyright 1997,2005 M. Singer andA. R. Webb
Ovid: Oxford Handbook of Critical ication%20Data/Mozilla/Firefox/Profiles/2.Ovid: Oxford Handbook of Critical CareEd itors:Si nge r, M ervyn; We bb, An dre w R.Ti tle : O xf ord Ha ndbook of Cr itic al Car e, 2nd Ed itionCop yri ght 1997,2005 M. Si nge r and A. R. W ebb , 1997, 2005. Publ i shed i n the Uni te d Stat es by Oxford Uni ve rsi tyPress Inc Tab le of Co n te n ts Resp ir a tor y T h e r ap y T ech n iq u e sRespiratory Therapy TechniquesOxygen therapyAl l cri t i call y i l l pat i ents shoul d re cei ve add i ti onal i ns pi red oxy gen on a ‘ more not l es s i s b est ’ p hi l os ophy.PrinciplesHi g h fl ow , hi gh conce ntrati on oxy gen shoul d b e g i ve n t o any acut el y dy spnoei c or hypoxaem i c pat i e nt unt i l acc urateti trati on c an be performed usi ng arteri al bl ood gas anal ysi s.In general, mai ntain SaO 2 90%, t hough pre ferabl y 95%. Compromi ses may ne ed to be made duri ng acut e onchroni c hyp oxae mi c re spi ratory fai l ure , or p rol ong ed sev ere AR DS, when l owe r v al ues may suffi ce provi d ed ti s sueoxy gen del i v ery i s maint ai ned.Al l p ati ent s p l ac ed on mec hani cal v ent i l a ti on s houl d i ni ti al l y rec ei v e a hi g h FIO 2 unti l ac curat e t i trati on i s pe rforme dusi ng arteri al bl ood gas anal ysi s.Apart from p ati ent s rec ei v i ng hy perbari c O 2 therapy (e.g . for carbon monox i de poi soni ng, di v i ng ac ci d ent s), there i sno nee d t o maint ai n s upranormal l eve l s of PaO 2 .CautionsA s mal l p rop orti on of pati ent s i n c hroni c Ty pe II (hy poxaemi c, hyp erc apni c ) re spi ratory fai l ure wi l l dev el op apnoea i fthe i r ce ntral hyp oxi c d ri v e i s removed by suppl emental ox yge n. How ever, t hi s i s s el d om (i f eve r) abrupt and a pe ri odof det eri orati on and i nc re asi ng drowsi nes s w i l l al ert me di cal and nurs i ng st aff to consi der ei the r (i ) FIO 2 red uct i on i fove ral l c ond i t i on al l ow s, (i i ) non-i nvasi ve or i nvasi ve m echani cal ve nti l a ti on i f fati gui ng or (i i i ) use of re spi rat orysti mul ants suc h as d oxep ram. T he corol l ary i s t hat cl ose supervi s i on and m oni tori ng i s nece ssary i n al l cri t i call y i l lpat i ents .A norm al pul se oxi met ry readi ng m ay obs cure d ete ri orat i ng g as exchang e and progre ssi ve hyp erc apni a.Oxy gen toxi c i ty i s de sc ri b ed i n ani mal model s. Normal vol untee rs wi l l b ecome sym ptomat i c aft er sev eral hours ofbre athi ng pure oxy gen. Furt hermore, was hout of ni trogen may l ead to mi croate l ec tas i s . Howev er, the rel e vance andrel at i ve i m portance of oxyg en toxi ci ty com pared to other forms of v ent i l a tor t rauma i n c ri ti c al l y i l l pati ent s i s s ti l l farfrom c l ear. Effort s s houl d nev ert hel ess be made to mi ni mi se FIO 2 whene ver pos si bl e . D ebate conti nues as to whe the rFIO 2 or othe r v ent i l ator s ett i ng s (e.g . PEEP, V T , i nsp i ratory p res sures ) s houl d be red uce d fi rs t. The authors' prese ntvi e w i s t o m i ni mi s e t he ri sks of venti l at or trauma.MonitoringAn oxy gen anal y ser i n the i nsp i ratory l i m b of the v ent i l ator or CPAP/Bi PAP ci rcui t confi rms the p ati ent i