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of Respiratory System:
Upper Airways
Nasal cavity and pharynx
Lower Airways
Larynx, trachea, bronchial tree
Lung Lobes
2 on left, 3 on right
Tracheobronchial tree
Alveolar unit
Pharynx:
NASOPHARYNX
OROPHAYNX
LARYNGOPHARYNX
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
VOCAL
VOCAL CORDS
CORDS
Lined
Lined by
by mucous
mucous membrane
membrane that
that forms
forms two
two folds
folds that
that protrude
protrude inward.
inward.
LARYNX
Upper
Upper folds
folds are
are called
called false
false vocal
vocal cords.
cords.
Framework of nine cartilages held in position by intrinsic and extrinsic muscles.
Lower
Lower pair
pair are
are the
the true
true vocal
vocal cords.
cords.
SINGLE:
Thyroid
Cricoid
Epiglottis
Medial
Medial border
border is
is composed
composed of
of aa strong
strong band
band of
of elastic
elastic tissue
tissue called
called the
the vocal
vocal
ligament.
PAIRED:
Arytenoid
Corniculate Cuneiform
ligament.
Space
Space in
in between
between the
the true
true vocal
vocal cords
cords is
is called
called the
the rima
rima glottidis
glottidis or
or glottis.
glottis.
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
NOTE:
NOTE: The
The precise
precise number
number of
of generations
generations between
between the
the
subsegmental
subsegmental bronchi
bronchi and
and the
the alveolar
alveolar sacs
sacs is
is not
not known.
known.
Schematic
Schematic drawing
drawing of
of the
the anatomic
anatomic structures
structures distal
distal to
to the
the terminal
terminal
bronchioles;
bronchioles; collectively,
collectively, these
these are
are referred
referred to
to as
as the
the primary
primary lobule.
lobule.
Alveolar unit
Back to Index
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
Quick Review
Although the respiratory system can be viewed as
3 main components, a functional description is
more useful because it distinguishes the process of
ventilation from that of respiration. The two functional
areas are the conducting and respiratory zones. The
conducting zone participates in ventilation. Inspired gas
is filtered, warmed, and humidified as it is enters the
lungs. Gas movement in the conducting zone is termed
dead space ventilation. Increased levels of dead space
can cause the patient to increase their rate and depth
of breathing to compensate for the effect on ventilation
and respiration.
Quick Review
The exchange of gases between the alveoli and blood
is called respiration and occurs in the respiratory
zone. This area is comprised of small airways, alveoli,
and the pulmonary capillaries. Gas enters the
respiratory zone from the conducting airways and
blood circulates the alveoli from the pulmonary
capillaries. In order to have affective respiration there
must be adequate levels of ventilation and pulmonary
blood flow.
Pulmonary Mechanics
Respiratory Mechanics
Pulmonary Mechanics
Requires chest wall (thorax) and
respiratory muscles
Pleura (lining) - lubricant
Opposing forces keep lungs inflated
(thorax=out, lungs=in)
Muscles provide force(work)
Diaphragm = major muscle of ventilation
Back to Index
Inspiration (ACTIVE)
Diaphragm contracts - moves downward
Thoracic volume increases
Lung (pleural) pressure decreases - air
moves in
Back to Index
Expiration (PASSIVE)
Diaphragm relaxes - moves up
Thoracic volume decreases
Lung (pleural) pressure decreases air moves
out
EXPIRATION
Back to Index
END-EXPIRATION
EXPIRATION
END-EXPIRATION
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
Pulmonary Mechanics
Compliance
Amount of work required to inflate lungs
how stiff is the lung?
Compliance = Volume (L/cmH20)
Pressure
Back to Index
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
Preset VT
COMPLIANCE
COMPLIANCE
Increased
Normal
Decreased
Volume (mL)
Paw (cm H2O)
PIP levels
Overdistension
With
With little
little or
or no
no change
change in
in V
VTT
Volume (ml)
Normal
Abnormal
P
rises
Paw
aw rises
Pulmonary Mechanics
Elastance
Amount of work required to exhale
Elastance =
Pressure (cmH 0/L)
Volume
Reciprocal of compliance
Good compliance = bad elastance
Bad compliance = good elastance
Back to Index
Pulmonary Mechanics
Resistance
Amount of work required to move air
through the lungs
Resistance =
Pressure (cmH220/L/sec)
Flow
Primarily influenced by airway diameter
Normal = 0.6 - 2.4 cmH220/L/sec
Back to Index
Quick Review
Ventilation occurs due to a pressure gradient
between the lungs and mouth. Contraction of the
respiratory muscles results in a pressure - volume
change in the lungs. As pressure decreases air
moves into the lungs during inspiration, and as lung
pressure increases gas moves out of the lungs during
expiration. The compliance of the pulmonary
system influences the amount of pressure required
to affect a volume change. Airway resistance also
influences the effort needed to create a volume
change.
