Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance
Avulsion of skin due to
adhesive tape
Trauma to the lips and
cheeks from tube ties
Pressure ulcers to the
palate and oropharynx
Injuries to the
entrapped tongue
Perioral herpes
3-4 cm
Secure ET tube in place, note the number
Sedate patient with appropriate MAAS
Avoid accidental, or self extubation
Laceration and hematoma in the left vocal fold during direct
laryngoscopy. Exam performed with rigid telescope
Bilateral intubation granulomas
inserted in the vocal apophasis.
Exam performed with rigid
telescope.
Ulcerated lesion in the posterior
glottic commissure soon after
extubation. Exam performed
with rigid telescope.
diffuse posterior erythema, edema and piled-up mucosa of inter-arytenoid area
Risk of mechanical complications
Risk of aspiration
Prince J S et al. Radiographics 2002;22:S215-S230
Tracheal stenosis (exam
performed with flexible
nasofibroscope)
Glottic stenosis (exam
performed with rigid
telescope).
Tracheal collapse of
more than 50% during
expiration is diagnostic
of tracheomalacia
The AnapnoGuard system detects air leakage from the lungs by measuring the CO2 level
above the cuff. Detection of high CO2 levels above the cuff represents leakage




Air inflation of the tube cuff until the airflow
heard escaping around the cuff during
positive pressure breath ceases.
Place a stethoscope over larynx. Indirectly
assesses inflation of cuff.
Slowly withdraw air (in 0.1-mL increments)
until a small leak is heard on inspiration.
Remove syringe tip, check inflation of pilot
balloon
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance


64 year old male with history of COPD who
presented with severe respiratory distress
and required to be intubated and placed on
CMV, VT of 650 ml and a rate of 24/min.
Immediately post intubation, his systolic
blood pressure dropped from 132 mm Hg to
73 mm Hg.
120
5
3
0
-3
10
0
110
5
3
0
-3
8
0




No effect in Normal individual with PEEP less
than 10 cmH2O
Major effect in patients with Dynamic
Hyperinflation such as asthma and COPD,
and in pre-existing pulmonary hypertension
Small changes in PVR can cause considerable
hemodynamic compromise secondary to
acute increase in PVR
Avoid air trapping in these patients


Decreased cardiac output, decreased venous
return
Observe for:
▪
▪
▪
▪
▪
▪
Decreased BP
Restlessness, decreased LOC
Decreased urine output
Decreased peripheral pulses
Slow capillary refill
Increasing Tachycardia
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance
Volutrauma
• Overdistention
Atelectetrauma • Repeated recruitment and collapse
Bio trauma
• Inflammatory mediators
Barotrauma
• High-pressure induced lung damage
Oxygen toxic
effect
• FiO2
Atelectrauma:
Repetitive alveolar collapse
and reopening of the underrecruited alveoli
Volutrauma:
Over-distension of normally
aerated alveoli due to excessive
volume delivery
Biotrauma
Cytokines, complement,
prostanoids, leukotrienes,
O2- Proteases
*Dreyfuss: J Appl Physiol 1992
Pinsp = 40 mbar
Airway Trauma
“Stretch”
“Shear”

Overdistension





Edema fluid accumulation
Surfactant degradation
High oxygen exposure
Mechanical disruption
Zone of
Overdistention
Injury
“Safe”
Window
Derecruitment, Atelectasis
 Repeated closure / re-expansion
 Stimulation inflammatory
response
 Inhibition surfactant
 Local hypoxemia
 Compensatory overexpansion
Volume
Zone of
Derecruitment
and Atelectasis
Injury
Pressure
Diseased Lungs Do
Not Fully Collapse,
Despite Tension
Pneumothorax
And they cannot always
be fully “opened”
Dimensions of a fully
Collapsed Normal Lung
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance
Alveolar pressure  PAO2  PACO2  PAH2O  PAN2
Absorptive atelectasis
 O2/N2 = 21/79
>>>>>> 50/50
 Accentuation of
hypercapnia

 Chronic respiratory
failure: PCO2 with
PO2

Carbon
dioxide
Damage to airways
 Bronchopulmonary
dysplasia

Oxygen
Diffuse alveolar
damage
Water
vapour
Nitrogen



PEEP
Alveolar recruitment maneuvers
Alternative modes of ventilation
 Inverse-ratio , APRV, HFV, …..