s re cei vi ng aknown FIO 2 . Mos t m ode rn vent i l ators hav e a bui l t -i n calib rati on d evi ce.Ade quacy and chang es i n art eri al oxy gen saturati on can be conti nuousl y m oni tored by pul se oxi met ry andi nt ermi t tent or c ont i nuous i nvas i ve bl ood gas anal ysi s.P.3Oxygen masksHuds on-typ e m ask s or nasal ‘ spe ctacl e s’ gi ve an i mpreci se FIO 2 and s houl d onl y b e used when hypoxae mi a i s nota major conce rn. Hudson-t ype mas ks do al l ow del i ve ry of humi di fi e d g as (e.g . v i a an ‘Aq uap ak’ ). Val ves fi tte d t othe Aq uapak s yst em do not del i v er an acc urate FIO 2 unl es s g as fl ow i s at t he rec omm ende d l eve l .Mask s fi tt ed wi t h a Ve nturi val ve del i v er a reasonab l y acc urate FIO 2 (0.24, 0.28, 0. 35, 0. 40, 0. 60) ex cep t i npati ents wi t h v ery hi gh i ns pi ratory fl ow rate s. The se mas ks do not al l ow del i ve ry of hum i di fi e d g as but arepre ferabl e i n t he s hort term for dys pnoe i c pat i e nts as they e nab l e more p rec i s e moni t ori ng of PaO 2 /F IO 2 rati os.A t i ght-fi tt i ng anaes the ti c mask and re servoi r b ag al l ows 100% oxyg en to be del i ve red .See also:Venti l at ory support— ind i c ati ons , p 4; Conti nuous pos i ti ve ai rway press ure , p 26; Bas i c res usc i t ati on, p270; Re spi ratoryfai l ure, p282P.4Ventilatory support—indicationsAcute ventilatory insufficiency1 из 25407.11.2006 1:04
Ovid: Oxford Handbook of Critical ication%20Data/Mozilla/Firefox/Profiles/2.Defi ne d b y an ac ut e ri se i n PaC O 2 and a si g ni fi c ant re spi rat ory ac i d osi s. PaCO 2 i s di re ctl y p rop ort i onal to the body' sCO 2 producti on and i nversel y p rop orti onal to al veol ar venti l at i on (m i nute venti l ati on mi nus dead s pac e v ent i l a ti on).Causes i ncl ude:Resp i ratory centre de pre ssi on, e. g. dep res sant d rug s or i ntrac rani al pathol og yPeri pheral neuromuscul ar di sease, e. g. Gui l l ai n–Barré sy ndrome , m yas the ni a gravi s or s pi nal cord pat hol ogyTherape uti c mus cl e paral ysi s, e.g . as p art of balanced anaest hes i a , for m anagem ent of tet anus or s tat usepi l ep ti c usLos s of chest wall i nteg ri t y, e.g . c hes t t rauma, di aphrag m rupt ureHi g h CO 2 p roduc ti on, e.g . b urns, sep si s or se vere agi t ati onReduced al veol ar ve nti l at i on, e .g. ai rway obst ruc ti on (ast hma, acut e b ronchi ti s, forei g n b ody), atel ect asi s,pneumoni a, pul monary oede ma (ARD S, cardi ac fai l ure), pl eural pat hol ogy , fi broti c l ung di se ase , ob esi tyPul monary vas cul ar di sease (pul monary em bol us, cardi ac fai l ure, AR DS)Oxygenation failureHyp oxaemi a i s d efi ned by PaO 2 11k Pa on F IO 2 0. 4. May be due to:Venti l ati on–perfus i on mi sm atc hi ng (red uce d ve nti l a ti on i n, or pre ferent i al pe rfusi on of, som e l ung areas ), e.g.pneumoni a, pul monary oede ma, pul monary vascul ar di se ase, ex tre mel y hi gh cardi ac out putShunt (normal pe rfusi on but abs ent ve nti l a ti on i n s ome l ung zones), e. g. pne umoni a , p ul m onary oede maDi ffus i on l i mi t ati on (re duc ed al v eol ar surfac e area wi th normal ve nti l at i on), e.g . e mphysem a; red uce d i nsp i redoxyg en tensi on, e.g . alti tud e, suffoc ati onAcute