Capacities
Back to Index
Assessment of Ventilation
Signs & Symptoms
Assessment of Ventilation
Qualitative
Respiratory pattern
Accessory muscle use
Prolonged expiration
Shortness of Breath (SOB)
Cyanosis
Minute ventilation (VE=f x VTT)
Back to Index
Assessment of Ventilation
Quantitative
Control of Respiration
1. Chemical Stimulants
Oxygen and carbon dioxide influence rate
and depth of respiration
CO22 is the primary stimulus
CO22 = rate and/or depth
CO22 = rate and/or depth
O22 = ventilation
O22 = ventilation
Back to Index
Quick Review
Respiration is the exchange of gases between
the lungs and pulmonary blood vessels (external
respiration) and between the blood and tissues
(internal respiration). Oxygen and carbon dioxide
move from one area to the other due to pressure
gradients. Systemic levels of CO22 and O22, influence
the depth and rate of ventilation with carbon
dioxide acting as the primary stimulus for
ventilation.
Assessment of Respiration
PaCO22
Back to Index
Assessment of Respiration
SaO22
Back to Index
FYI
Gas pressures, or tensions, are usually
expressed in units of torr. One torr is equal to
one mm Hg (millimeter of mercury pressure),
similar to what your local weatherman uses.
Torr is used to honor Evangelista Torricelli who
invented the mercury barometer. Torr and mm
Hg can be used interchangeably, however torr is
the preferred unit.
Ventilation-Perfusion Relationships
Perfusion(Q)
Ventilation(V)
Need V/Q matching to achieve effective gas
exchange.
Normal V/Q ratio = 0.8
Increased V/Q ventilation>perfusion (deadspace)
Decreased V/Q perfusion>ventilation (shunt)
Abnormal V/Q ratios alter work of breathing
Back to Index
From Cardiopulmonary Anatomy and Physiology. Terry Des Jardins. 3rd Ed. Delmar. Albany,NY.1998
Quick Review
ABGs are used to assess the effectiveness of respiration.
Problems in external respiration occur from V/Q
mismatches. Low V/Q areas produce oxygenation
problems (shunting) and high V/Q ratios represent
alveolar dead space ventilation. Internal respiration is
the exchange of O22 and CO22 between the arterial blood
and the tissues. Metabolic activity of the cells requires O22
and produces CO22 as a byproduct. ABGs are used to
assess the level of O22 available for metabolism and the
effectiveness of lungs in removing CO22.
Back to Index
2. Bronchitis
Pathology: Chronic inflammation of mucousproducing cells. Hyper-reactive airways.
Excessive abnormal secretions from irritation
(infection, allergies, smoke, etc.).
Concerns: Ventilation only supportive; must
reduce volume of secretions and remove
irritants.
Respiratory Dysfunction
Diagnosis confirmed via PFTs
Respiratory Dysfunction
Restrictive Lung Disease
Work of Breathing
Work = Force (pressure) x Distance (volume)
Mechanical Ventilation
1. Negative Pressure Ventilators
Iron lung
Cuirass
Back to Index
Ventilator Parameters
Settings
Volume-Targeted Ventilation
Tidal Volume
Definition: How much air movement is
needed to adequately remove CO22 from the
blood.
Setting: Usually 8-10mL/kg or adjusted as
indicated by arterial CO22 levels.
Respiratory Rate
Definition: The frequency that the tidal
volume must be delivered to adequately
remove CO22.
Setting: Usually 12-14/min may be
increased or decreased as indicated by
arterial CO22 levels.
Inspiratory Time
Definition: Part of the ventilatory cycle
necessary for inspiration
Setting: Maintain an I:E of 1:2 or
greater (1:3, 1:4, etc.)
Pressure-Targeted Ventilation
Peak Inspiratory Pressure
Definition: Reflects airway resistance and/or
lung compliance.
Setting: Set to allow the delivery of an
adequate tidal volume.
Back to Index
Modes of Ventilation
Control
Indicated when patient cannot initiate
inspiration.
Inspiration is initiated by timing device.
Machine controlled breath.
Control Mode
(Pressure-Targeted Ventilation)
TimeTime-Cycled
Flow
(L/min)
Set PC level
Pressure
(cm H2O)
Volume
(ml)
Tim
Time (sec)
From CD: Essentials of Ventilator Graphics
Click
Click on
on the
the graphic
graphic to
to see
see details
details
Back to Index
Control Mode
(Pressure-Targeted Ventilation)
Time-Cycled
Flow
(L/min)
Set PC level
Press
(cm H2O)
ure
Volume
(ml)
Time (sec)
From CD Esssentials of Ventilator Graphics. 2000 RespiMedu. With permission
Assist-Control
Breath initiated by patient unless rate falls below
selected respiratory rate.
