0071643192.pdf

BI-LEVELPOSITIVEAIRWAYPRESSURE(BIPAP)

■ It is a combination of CPAP and inspiratory assist.

■ Inspiratory positive pressure (8–10cm H 2 O) exceeds that of expiratory

positive pressure (3–5cm H 2 O) provided.

■ It provides extrinsic PEEP.

■ Each cycle is triggered by patient initiation of inhalation.

COMPLICATIONS

■ Volutrauma, pressure necrosis of the skin from an ill-fitting mask, gastric

distention, delayed definitive airway management.

A 60-year-old smoker in COPD exacerbation is failing aggressive noninva-

sive therapy. He is now orotracheally intubated. What should his initial

ventilator settings be?

In a patient with COPD, the initial selected tidal volume and rate should be

slightly reduced to avoid hyperinflation and hyperventilation. Begin with 10 mL/kg

of patient’s ideal body weight at 10 breaths per minute and 100% FiO 2 and

wean as tolerated.

MECHANICALVENTILATION

Initial ventilator setting should be based on review of the underlying pulmonary

process (see Table 1.6).

COMPLICATIONS

■ Volutrauma

■ Overdistention of alveoli

■ Prevented by using smaller tidal volumes

RESUSCITATION

BiPAP is a combination of

CPAP and inspiratory assist.

TABLE 1.6. Initial Ventilator Settings

PULMONARYPROCESS VENTILATORSETTINGS

Pulmonary contusion Low tidal volume (5–10 mL/kg) to prevent barotrauma

PEEP of 5–15 cm H 2 O to prevent alveoli collapse

Asthma/COPD Slow respiratory rate and prolonged exhalation phase PEEP

ARDS Low respiratory rate (maximize recruitment)

Low tidal volume (6 mL/kg) to prevent volutrauma

PEEP

Neonates Best setting = pressure controlled ventilation

Acidosis Continue respiratory compensation with a high respiratory rate

Head injury Avoid hypercapnea, which causes cerebral vasodilation and ↑ICP.