vent i l atory i ns uffi ci ency (as above)To reduce intracranial pressureRed uct i on of PaCO 2 to ap proxi m ate l y 4kPa cause s c ere bral v asoconstri c ti on and the refore re duc es i nt rac rani a lpre ss ure aft er brai n i njury. Rec ent st udi es sug ges t t hi s effec t i s t ransi ent and may i mpair an al read y c ri ti c al cerebralbl ood fl ow.To reduce work of breathingAs si s ted ve nti l at i on sed ati on and muscl e rel a xat i on re duc es res pi rat ory muscl e acti vi t y and thus t he work ofbre athi ng. In c ardi a c fai l ure or non-c ard i og eni c p ul m onary oed ema the re sul ti ng red uct i on i n my ocardi al oxy gendem and i s more eas i l y matched to t he sup pl y of ox yge n.P.5Indications for ventilatory supportVenti l at ory support (i nvas i ve or non-i nvas i v e) s houl d be consi d ered i f:Resp i ratory rat e 30/m i nVi t al cap aci ty 10–15ml /mi nPaO 2 11kPa on FIO 2 0. 4PaCO 2 hi g h wi th si gni fi c ant resp i ratory aci d osi s (e.g . p H 7.2)Vd/V T 60%Qs/Qt 15–20%Exhaust i onConfusi onSeve re shockSeve re LVFRai s ed ICPSee also:Dys pnoea, p278; Ai rway ob st ruc ti on, p280; R esp i ratory fai l ure, p282; Atel ect asi s and pul monary col l aps e, p 284;Chroni c airfl ow l i mi tat i on, p 286; Ac ut e chest i nfec ti on (1), p288; Acute che st i nfec ti on (2), p290; Acut e res pi ratorydi s tress sy ndrome (1), p 292; Acut e resp i ratory di s tre ss syndrome (2), p294; Ast hma—ge neral manage ment , p 296;As thm a—ve nti l a tory m anag eme nt, p298; Inhal ati on i nj ury , p 306; Pul monary e mbol us , p 308; He artfai l ure— ass ess ment, p324; Heart fail ure —manag ement, p326; Acute l i ver fai l ure, p360; Acut e we akness , p 368;Agi tati on/c onfusi on, p370; Generalis ed sei zures , p 372; Int rac rani a l haemorrhag e, p 376; Subarachnoi d haem orrhag e,p378; Stroke , p 380; Rais ed i nt rac rani al pres sure, p382; Gui l l ai n–Barr é s ynd rom e, p384; My ast heni a gravi s , p 386;ICU ne uromus cul ar di s orders, p388; Te tanus, p390; Botul i s m, p 392; Poi soni ng—gene ral p ri nci p l e s, p452; Sed ati ve2 из 25407.11.2006 1:04
Ovid: Oxford Handbook of Critical ication%20Data/Mozilla/Firefox/Profiles/2.poi soni ng, p 458; T ri c ycl i c anti d epress ant poi soni ng, p460; Coc ai ne, p464; Inhal e d p oi s ons , p 466; Organophosp hat epoi soni ng, p 472; Syst emi c i nfl amm ati on/mul ti -org an fai l ure, p484; Mul t i pl e t rauma (1), p500; Mul ti pl e trauma (2),p502; Head i njury (1), p504; He ad i nj ury (2), p 506; Spi nal cord i nj ury, p 508; Burns—fl ui d m anagem ent , p510;Burns —ge neral managem ent , p 512; N ear-drowni ng , p526; Post-ope rat i ve i ntensi v e c are , p 534P.6IPPV—description of ventilatorsClassification of mechanical ventilatorsThe se may be cl ass i fi ed by the met hod of cy cl i ng from i nsp i rati on to expi rati on. Thi s m ay be w hen a pre set ti me hasel a pse d (ti m e-c ycl ed), a preset pres sure reac hed (pres sure-c ycl ed) or a p res et vol ume de l i v ere d (vol ume -cyc l e d).Though the m ethod of c ycl i ng i s c l as si fi e d ac cordi ng to a s i ng l e constant, modern v ent i l a tors all ow a great er deg reeof control . In vol ume -cy cl e d m ode wi t h p res sure l i m i tati on, the up per pres sure alarm