Inhaled nitric oxide (iNO)
Extracorporeal membrane oxygenation (ECMO)
Diuresis
 if pulmonary edema is possible

Bronchopulmonary hygiene
 if secretions are prominent

Augmentation of antioxidants??
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance

VAP – ventilator associated pneumonia
 >48 hours on vent
 Combination of:
▪ CXR changes
▪ Sputum changes
▪ Fever, ↑ WBC
▪ positive sputum culture

Occurs secondary to micro-aspiration of
upper airway secretions
No 1 risk factor is endotracheal intubation
Factors that related to cross contamination:
 Poor adherence to infection control standards
 Factors that enhance colonization of the oropharynx &/or stomach:
 Poor oral hygiene
 Conditions favoring aspiration into the respiratory tract or reflux
from GI tract:
 Supine position
 NGT placement
 Re-Intubation and self-extubation
 Surgery of head/neck/thorax/upper abdomen
 GERD
 Coma/ depressed Glascow coma scale


 45o head-up tilt is
the goal in all
patients unless
contraindicated
 No benefit of
semi-recumbency
~30o over standard
care ~10o
 Supine position is
harmful

HOB at 30-45º
CDC Guideline for Prevention of Healthcare
Associated Pneumonias 2004 ATS / IDSA
Guidelines for VAP 2005

Elevation of the head of the bed 30-45o
 Use 15-30o for neonates and small infants,
otherwise 30-45o





Daily sedation vacations (minimize duration
of intubation)
Daily assessment of readiness to extubate
Peptic ulcer disease (PUD) prophylaxis
Oral care protocol (chlorhexidine)
DVT prophylaxis option
25
% VAP
20
15
10
5
0
Supine

HOB Elevation
Dravulovic et al. Lancet 1999;354:1851-1858
CCU VAP Bundle Compliance Vs Infection Rate
VAP Bundle Com pliance%
Linear (VAP Bundle Com pliance%)
VAP Infection Rate
Linear (VAP Infection Rate)
100%
40
35
80%
30
25
60%
20
40%
15
10
20%
Feb-08
Jan-08
0%
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Apr-07
Mar-07
Feb-07
Jan-07
Dec-06
Nov-06
0
Oct-06
5
NHSN 50th
Percentile 4.1
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance

Elevation of the head of the bed 30-45o
 Use 15-30o for neonates and small infants,
otherwise 30-45o





Daily sedation vacations (minimize duration
of intubation)
Daily assessment of readiness to extubate
Peptic ulcer disease (PUD) prophylaxis
Oral care protocol (chlorhexidine)
DVT prophylaxis option
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance






Fighting the ventilators
Inconsistent tidal volume
Increase work of breathing
Barotraumas and thoracic air leak
Insufficient gas exchange
Disturbances in the cerebral blood flow
Airway complications
Hemodynamic disturbances
Ventilator associated lung injury: VILI
Oxygen toxicity
Ventilator associated pneumonia
Pulmonary emboli
Patient ventilator asynchrony
Sleep disturbance
300
Sleep Time (minutes)
Non REM
200
Stage 4
Stage 3
100
Stage 2
Stage 1
0
REM
100
Age 40
Age 40
MV
8
10
12
14
16
Stage 1
Stage 3
Stage 2
Stage 4
18
REM
20
22
0
2
4
6
8
8
10
12
14
16
Stage 1
Stage 3
Stage 2
Stage 4
18
REM
20
22
0
2
4
6
8

Noise disruption
 Ventilator alarm:
▪ inappropriate threshold
▪ Delayed alarm inactivation
 Humidifier alarms

Disruption by nursing interventions
 Airway suction
 Nebulizer delivery

Ventilation-related pharmacological disruption
 Benzodiazepines (↓REM, ↓deep NREM)
 Opioids (↓REM, ↓deep NREM)
 Neuromuscular blocking drugs
‫‪‬‬
‫تبق نظام اإلنذار مكتوما‪.‬‬
‫ال‬
‫ِ‬
‫ال تتجاهل اإلنذار حتى لو كنت تعلم سببه أو‬
‫كان ليس شيئا مهما‪.‬‬
‫‪‬‬
‫ضع المريض في وضعية مشابهة لوضعية فولر‬
‫أو أخفض منها لزيادة راحة المريض وتسهيل‬
‫التنفس‪.‬‬
‫‪‬‬
Thank you