Each breaths pressure or volume is preset.
Assisted Mode
Assisted Mode
(Pressure-Targeted Ventilation)
(Volume-Targeted Ventilation)
Time-Cycled
Flow
(L/m)
Flow
(L/min)
Pressure
Pressure
(cm H2O)
Set PC level
(cm H2O)
Volume
(ml)
Preset VT
Volume
(mL)
Volume Cycling
Time (sec)
Time (sec)
Click
Click on
on the
the graphics
graphics to
to see
see details
details
Back to Index
Assist-Control Mode
(Pressure-Targeted Ventilation)
Patient Triggered, Pressure Limited, Time Cycled Ventilation
Time-Cycled
Flow
(L/min)
Press
(cm H2O)
ure
Set PC level
Volume
(ml)
Time (sec
Assist-Control Mode
(Volume-Targeted Ventilation)
Patient triggered, Flow limited, Volume cycled Ventilation
Flow
(L/m)
Pressure
(cm H2O)
Preset VT
Volume
(mL)
Volume Cycling
Time (sec)
From CD Esssentials of Ventilator Graphics. 2000 RespiMedu. With permission
Flow-Trak
VCV made easy!
What Is Flow-Trak
Its an enhancement to standard VCV
Doesnt punish the patient if Peak Flow
setting is inappropriately low
If the peak flow or tidal volume does not
meet the patients demand, Flow-Trak
will give additional flow to satisfy patient
need
Flow-Trak
Features
Its always on
No additional settings
Allows unrestricted
access to flow/volume
within a VCV breath
without increasing
driving pressure
Maintains the same
expiratory time
Benefits
Easy to use
Enhances patient-toventilator synchrony
Flow-Trak
Features
High Ve alarm
Benefits
Alerts clinician to
consistent increased
ventilatory demands
Ensures the preset Vt
is always delivered
Patient-to ventilator
synchrony
Without FlowTrak
Concave Pressure
Curve
Pressure
cmH2O
Without FlowTrak
Breath Triggered
Pressure
cmH2O
Flow
LPM
Flow-Trak
60
VCV
Breath
Flow-Trak
Breath
Flow
LPM
20
Pressure
decrease
Pressure
cmH2O
5
Time
SIMV+PS
(Volume-Targeted Ventilation)
PS Breath
Flow
(L/min)
Pressure
Flow-cycled
Set PS level
(cm H2O)
Volume
(ml)
(L/min)
Pressure
(cm H2O)
CPAP level
Volume
(ml)
Time (sec)
Click
Click on
on the
the graphic
graphic to
to see
see details
details
Back to Index
CPAP
Flow
(L/min)
Pressure
(cm H2O)
CPAP level
Volume
(ml)
Time (sec)
From CD Esssentials of Ventilator Graphics. 2000 RespiMedu. With permission
Back to Index
PSV
Pressure
(cm H2O)
Flow
Flow Cycling
Cycling
Set PS
level
Volume
(mL)
Time (sec)
From CD Esssentials of Ventilator Graphics. 2000 RespiMedu. With permission
Back to Index
Back to Index
Non-invasive ventilation.
Set IPAP to obtain level of pressure support.
Improve ventilation.
Set EPAP to obtain level of CPAP.
Improve oxygenation.
Back to Index
Back to Index
Ventilator Controls
Ventilator Controls
1. Mode
2. Tidal Volume (volume ventilator)
-6-10 mL/Kg ideal body weight
-measured at ventilator outlet
3. Respiratory Rate
-normally 12-15 bpm
-alters E time, I:E ratio, CO2
Back to Index
Ventilator Controls
4. Flowrate
-normal setting is 40-60 Lpm
-alters inspiratory time
5. I: E ratio
-normal is 1: 2(adult); 1: 1 (infant)
-volume, flowrate, and rate control alter
I:E ratio
6. FiO2
-Titrate to keep SpO22 > 90%
Back to Index
Ventilator Controls
7. Sensitivity
-normally -0.5 to -2 cmH20
8. Inflation hold
-used to improve oxygenation, calculate
static compliance
9. PEEP
-used to increase FRC - improve
oxygenation
10. Alarms
Back to Index
Ventilatory
Management
Appropriate
Initial Settings
Establish ARF
Weaning
&
Extubation
Titrating
Parameters
Mechanical
Ventilation
Appropriate
Alarm Settings
Monitoring
Pressure
Parameter
Titration
Noninvasive
Assessment
Volume
Mechanical
Ventilation
Other
Ventilator
Parameters
Acidbase Balance
&
Oxygenation
Modes of Ventilation
FULL SUPPORT
SPONTANEOUS
PARTIAL SUPPORT
Control
Assist
Spontaneous
SIMV
CPAP
SIMV
+
CPAP
Assist/control
PSV
SIMV
+
PSV
CPAP
+
PSV
SIMV
+
PSV
+
CPAP
VA and PaCO2
.