l i mi t i s set or the maxi m umi ns pi rat ory press ure control l ed . T he vent i l ator d el i vers a prese t t i d al vol ume (V T ) unl es s t he l ungs are non-c omp l i antor ai rway re si s tance i s hi gh. Thi s i s use ful to av oi d hi gh peak ai rw ay p res sures . In v ol ume-c ycl ed mod e w i th a ti m el i mi t , t he i ns pi rat ory fl ow i s reduced ; t he venti l ator d el i vers the prese t V T unl e ss i mp oss i bl e at t he set re spi ratoryrat e. If pre ssure l i mi t ati on i s not av ai l abl e t hi s i s useful to l i m i t peak airw ay pre ssures . In t i me -cy cl e d m ode wi thpre ss ure control , prese t p res sure i s del i ve red throughout i ns pi rat i on (unl i ke pre ssure-cyc l ed ve nti l at i on), cyc l i ngbei ng det erm i ne d b y t i me . V T i s d epe nde nt on res pi ratory com pl i ance and ai rway re si s tance . He re, too, hi g h p eakai rway press ures c an be avoi de d.Setting up the mechanical ventilatorTidal volumeConventi onal l y set at 7–10m l /k g, t hough rec ent data sug ges t l owe r v al ues (6–7ml /kg ) may b e be tt er i n sev ere acuteres pi rat ory failure, re duc i ng barot rauma and i m provi ng outc ome . In s eve re ai rfl ow l i mi tat i on (e .g. as thm a, acutebronchi t i s) sm al l er V T and mi nute vol um e may b e neede d t o allow p rol ong ed exp i rati on.Respiratory rateUsual l y s et i n acc ordance w i t h V T t o provi de mi nut e ve nti l a ti on of 85–100ml /kg /mi n. In ti m e-c ycl ed or ti m e-l i mi tedmod es the se t resp i ratory rat e de termi nes the ti mi ng of t he venti l at or cyc l es .Inspiratory flowUsual l y s et bet wee n 40–80l /mi n. A hi ghe r fl ow rate i s more c omfort abl e for alert pat i ents. Thi s al l ows for l ong erexp i rati on i n pat i ents wi t h s eve re ai rfl ow l i mi tat i on but m ay be ass oci ate d wi th hi ghe r p eak ai rway press ures. Thefl ow p att ern may be ad jus ted on mos t vent i l ators. A square waveform i s oft en use d b ut dec el e rat i ng fl ow may re duc epeak airw ay p re ssure.I:E ratioA func ti on of resp i ratory rat e, V T , i ns pi rat ory fl ow and i nspi rat ory ti me. Prol onge d e xpi rat i on i s us eful i n seve reai rfl ow l i m i tati on w hi l e a prol onge d i nsp i ratory t i m e i s used i n AR DS to al l ow sl ow reac ti ng alve ol i ti me to fi l l . Al ertpat i ents are more com fortab l e wi t h s horter i nsp i ratory t i me s and hi g h i nsp i ratory fl ow rate s.FIO 2Set ac cordi ng to art eri al bl ood gas es. Us ual to st art at FIO 2 0. 6–1 then adjust ac cordi ng t o arte ri a l b l ood g ase s.Airway pressureIn pre ss ure -control l ed or pre ssure-l i mi t ed mode s t he peak airw ay p re ssure (ci rcui t rathe r t han al veol ar press ure ) c anbe set (usually 35–40cm H 2 O). PEEP i s us ual l y i ncre ase d t o m ai ntai n F RC w hen re spi rat ory compl i ance i s l ow.P.7Initial ventilator set-upChe ck for l e aks3 из 25407.11.2006 1:04
Ovid: Oxford Handbook of Critical ication%20Data/Mozilla/Firefox/Profiles/2.Check oxygen is flowingFIO 20.6–1VT5–10ml/kgRate10–15/minI:E ratio1:2Peak pressure 35cmH 2 OPEEP3–5cmH 2 OKey trialAc ute Res pi rat ory Di stress Synd rom e Ne twork. Ve nti l a ti on wi th l ower ti dal vol um es com pared w i t h t rad i ti onal t i d alvol ume s for acute l ung i njury and the ac ut e resp i ratory d i st re ss syndrome. N Engl J Med 2000; 342:1301–8See also:IPPV—m ode s of ve nti l a ti on, p8; IPPV—adjusti ng the ve nti l at or, p10; IPPV—failure to tol erate venti l at i on, p 12;IPPV—c omp l i cat i ons of ve nti l a ti on, p14; IPPV—w eani ng te chni ques, p16; IPPV—as ses sm ent of weani ng, p18; Hi ghfre que ncy ve nti l at i on, p 20; Pos i t i ve end ex pi ratory press ure (1), p 22; Pos i t i ve end ex pi rat ory press ure (2), p 24; Lungrec rui tm ent , p 28; Non-i nvas i ve re spi rat ory support, p32; CO 2 moni tori ng, p92; Bl ood gas anal ysi s, p100P.8IPPV—modes of ventilationControlled mechanical ventilation (CMV)A p res et num ber of breat hs are de l i v ere d t o s upp l y al l the p ati ent 's venti l at ory re qui rem ent s. The se bre aths m ay beat a p res et V T (vol um e c ont rol l ed ) or at a prese t i nsp i ratory p res sure (press ure control l ed).Assist control mechanical ventilation (ACMV)Pat i ents can tri g ger the v ent i l a tor to de termi ne t he res pi rat ory rate b ut , as wi th CMV, a prese t numb er of b re aths aredel i ve red i f the s pontaneous resp i ratory rat e fall s b el ow t he p res et l e vel .Intermittent mandatory ventilation (IMV)A p res et mandat ory rate i s set but p ati ent s are free t o b reathe sp ont ane ous l y bet ween se t v ent i l ator b reaths .Mandat ory breat hs may be synchroni se d wi th pat i e nts ' s pontaneous e fforts (SIMV) t o av oi d mandatory b reathsocc urri ng d uri ng a s pontaneous b reath. Thi s effect , k nown as ‘s tac ki ng’ may l e ad to exc ess i ve ti dal vol um es, hi ghai rway press ure, i nc ompl et e ex hal ati on and ai r t rappi ng. Press ure support may be add ed to spontaneous bre aths t oove rcome the work of b reathi ng ass oci ate d w i th op eni ng the ve nti l at or dem and valve .Pressure support ventilation (PSV)A p res et i nspi rat ory press ure i s adde d t o the v ent i l ator c i rc ui t d uri ng i ns pi rat i on i n sp ont ane ous l y bre athi ng pati e nts .The prese t p res sure s houl d be adj ust ed to ens ure ad equate V T .Choosing the appropriate modePre ssure control l ed venti l ati on avoi ds the d ang ers as soc i at ed wi t h hi gh pe ak ai rway press ure s, al t hough i t may re sul ti n marked chang es i n V T i f com pl i anc e alte rs . Al l owi ng t he pat i ent t o m ake som e s pontaneous resp i ratory e ffort mayred uce se dat i on re qui re ment s, re train res pi rat ory muscl es and re duc e m ean ai rway press ures.Apnoeic patientUse of IM V or ACMV i n pati e nts who are t ot al l y apnoe i c provi des the t otal m i nute vol ume req ui rem ent i f the pres etrat e i s hi g h enoug h (thi s i s effe cti vel y C MV) but allows spontaneous res pi ratory effort on re cov ery .Patient taking limited spontaneous breathsA g uarant eed mi ni m um mi nute vol um e i s assured wi th bot h ACMV and IMV dep end i ng on the pres et rat e. T he work ofspontaneous bre athi ng i s reduced by sup pl yi ng t he p re set V T for spontaneousl y t ri g gered bre aths w i th AC MV, or byadd i ng press ure s upp ort to sp ont ane ous breat hs wi t h IMV. Wi th ACM V t he spontaneous ti d al vol ume i s guarante edwhe reas w i th IM V and pre ssure sup port s pontaneous t i dal v ol ume dep end s on l ung compl i ance and may be l e ss thanthe prese t t i d al vol ume. The advantage of IMV and press ure support i s that gradual reducti on of pre set rate, asspontaneous effort i ncre ase s, al l ows a smooth trans i ti on to pre ss ure support venti l ati on. Subs eque nt weani ng i s b y4 из 25407.11.2006 1:04