VA
PaCO2
.
.
.
VA = VE VD
= ( VT VD ) f
Titration
of
Parameters
.
VE and PaCO2
Tidal Volume (VT)
x
Frequency (f)
.
VE
PaCO2
Titration
of
Parameters
.
VE and PaCO2
VE
PaCO
Titration
of
Parameters
.
VE and PaCO2
Tidal Volume (VT)
x
Frequency (f)
O
2
C
a
P
VE
Titration of Parameters
f and PaCO2
Tidal Volume (VT)
x
Frequency (f)
f
PaCO
Titration of Parameters
f and PaCO2
Tidal Volume (VT)
x
Frequency (f)
O
2
C
a
P
Parameter Titration
PaO2 and FiO2
Increased FiO2 increases PaO2
PaO2
FiO2
Decreased FiO2 decreases PaO2
Capnography
EtCO22
Capnogram
Respiratory
Rate
Volumetric CO2
CO22 Elimination
Deadspace
Alveolar Ventilation
Physiologic Vd/Vt
EtCO
CO Elimination
Cardiac Output
Capnogram
Airway Deadspace
2
Respiratory
Rate
Alveolar
Ventilation
Physiologic Vd/Vt
Cardiac Output
CO2 Metabolism
CO2
Muscle
Circulation
O2
O2
Ventilation
CO2
VO2
VCO2
2
Things that affect
CO2 elimination
PaCO2
CO2 Elimination
(VCO2)
Circulation
Diffusion
Ventilation
HMM!! VCO2?
VCO2
Oxygen
CO= 5.0
Open Lungs
Pressure
Principles and
Application
of NPPV
Performa Trak SE
For use with critical care ventilators with
dual limb circuits and internal safety valves
Standard Elbow
Blue Packaging
Auto-Trak Sensitivity
This is what we do.
When?
NIPPV Goal 1:
Resting the
respiratory muscles
Increasing in
Lung Compliance
Mechanisms
for Improvement
Augment
patients ability
to breathe on a
spontaneous basis
Resetting
Central Chemoreceptors
CO2 sensitivity
is blunted
during failure
Sinusitis
For the
Patient
Avoid complication of
ET-Intubation
Cuff ulceration,
oedema,
haemorrhage
Avoid
Significant risk of
nosocomial infection
Pneumonia
Reduce needs
for sedation
Injury to the
pharynx
, larynx, trachea
Correct Gas
Exchange
Abnormalities
Augment
spontaneous
breathing
Decrease Work
of Breathing
Improve quality
of sleep
Main
concern
Improve quality
of life
NIPPV
Mechanisms for improvement
Patient
Circuit
Air Filter
AFM
(mass airflow
sensor)
PVA
Exhaust (pressure
valve assy)
Ambient Air
BiPAP
The Concept
Two pressure levels:
PS
= IPAP - EPAP
PEEP = EPAP
Pressure Support with
PEEP (Especially suited
for Non Invasive
Ventilation)
Continuous flow circuit
Systems
Our Know
How
Detects and learns
leaks
> To maintain
automatic
trigger
sensibility
> Optimise
performance
BECAUSE:
It is virtually
impossible for
preset sensitivity
settings to keep
pace with
BECAUSE:
It is difficult to
maintain proper patient
ventilator synchrony
in the presence:
RESPIRONICS is
Auto-Trak
Sensitivity
Sensitivity
2 - Sensitivity
Variable Trigger Thresholds (EPAP
to IPap
Variable Cycle Thresholds
(IPAP to
EPap
Vtot = Vest +
Vleak
EPAP
Variable Cycle
Threshold
FLOW
Variable Trigger
Threshold
VInspiration
VInspiration
= VExpiration
>
VExpiration
No change
in baseline
New
Baseline
Adjustment
of Vleak
for the next breath
VInspiration
<
VExpiration
New
Baseline
Cycle Variables
SET (Spontaneous Expiratory
Threshold)
SET
Flow
Benefit :
Detects gradual changes in patient
flow
from prolonged exhalation periods.
BEST
PATIENT
COMPLIANCE
Sensitivity
technology is integrated:
Duet Lx
BiPAP ST30, ST/D30
Harmony
Focus
Vision
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chicken!