Ovid: Oxford Handbook of Critical ication%20Data/Mozilla/Firefox/Profiles/2.red uct i on of the p res sure s up port l eve l .See also:IPPV—d esc ri pti on of vent i l ators, p6; IPPV—adjusti ng the ve nti l at or, p10; IPPV—failure to tol erate venti l at i on, p 12;IPPV—c omp l i cat i ons of ve nti l a ti on, p14; IPPV—w eani ng te chni ques, p16; IPPV—as ses sm ent of weani ng, p18; Hi ghfre que ncy ve nti l at i on, p 20; Pos i t i ve end ex pi ratory press ure (1), p 22; Pos i t i ve end ex pi rat ory press ure (2), p 24; Lungrec rui tm ent , p 28; Non-i nvas i ve re spi rat ory support, p32P.9P.10IPPV—adjusting the ventilatorVenti l at or adj ust ments are us ual l y mad e i n resp ons e t o bl ood gases , p ul s e oxi m etry or c apnography, pat i ent agi t ati onor di s comfort, or duri ng w eani ng . ‘ Mi g rat i on’ of t he endotracheal tube, ei the r d i st al l y t o t he cari na or be yond, orproxi m al l y s uc h t hat the c uff i s at voc al cord l eve l , may re sul t i n agi tat i on, e xces s coughi ng and a d ete ri orati on i nbl ood gas es. Thi s, and t ube ob struct i on, s houl d be consi dered and rec ti fi e d b efore c hangi ng vent i l ator or s edati ondos e s ett i ng s.The choi c e of v ent i l a tor mode depe nds up on the l e vel of consc i ousne ss, the numb er of s pontaneous b reaths be i ngtak en, and t he b l ood g as val ues . T he spontaneousl y b reathi ng pat i ent c an usual l y c ope ad equate l y wi t h p res suresup port v ent i l ati on al one. How eve r, on occ asi on, a few i nt erm i t tent m andatory b reaths (SIMV) m ay be nec ess ary toass i s t g as exchang e or s l ow an exc es si v e s pontaneous rate. The p aralys ed or heavi l y s edated pati e nt wi l l requi remandat ory breat hs, ei the r v ol ume- or press ure -control l ed.The order of chang e wi l l be di ctated by the s everi t y of re spi ratory fai l ure and i ndi vi d ual op erator prefe rence. Earl i eruse of i ncre ase d PEEP i s ad voc ated to re crui t col l a pse d alve ol i and t hus i m prove oxy genati on i n sev ere re spi rat oryfai l ure.Low PaO 2 considerationsInc rease FIO 2Revi ew V T and resp i ratory rateInc rease PEEP (m ay rai se peak ai rway p res sure or reduce CO)Inc rease I:E rat i oInc rease pre ssure sup port/p res sure c ont rolCMV, i ncreas e s edat i on mus cl e re l ax ant sCons i de r t ol erati ng l ow l ev el (‘p erm i ss i ve hy pox aemi a’)Prone v ent i l ati on, i nhal ed ni t ri c ox i d eHigh PaO 2 considerationsDec rease l eve l of p res sure c ont rol /p res sure s upp ort i f V T adeq uat eDec rease PEEPDec rease FIO 2Dec rease I:E rat i oHigh PaCO 2 considerationsInc rease V T (i f l ow and p eak ai rway pres sure allows)Inc rease res pi ratory rat eReduce rat e
Ovid: Oxford Handbook of Critical Care ion%20Data/Mozilla/Firefox/Profiles/2. 4 из 254 07.11.2006 1:04
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